research paper healthy eating

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• My Account Login
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 06 December 2017

Healthy food choices are happy food choices: Evidence from a real life sample using smartphone based assessments

• Deborah R. Wahl 1   na1 ,
• Karoline Villinger 1   na1 ,
• Laura M. König   ORCID: orcid.org/0000-0003-3655-8842 1 ,
• Katrin Ziesemer 1 ,
• Harald T. Schupp 1 &
• Britta Renner 1  

Scientific Reports volume  7 , Article number:  17069 ( 2017 ) Cite this article

132k Accesses

54 Citations

262 Altmetric

Metrics details

• Health sciences
• Human behaviour

Research suggests that “healthy” food choices such as eating fruits and vegetables have not only physical but also mental health benefits and might be a long-term investment in future well-being. This view contrasts with the belief that high-caloric foods taste better, make us happy, and alleviate a negative mood. To provide a more comprehensive assessment of food choice and well-being, we investigated in-the-moment eating happiness by assessing complete, real life dietary behaviour across eight days using smartphone-based ecological momentary assessment. Three main findings emerged: First, of 14 different main food categories, vegetables consumption contributed the largest share to eating happiness measured across eight days. Second, sweets on average provided comparable induced eating happiness to “healthy” food choices such as fruits or vegetables. Third, dinner elicited comparable eating happiness to snacking. These findings are discussed within the “food as health” and “food as well-being” perspectives on eating behaviour.

Similar content being viewed by others

Effects of single plant-based vs. animal-based meals on satiety and mood in real-world smartphone-embedded studies

Eating Style and the Frequency, Size and Timing of Eating Occasions: A cross-sectional analysis using 7-day weighed dietary records

Interindividual variability in appetitive sensations and relationships between appetitive sensations and energy intake

Introduction.

When it comes to eating, researchers, the media, and policy makers mainly focus on negative aspects of eating behaviour, like restricting certain foods, counting calories, and dieting. Likewise, health intervention efforts, including primary prevention campaigns, typically encourage consumers to trade off the expected enjoyment of hedonic and comfort foods against health benefits 1 . However, research has shown that diets and restrained eating are often counterproductive and may even enhance the risk of long-term weight gain and eating disorders 2 , 3 . A promising new perspective entails a shift from food as pure nourishment towards a more positive and well-being centred perspective of human eating behaviour 1 , 4 , 5 . In this context, Block et al . 4 have advocated a paradigm shift from “food as health” to “food as well-being” (p. 848).

Supporting this perspective of “food as well-being”, recent research suggests that “healthy” food choices, such as eating more fruits and vegetables, have not only physical but also mental health benefits 6 , 7 and might be a long-term investment in future well-being 8 . For example, in a nationally representative panel survey of over 12,000 adults from Australia, Mujcic and Oswald 8 showed that fruit and vegetable consumption predicted increases in happiness, life satisfaction, and well-being over two years. Similarly, using lagged analyses, White and colleagues 9 showed that fruit and vegetable consumption predicted improvements in positive affect on the subsequent day but not vice versa. Also, cross-sectional evidence reported by Blanchflower et al . 10 shows that eating fruits and vegetables is positively associated with well-being after adjusting for demographic variables including age, sex, or race 11 . Of note, previous research includes a wide range of time lags between actual eating occasion and well-being assessment, ranging from 24 hours 9 , 12 to 14 days 6 , to 24 months 8 . Thus, the findings support the notion that fruit and vegetable consumption has beneficial effects on different indicators of well-being, such as happiness or general life satisfaction, across a broad range of time spans.

The contention that healthy food choices such as a higher fruit and vegetable consumption is associated with greater happiness and well-being clearly contrasts with the common belief that in particular high-fat, high-sugar, or high-caloric foods taste better and make us happy while we are eating them. When it comes to eating, people usually have a spontaneous “unhealthy = tasty” association 13 and assume that chocolate is a better mood booster than an apple. According to this in-the-moment well-being perspective, consumers have to trade off the expected enjoyment of eating against the health costs of eating unhealthy foods 1 , 4 .

A wealth of research shows that the experience of negative emotions and stress leads to increased consumption in a substantial number of individuals (“emotional eating”) of unhealthy food (“comfort food”) 14 , 15 , 16 , 17 . However, this research stream focuses on emotional eating to “smooth” unpleasant experiences in response to stress or negative mood states, and the mood-boosting effect of eating is typically not assessed 18 . One of the few studies testing the effectiveness of comfort food in improving mood showed that the consumption of “unhealthy” comfort food had a mood boosting effect after a negative mood induction but not to a greater extent than non-comfort or neutral food 19 . Hence, even though people may believe that snacking on “unhealthy” foods like ice cream or chocolate provides greater pleasure and psychological benefits, the consumption of “unhealthy” foods might not actually be more psychologically beneficial than other foods.

However, both streams of research have either focused on a single food category (fruit and vegetable consumption), a single type of meal (snacking), or a single eating occasion (after negative/neutral mood induction). Accordingly, it is unknown whether the boosting effect of eating is specific to certain types of food choices and categories or whether eating has a more general boosting effect that is observable after the consumption of both “healthy” and “unhealthy” foods and across eating occasions. Accordingly, in the present study, we investigated the psychological benefits of eating that varied by food categories and meal types by assessing complete dietary behaviour across eight days in real life.

Furthermore, previous research on the impact of eating on well-being tended to rely on retrospective assessments such as food frequency questionnaires 8 , 10 and written food diaries 9 . Such retrospective self-report methods rely on the challenging task of accurately estimating average intake or remembering individual eating episodes and may lead to under-reporting food intake, particularly unhealthy food choices such as snacks 7 , 20 . To avoid memory and bias problems in the present study we used ecological momentary assessment (EMA) 21 to obtain ecologically valid and comprehensive real life data on eating behaviour and happiness as experienced in-the-moment.

In the present study, we examined the eating happiness and satisfaction experienced in-the-moment, in real time and in real life, using a smartphone based EMA approach. Specifically, healthy participants were asked to record each eating occasion, including main meals and snacks, for eight consecutive days and rate how tasty their meal/snack was, how much they enjoyed it, and how pleased they were with their meal/snack immediately after each eating episode. This intense recording of every eating episode allows assessing eating behaviour on the level of different meal types and food categories to compare experienced eating happiness across meals and categories. Following the two different research streams, we expected on a food category level that not only “unhealthy” foods like sweets would be associated with high experienced eating happiness but also “healthy” food choices such as fruits and vegetables. On a meal type level, we hypothesised that the happiness of meals differs as a function of meal type. According to previous contention, snacking in particular should be accompanied by greater happiness.

Eating episodes

Overall, during the study period, a total of 1,044 completed eating episodes were reported (see also Table  1 ). On average, participants rated their eating happiness with M  = 77.59 which suggests that overall eating occasions were generally positive. However, experienced eating happiness also varied considerably between eating occasions as indicated by a range from 7.00 to 100.00 and a standard deviation of SD  = 16.41.

Food categories and experienced eating happiness

All eating episodes were categorised according to their food category based on the German Nutrient Database (German: Bundeslebensmittelschlüssel), which covers the average nutritional values of approximately 10,000 foods available on the German market and is a validated standard instrument for the assessment of nutritional surveys in Germany. As shown in Table  1 , eating happiness differed significantly across all 14 food categories, F (13, 2131) = 1.78, p  = 0.04. On average, experienced eating happiness varied from 71.82 ( SD  = 18.65) for fish to 83.62 ( SD  = 11.61) for meat substitutes. Post hoc analysis, however, did not yield significant differences in experienced eating happiness between food categories, p  ≥ 0.22. Hence, on average, “unhealthy” food choices such as sweets ( M  = 78.93, SD  = 15.27) did not differ in experienced happiness from “healthy” food choices such as fruits ( M  = 78.29, SD  = 16.13) or vegetables ( M  = 77.57, SD  = 17.17). In addition, an intraclass correlation (ICC) of ρ = 0.22 for happiness indicated that less than a quarter of the observed variation in experienced eating happiness was due to differences between food categories, while 78% of the variation was due to differences within food categories.

However, as Figure  1 (left side) depicts, consumption frequency differed greatly across food categories. Frequently consumed food categories encompassed vegetables which were consumed at 38% of all eating occasions ( n  = 400), followed by dairy products with 35% ( n  = 366), and sweets with 34% ( n  = 356). Conversely, rarely consumed food categories included meat substitutes, which were consumed in 2.2% of all eating occasions ( n  = 23), salty extras (1.5%, n  = 16), and pastries (1.3%, n  = 14).

Left side: Average experienced eating happiness (colour intensity: darker colours indicate greater happiness) and consumption frequency (size of the cycle) for the 14 food categories. Right side: Absolute share of the 14 food categories in total experienced eating happiness.

Amount of experienced eating happiness by food category

To account for the frequency of consumption, we calculated and scaled the absolute experienced eating happiness according to the total sum score. As shown in Figure  1 (right side), vegetables contributed the biggest share to the total happiness followed by sweets, dairy products, and bread. Clustering food categories shows that fruits and vegetables accounted for nearly one quarter of total eating happiness score and thus, contributed to a large part of eating related happiness. Grain products such as bread, pasta, and cereals, which are main sources of carbohydrates including starch and fibre, were the second main source for eating happiness. However, “unhealthy” snacks including sweets, salty extras, and pastries represented the third biggest source of eating related happiness.

Experienced eating happiness by meal type

To further elucidate the contribution of snacks to eating happiness, analysis on the meal type level was conducted. Experienced in-the-moment eating happiness significantly varied by meal type consumed, F (4, 1039) = 11.75, p  < 0.001. Frequencies of meal type consumption ranged from snacks being the most frequently logged meal type ( n  = 332; see also Table  1 ) to afternoon tea being the least logged meal type ( n  = 27). Figure  2 illustrates the wide dispersion within as well as between different meal types. Afternoon tea ( M  = 82.41, SD  = 15.26), dinner ( M  = 81.47, SD  = 14.73), and snacks ( M  = 79.45, SD  = 14.94) showed eating happiness values above the grand mean, whereas breakfast ( M  = 74.28, SD  = 16.35) and lunch ( M  = 73.09, SD  = 18.99) were below the eating happiness mean. Comparisons between meal types showed that eating happiness for snacks was significantly higher than for lunch t (533) = −4.44, p  = 0.001, d  = −0.38 and breakfast, t (567) = −3.78, p  = 0.001, d  = −0.33. However, this was also true for dinner, which induced greater eating happiness than lunch t (446) = −5.48, p  < 0.001, d  = −0.50 and breakfast, t (480) = −4.90, p  < 0.001, d  = −0.46. Finally, eating happiness for afternoon tea was greater than for lunch t (228) = −2.83, p  = 0.047, d  = −0.50. All other comparisons did not reach significance, t  ≤ 2.49, p  ≥ 0.093.

Experienced eating happiness per meal type. Small dots represent single eating events, big circles indicate average eating happiness, and the horizontal line indicates the grand mean. Boxes indicate the middle 50% (interquartile range) and median (darker/lighter shade). The whiskers above and below represent 1.5 of the interquartile range.

Control Analyses

In order to test for a potential confounding effect between experienced eating happiness, food categories, and meal type, additional control analyses within meal types were conducted. Comparing experienced eating happiness for dinner and lunch suggested that dinner did not trigger a happiness spill-over effect specific to vegetables since the foods consumed at dinner were generally associated with greater happiness than those consumed at other eating occasions (Supplementary Table  S1 ). Moreover, the relative frequency of vegetables consumed at dinner (73%, n  = 180 out of 245) and at lunch were comparable (69%, n  = 140 out of 203), indicating that the observed happiness-vegetables link does not seem to be mainly a meal type confounding effect.

Since the present study focuses on “food effects” (Level 1) rather than “person effects” (Level 2), we analysed the data at the food item level. However, participants who were generally overall happier with their eating could have inflated the observed happiness scores for certain food categories. In order to account for person-level effects, happiness scores were person-mean centred and thereby adjusted for mean level differences in happiness. The person-mean centred happiness scores ( M cwc ) represent the difference between the individual’s average happiness score (across all single in-the-moment happiness scores per food category) and the single happiness scores of the individual within the respective food category. The centred scores indicate whether the single in-the-moment happiness score was above (indicated by positive values) or below (indicated by negative values) the individual person-mean. As Table  1 depicts, the control analyses with centred values yielded highly similar results. Vegetables were again associated on average with more happiness than other food categories (although people might differ in their general eating happiness). An additional conducted ANOVA with person-centred happiness values as dependent variables and food categories as independent variables provided also a highly similar pattern of results. Replicating the previously reported analysis, eating happiness differed significantly across all 14 food categories, F (13, 2129) = 1.94, p  = 0.023, and post hoc analysis did not yield significant differences in experienced eating happiness between food categories, p  ≥ 0.14. Moreover, fruits and vegetables were associated with high happiness values, and “unhealthy” food choices such as sweets did not differ in experienced happiness from “healthy” food choices such as fruits or vegetables. The only difference between the previous and control analysis was that vegetables ( M cwc  = 1.16, SD  = 15.14) gained slightly in importance for eating-related happiness, whereas fruits ( M cwc  = −0.65, SD  = 13.21), salty extras ( M cwc  = −0.07, SD  = 8.01), and pastries ( M cwc  = −2.39, SD  = 18.26) became slightly less important.

This study is the first, to our knowledge, that investigated in-the-moment experienced eating happiness in real time and real life using EMA based self-report and imagery covering the complete diversity of food intake. The present results add to and extend previous findings by suggesting that fruit and vegetable consumption has immediate beneficial psychological effects. Overall, of 14 different main food categories, vegetables consumption contributed the largest share to eating happiness measured across eight days. Thus, in addition to the investment in future well-being indicated by previous research 8 , “healthy” food choices seem to be an investment in the in-the moment well-being.

Importantly, although many cultures convey the belief that eating certain foods has a greater hedonic and mood boosting effect, the present results suggest that this might not reflect actual in-the-moment experiences accurately. Even though people often have a spontaneous “unhealthy = tasty” intuition 13 , thus indicating that a stronger happiness boosting effect of “unhealthy” food is to be expected, the induced eating happiness of sweets did not differ on average from “healthy” food choices such as fruits or vegetables. This was also true for other stereotypically “unhealthy” foods such as pastries and salty extras, which did not show the expected greater boosting effect on happiness. Moreover, analyses on the meal type level support this notion, since snacks, despite their overall positive effect, were not the most psychologically beneficial meal type, i.e., dinner had a comparable “happiness” signature to snacking. Taken together, “healthy choices” seem to be also “happy choices” and at least comparable to or even higher in their hedonic value as compared to stereotypical “unhealthy” food choices.

In general, eating happiness was high, which concurs with previous research from field studies with generally healthy participants. De Castro, Bellisle, and Dalix 22 examined weekly food diaries from 54 French subjects and found that most of the meals were rated as appealing. Also, the observed differences in average eating happiness for the 14 different food categories, albeit statistically significant, were comparable small. One could argue that this simply indicates that participants avoided selecting bad food 22 . Alternatively, this might suggest that the type of food or food categories are less decisive for experienced eating happiness than often assumed. This relates to recent findings in the field of comfort and emotional eating. Many people believe that specific types of food have greater comforting value. Also in research, the foods eaten as response to negative emotional strain, are typically characterised as being high-caloric because such foods are assumed to provide immediate psycho-physical benefits 18 . However, comparing different food types did not provide evidence for the notion that they differed in their provided comfort; rather, eating in general led to significant improvements in mood 19 . This is mirrored in the present findings. Comparing the eating happiness of “healthy” food choices such as fruits and vegetables to that of “unhealthy” food choices such as sweets shows remarkably similar patterns as, on average, they were associated with high eating happiness and their range of experiences ranged from very negative to very positive.

This raises the question of why the idea that we can eat indulgent food to compensate for life’s mishaps is so prevailing. In an innovative experimental study, Adriaanse, Prinsen, de Witt Huberts, de Ridder, and Evers 23 led participants believe that they overate. Those who characterised themselves as emotional eaters falsely attributed their over-consumption to negative emotions, demonstrating a “confabulation”-effect. This indicates that people might have restricted self-knowledge and that recalled eating episodes suffer from systematic recall biases 24 . Moreover, Boelsma, Brink, Stafleu, and Hendriks 25 examined postprandial subjective wellness and objective parameters (e.g., ghrelin, insulin, glucose) after standardised breakfast intakes and did not find direct correlations. This suggests that the impact of different food categories on wellness might not be directly related to biological effects but rather due to conditioning as food is often paired with other positive experienced situations (e.g., social interactions) or to placebo effects 18 . Moreover, experimental and field studies indicate that not only negative, but also positive, emotions trigger eating 15 , 26 . One may speculate that selective attention might contribute to the “myth” of comfort food 19 in that people attend to the consumption effect of “comfort” food in negative situation but neglect the effect in positive ones.

The present data also show that eating behaviour in the real world is a complex behaviour with many different aspects. People make more than 200 food decisions a day 27 which poses a great challenge for the measurement of eating behaviour. Studies often assess specific food categories such as fruit and vegetable consumption using Food Frequency Questionnaires, which has clear advantages in terms of cost-effectiveness. However, focusing on selective aspects of eating and food choices might provide only a selective part of the picture 15 , 17 , 22 . It is important to note that focusing solely on the “unhealthy” food choices such as sweets would have led to the conclusion that they have a high “indulgent” value. To be able to draw conclusions about which foods make people happy, the relation of different food categories needs to be considered. The more comprehensive view, considering the whole dietary behaviour across eating occasions, reveals that “healthy” food choices actually contributed the biggest share to the total experienced eating happiness. Thus, for a more comprehensive understanding of how eating behaviours are regulated, more complete and sensitive measures of the behaviour are necessary. Developments in mobile technologies hold great promise for feasible dietary assessment based on image-assisted methods 28 .

As fruits and vegetables evoked high in-the-moment happiness experiences, one could speculate that these cumulate and have spill-over effects on subsequent general well-being, including life satisfaction across time. Combing in-the-moment measures with longitudinal perspectives might be a promising avenue for future studies for understanding the pathways from eating certain food types to subjective well-being. In the literature different pathways are discussed, including physiological and biochemical aspects of specific food elements or nutrients 7 .

The present EMA based data also revealed that eating happiness varied greatly within the 14 food categories and meal types. As within food category variance represented more than two third of the total observed variance, happiness varied according to nutritional characteristics and meal type; however, a myriad of factors present in the natural environment can affect each and every meal. Thus, widening the “nourishment” perspective by including how much, when, where, how long, and with whom people eat might tell us more about experienced eating happiness. Again, mobile, in-the-moment assessment opens the possibility of assessing the behavioural signature of eating in real life. Moreover, individual factors such as eating motives, habitual eating styles, convenience, and social norms are likely to contribute to eating happiness variance 5 , 29 .

A key strength of this study is that it was the first to examine experienced eating happiness in non-clinical participants using EMA technology and imagery to assess food intake. Despite this strength, there are some limitations to this study that affect the interpretation of the results. In the present study, eating happiness was examined on a food based level. This neglects differences on the individual level and might be examined in future multilevel studies. Furthermore, as a main aim of this study was to assess real life eating behaviour, the “natural” observation level is the meal, the psychological/ecological unit of eating 30 , rather than food categories or nutrients. Therefore, we cannot exclude that specific food categories may have had a comparably higher impact on the experienced happiness of the whole meal. Sample size and therefore Type I and Type II error rates are of concern. Although the total number of observations was higher than in previous studies (see for example, Boushey et al . 28 for a review), the number of participants was small but comparable to previous studies in this field 20 , 31 , 32 , 33 . Small sample sizes can increase error rates because the number of persons is more decisive than the number of nested observations 34 . Specially, nested data can seriously increase Type I error rates, which is rather unlikely to be the case in the present study. Concerning Type II error rates, Aarts et al . 35 illustrated for lower ICCs that adding extra observations per participant also increases power, particularly in the lower observation range. Considering the ICC and the number of observations per participant, one could argue that the power in the present study is likely to be sufficient to render the observed null-differences meaningful. Finally, the predominately white and well-educated sample does limit the degree to which the results can be generalised to the wider community; these results warrant replication with a more representative sample.

Despite these limitations, we think that our study has implications for both theory and practice. The cumulative evidence of psychological benefits from healthy food choices might offer new perspectives for health promotion and public-policy programs 8 . Making people aware of the “healthy = happy” association supported by empirical evidence provides a distinct and novel perspective to the prevailing “unhealthy = tasty” folk intuition and could foster eating choices that increase both in-the-moment happiness and future well-being. Furthermore, the present research lends support to the advocated paradigm shift from “food as health” to “food as well-being” which entails a supporting and encouraging rather constraining and limiting view on eating behaviour.

The study conformed with the Declaration of Helsinki. All study protocols were approved by University of Konstanz’s Institutional Review Board and were conducted in accordance with guidelines and regulations. Upon arrival, all participants signed a written informed consent.

Participants

Thirty-eight participants (28 females: average age = 24.47, SD  = 5.88, range = 18–48 years) from the University of Konstanz assessed their eating behaviour in close to real time and in their natural environment using an event-based ambulatory assessment method (EMA). No participant dropped out or had to be excluded. Thirty-three participants were students, with 52.6% studying psychology. As compensation, participants could choose between taking part in a lottery (4 × 25€) or receiving course credits (2 hours).

Participants were recruited through leaflets distributed at the university and postings on Facebook groups. Prior to participation, all participants gave written informed consent. Participants were invited to the laboratory for individual introductory sessions. During this first session, participants installed the application movisensXS (version 0.8.4203) on their own smartphones and downloaded the study survey (movisensXS Library v4065). In addition, they completed a short baseline questionnaire, including demographic variables like age, gender, education, and eating principles. Participants were instructed to log every eating occasion immediately before eating by using the smartphone to indicate the type of meal, take pictures of the food, and describe its main components using a free input field. Fluid intake was not assessed. Participants were asked to record their food intake on eight consecutive days. After finishing the study, participants were invited back to the laboratory for individual final interviews.

Immediately before eating participants were asked to indicate the type of meal with the following five options: breakfast, lunch, afternoon tea, dinner, snack. In Germany, “afternoon tea” is called “Kaffee & Kuchen” which directly translates as “coffee & cake”. It is similar to the idea of a traditional “afternoon tea” meal in UK. Specifically, in Germany, people have “Kaffee & Kuchen” in the afternoon (between 4–5 pm) and typically coffee (or tea) is served with some cake or cookies. Dinner in Germany is a main meal with mainly savoury food.

After each meal, participants were asked to rate their meal on three dimensions. They rated (1) how much they enjoyed the meal, (2) how pleased they were with their meal, and (3) how tasty their meal was. Ratings were given on a scale of one to 100. For reliability analysis, Cronbach’s Alpha was calculated to assess the internal consistency of the three items. Overall Cronbach’s alpha was calculated with α = 0.87. In addition, the average of the 38 Cronbach’s alpha scores calculated at the person level also yielded a satisfactory value with α = 0.83 ( SD  = 0.24). Thirty-two of 38 participants showed a Cronbach’s alpha value above 0.70 (range = 0.42–0.97). An overall score of experienced happiness of eating was computed using the average of the three questions concerning the meals’ enjoyment, pleasure, and tastiness.

Analytical procedure

The food pictures and descriptions of their main components provided by the participants were subsequently coded by independent and trained raters. Following a standardised manual, additional components displayed in the picture were added to the description by the raters. All consumed foods were categorised into 14 different food categories (see Table  1 ) derived from the food classification system designed by the German Nutrition Society (DGE) and based on the existing food categories of the German Nutrient Database (Max Rubner Institut). Liquid intake and preparation method were not assessed. Therefore, fats and additional recipe ingredients were not included in further analyses, because they do not represent main elements of food intake. Further, salty extras were added to the categorisation.

No participant dropped out or had to be excluded due to high missing rates. Missing values were below 5% for all variables. The compliance rate at the meal level cannot be directly assessed since the numbers of meals and snacks can vary between as well as within persons (between days). As a rough compliance estimate, the numbers of meals that are expected from a “normative” perspective during the eight observation days can be used as a comparison standard (8 x breakfast, 8 × lunch, 8 × dinner = 24 meals). On average, the participants reported M  = 6.3 breakfasts ( SD  = 2.3), M  = 5.3 lunches ( SD  = 1.8), and M  = 6.5 dinners ( SD  = 2.0). In comparison to the “normative” expected 24 meals, these numbers indicate a good compliance (approx. 75%) with a tendency to miss six meals during the study period (approx. 25%). However, the “normative” expected 24 meals for the study period might be too high since participants might also have skipped meals (e.g. breakfast). Also, the present compliance rates are comparable to other studies. For example, Elliston et al . 36 recorded 3.3 meal/snack reports per day in an Australian adult sample and Casperson et al . 37 recorded 2.2 meal reports per day in a sample of adolescents. In the present study, on average, M  = 3.4 ( SD  = 1.35) meals or snacks were reported per day. These data indicate overall a satisfactory compliance rate and did not indicate selective reporting of certain food items.

To graphically visualise data, Tableau (version 10.1) was used and for further statistical analyses, IBM SPSS Statistics (version 24 for Windows).

Data availability

The dataset generated and analysed during the current study is available from the corresponding authors on reasonable request.

Cornil, Y. & Chandon, P. Pleasure as an ally of healthy eating? Contrasting visceral and epicurean eating pleasure and their association with portion size preferences and wellbeing. Appetite 104 , 52–59 (2016).

Article   PubMed   Google Scholar  

Mann, T. et al . Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychologist 62 , 220–233 (2007).

van Strien, T., Herman, C. P. & Verheijden, M. W. Dietary restraint and body mass change. A 3-year follow up study in a representative Dutch sample. Appetite 76 , 44–49 (2014).

Block, L. G. et al . From nutrients to nurturance: A conceptual introduction to food well-being. Journal of Public Policy & Marketing 30 , 5–13 (2011).

Article   Google Scholar  

Renner, B., Sproesser, G., Strohbach, S. & Schupp, H. T. Why we eat what we eat. The eating motivation survey (TEMS). Appetite 59 , 117–128 (2012).

Conner, T. S., Brookie, K. L., Carr, A. C., Mainvil, L. A. & Vissers, M. C. Let them eat fruit! The effect of fruit and vegetable consumption on psychological well-being in young adults: A randomized controlled trial. PloS one 12 , e0171206 (2017).

Article   PubMed   PubMed Central   Google Scholar  

Rooney, C., McKinley, M. C. & Woodside, J. V. The potential role of fruit and vegetables in aspects of psychological well-being: a review of the literature and future directions. Proceedings of the Nutrition Society 72 , 420–432 (2013).

Mujcic, R. & Oswald, A. J. Evolution of well-being and happiness after increases in consumption of fruit and vegetables. American Journal of Public Health 106 , 1504–1510 (2016).

White, B. A., Horwath, C. C. & Conner, T. S. Many apples a day keep the blues away – Daily experiences of negative and positive affect and food consumption in young adults. British Journal of Health Psychology 18 , 782–798 (2013).

Blanchflower, D. G., Oswald, A. J. & Stewart-Brown, S. Is psychological well-being linked to the consumption of fruit and vegetables? Social Indicators Research 114 , 785–801 (2013).

Grant, N., Wardle, J. & Steptoe, A. The relationship between life satisfaction and health behavior: A Cross-cultural analysis of young adults. International Journal of Behavioral Medicine 16 , 259–268 (2009).

Conner, T. S., Brookie, K. L., Richardson, A. C. & Polak, M. A. On carrots and curiosity: Eating fruit and vegetables is associated with greater flourishing in daily life. British Journal of Health Psychology 20 , 413–427 (2015).

Raghunathan, R., Naylor, R. W. & Hoyer, W. D. The unhealthy = tasty intuition and its effects on taste inferences, enjoyment, and choice of food products. Journal of Marketing 70 , 170–184 (2006).

Evers, C., Stok, F. M. & de Ridder, D. T. Feeding your feelings: Emotion regulation strategies and emotional eating. Personality and Social Psychology Bulletin 36 , 792–804 (2010).

Sproesser, G., Schupp, H. T. & Renner, B. The bright side of stress-induced eating: eating more when stressed but less when pleased. Psychological Science 25 , 58–65 (2013).

Wansink, B., Cheney, M. M. & Chan, N. Exploring comfort food preferences across age and gender. Physiology & Behavior 79 , 739–747 (2003).

Article   CAS   Google Scholar  

Taut, D., Renner, B. & Baban, A. Reappraise the situation but express your emotions: impact of emotion regulation strategies on ad libitum food intake. Frontiers in Psychology 3 , 359 (2012).

Tomiyama, J. A., Finch, L. E. & Cummings, J. R. Did that brownie do its job? Stress, eating, and the biobehavioral effects of comfort food. Emerging Trends in the Social and Behavioral Sciences: An Interdisciplinary, Searchable, and Linkable Resource (2015).

Wagner, H. S., Ahlstrom, B., Redden, J. P., Vickers, Z. & Mann, T. The myth of comfort food. Health Psychology 33 , 1552–1557 (2014).

Schüz, B., Bower, J. & Ferguson, S. G. Stimulus control and affect in dietary behaviours. An intensive longitudinal study. Appetite 87 , 310–317 (2015).

Shiffman, S. Conceptualizing analyses of ecological momentary assessment data. Nicotine & Tobacco Research 16 , S76–S87 (2014).

de Castro, J. M., Bellisle, F. & Dalix, A.-M. Palatability and intake relationships in free-living humans: measurement and characterization in the French. Physiology & Behavior 68 , 271–277 (2000).

Adriaanse, M. A., Prinsen, S., de Witt Huberts, J. C., de Ridder, D. T. & Evers, C. ‘I ate too much so I must have been sad’: Emotions as a confabulated reason for overeating. Appetite 103 , 318–323 (2016).

Robinson, E. Relationships between expected, online and remembered enjoyment for food products. Appetite 74 , 55–60 (2014).

Boelsma, E., Brink, E. J., Stafleu, A. & Hendriks, H. F. Measures of postprandial wellness after single intake of two protein–carbohydrate meals. Appetite 54 , 456–464 (2010).

Article   CAS   PubMed   Google Scholar  

Boh, B. et al . Indulgent thinking? Ecological momentary assessment of overweight and healthy-weight participants’ cognitions and emotions. Behaviour Research and Therapy 87 , 196–206 (2016).

Wansink, B. & Sobal, J. Mindless eating: The 200 daily food decisions we overlook. Environment and Behavior 39 , 106–123 (2007).

Boushey, C., Spoden, M., Zhu, F., Delp, E. & Kerr, D. New mobile methods for dietary assessment: review of image-assisted and image-based dietary assessment methods. Proceedings of the Nutrition Society , 1–12 (2016).

Stok, F. M. et al . The DONE framework: Creation, evaluation, and updating of an interdisciplinary, dynamic framework 2.0 of determinants of nutrition and eating. PLoS ONE 12 , e0171077 (2017).

Pliner, P. & Rozin, P. In Dimensions of the meal: The science, culture, business, and art of eating (ed H Meiselman) 19–46 (Aspen Publishers, 2000).

Inauen, J., Shrout, P. E., Bolger, N., Stadler, G. & Scholz, U. Mind the gap? Anintensive longitudinal study of between-person and within-person intention-behaviorrelations. Annals of Behavioral Medicine 50 , 516–522 (2016).

Zepeda, L. & Deal, D. Think before you eat: photographic food diaries asintervention tools to change dietary decision making and attitudes. InternationalJournal of Consumer Studies 32 , 692–698 (2008).

Stein, K. F. & Corte, C. M. Ecologic momentary assessment of eating‐disordered behaviors. International Journal of Eating Disorders 34 , 349–360 (2003).

Bolger, N., Stadler, G. & Laurenceau, J. P. Power analysis for intensive longitudinal studies in Handbook of research methods for studying daily life (ed . Mehl, M. R. & Conner, T. S.) 285–301 (New York: The Guilford Press, 2012).

Aarts, E., Verhage, M., Veenvliet, J. V., Dolan, C. V. & Van Der Sluis, S. A solutionto dependency: using multilevel analysis to accommodate nested data. Natureneuroscience 17 , 491–496 (2014).

Elliston, K. G., Ferguson, S. G., Schüz, N. & Schüz, B. Situational cues andmomentary food environment predict everyday eating behavior in adults withoverweight and obesity. Health Psychology 36 , 337–345 (2017).

Casperson, S. L. et al . A mobile phone food record app to digitally capture dietary intake for adolescents in afree-living environment: usability study. JMIR mHealth and uHealth 3 , e30 (2015).

Download references

Acknowledgements

This research was supported by the Federal Ministry of Education and Research within the project SmartAct (Grant 01EL1420A, granted to B.R. & H.S.). The funding source had no involvement in the study’s design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit this article for publication. We thank Gudrun Sproesser, Helge Giese, and Angela Whale for their valuable support.

Author information

Deborah R. Wahl and Karoline Villinger contributed equally to this work.

Authors and Affiliations

Department of Psychology, University of Konstanz, Konstanz, Germany

Deborah R. Wahl, Karoline Villinger, Laura M. König, Katrin Ziesemer, Harald T. Schupp & Britta Renner

You can also search for this author in PubMed   Google Scholar

Contributions

B.R. & H.S. developed the study concept. All authors participated in the generation of the study design. D.W., K.V., L.K. & K.Z. conducted the study, including participant recruitment and data collection, under the supervision of B.R. & H.S.; D.W. & K.V. conducted data analyses. D.W. & K.V. prepared the first manuscript draft, and B.R. & H.S. provided critical revisions. All authors approved the final version of the manuscript for submission.

Corresponding authors

Correspondence to Deborah R. Wahl or Britta Renner .

Ethics declarations

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Supplementary table s1, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Wahl, D.R., Villinger, K., König, L.M. et al. Healthy food choices are happy food choices: Evidence from a real life sample using smartphone based assessments. Sci Rep 7 , 17069 (2017). https://doi.org/10.1038/s41598-017-17262-9

Download citation

Received : 05 June 2017

Accepted : 23 November 2017

Published : 06 December 2017

DOI : https://doi.org/10.1038/s41598-017-17262-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

Financial satisfaction, food security, and shared meals are foundations of happiness among older persons in thailand.

• Sirinya Phulkerd
• Rossarin Soottipong Gray
• Sasinee Thapsuwan

BMC Geriatrics (2023)

Enrichment and Conflict Between Work and Health Behaviors: New Scales for Assessing How Work Relates to Physical Exercise and Healthy Eating

• Sabine Sonnentag
• Maria U. Kottwitz
• Jette Völker

Occupational Health Science (2023)

The value of Bayesian predictive projection for variable selection: an example of selecting lifestyle predictors of young adult well-being

• A. Bartonicek
• S. R. Wickham
• T. S. Conner

BMC Public Health (2021)

Smartphone-Based Ecological Momentary Assessment of Well-Being: A Systematic Review and Recommendations for Future Studies

• Lianne P. de Vries
• Bart M. L. Baselmans
• Meike Bartels

Journal of Happiness Studies (2021)

Exploration of nutritional, antioxidative, antibacterial and anticancer status of Russula alatoreticula: towards valorization of a traditionally preferred unique myco-food

• Somanjana Khatua
• Surashree Sen Gupta
• Krishnendu Acharya

Journal of Food Science and Technology (2021)

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

• Search Menu
• Advance Articles
• Editor's Choice
• Author Guidelines
• Submission Site
• Open Access
• About Health Education Research
• Editorial Board
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Introduction.

• < Previous

Young people and healthy eating: a systematic review of research on barriers and facilitators

• Article contents
• Figures & tables
• Supplementary Data

J Shepherd, A Harden, R Rees, G Brunton, J Garcia, S Oliver, A Oakley, Young people and healthy eating: a systematic review of research on barriers and facilitators, Health Education Research , Volume 21, Issue 2, 2006, Pages 239–257, https://doi.org/10.1093/her/cyh060

• Permissions Icon Permissions

A systematic review was conducted to examine the barriers to, and facilitators of, healthy eating among young people (11–16 years). The review focused on the wider determinants of health, examining community- and society-level interventions. Seven outcome evaluations and eight studies of young people's views were included. The effectiveness of the interventions was mixed, with improvements in knowledge and increases in healthy eating but differences according to gender. Barriers to healthy eating included poor school meal provision and ease of access to, relative cheapness of and personal taste preferences for fast food. Facilitators included support from family, wider availability of healthy foods, desire to look after one's appearance and will-power. Friends and teachers were generally not a common source of information. Some of the barriers and facilitators identified by young people had been addressed by soundly evaluated effective interventions, but significant gaps were identified where no evaluated interventions appear to have been published (e.g. better labelling of food products), or where there were no methodologically sound evaluations. Rigorous evaluation is required particularly to assess the effectiveness of increasing the availability of affordable healthy food in the public and private spaces occupied by young people.

Healthy eating contributes to an overall sense of well-being, and is a cornerstone in the prevention of a number of conditions, including heart disease, diabetes, high blood pressure, stroke, cancer, dental caries and asthma. For children and young people, healthy eating is particularly important for healthy growth and cognitive development. Eating behaviours adopted during this period are likely to be maintained into adulthood, underscoring the importance of encouraging healthy eating as early as possible [ 1 ]. Guidelines recommend consumption of at least five portions of fruit and vegetables a day, reduced intakes of saturated fat and salt and increased consumption of complex carbohydrates [ 2, 3 ]. Yet average consumption of fruit and vegetables in the UK is only about three portions a day [ 4 ]. A survey of young people aged 11–16 years found that nearly one in five did not eat breakfast before going to school [ 5 ]. Recent figures also show alarming numbers of obese and overweight children and young people [ 6 ]. Discussion about how to tackle the ‘epidemic’ of obesity is currently high on the health policy agenda [ 7 ], and effective health promotion remains a key strategy [ 8–10 ].

Evidence for the effectiveness of interventions is therefore needed to support policy and practice. The aim of this paper is to report a systematic review of the literature on young people and healthy eating. The objectives were

(i) to undertake a ‘systematic mapping’ of research on the barriers to, and facilitators of, healthy eating among young people, especially those from socially excluded groups (e.g. low-income, ethnic minority—in accordance with government health policy);

(ii) to prioritize a subset of studies to systematically review ‘in-depth’;

(iii) to ‘synthesize’ what is known from these studies about the barriers to, and facilitators of, healthy eating with young people, and how these can be addressed and

(iv) to identify gaps in existing research evidence.

General approach

This study followed standard procedures for a systematic review [ 11, 12 ]. It also sought to develop a novel approach in three key areas.

First, it adopted a conceptual framework of ‘barriers’ to and ‘facilitators’ of health. Research findings about the barriers to, and facilitators of, healthy eating among young people can help in the development of potentially effective intervention strategies. Interventions can aim to modify or remove barriers and use or build upon existing facilitators. This framework has been successfully applied in other related systematic reviews in the area of healthy eating in children [ 13 ], physical activity with children [ 14 ] and young people [ 15 ] and mental health with young people [16; S. Oliver, A. Harden, R. Rees, J. Shepherd, G. Brunton and A. Oakley, manuscript in preparation].

Second, the review was carried out in two stages: a systematic search for, and mapping of, literature on healthy eating with young people, followed by an in-depth systematic review of the quality and findings of a subset of these studies. The rationale for a two-stage review to ensure the review was as relevant as possible to users. By mapping a broad area of evidence, the key characteristics of the extant literature can be identified and discussed with review users, with the aim of prioritizing the most relevant research areas for systematic in-depth analysis [ 17, 18 ].

Third, the review utilized a ‘mixed methods’ triangulatory approach. Data from effectiveness studies (‘outcome evaluations’, primarily quantitative data) were combined with data from studies which described young people's views of factors influencing their healthy eating in negative or positive ways (‘views’ studies, primarily qualitative). We also sought data on young people's perceptions of interventions when these had been collected alongside outcomes data in outcome evaluations. However, the main source of young people's views was surveys or interview-based studies that were conducted independently of intervention evaluation (‘non-intervention’ research). The purpose was to enable us to ascertain not just whether interventions are effective, but whether they address issues important to young people, using their views as a marker of appropriateness. Few systematic reviews have attempted to synthesize evidence from both intervention and non-intervention research: most have been restricted to outcome evaluations. This study therefore represents one of the few attempts that have been made to date to integrate different study designs into systematic reviews of effectiveness [ 19–22 ].

Literature searching

A highly sensitive search strategy was developed to locate potentially relevant studies. A wide range of terms for healthy eating (e.g. nutrition, food preferences, feeding behaviour, diets and health food) were combined with health promotion terms or general or specific terms for determinants of health or ill-health (e.g. health promotion, behaviour modification, at-risk-populations, sociocultural factors and poverty) and with terms for young people (e.g. adolescent, teenager, young adult and youth). A number of electronic bibliographic databases were searched, including Medline, EMBASE, The Cochrane Library, PsycINFO, ERIC, Social Science Citation Index, CINAHL, BiblioMap and HealthPromis. The searches covered the full range of publication years available in each database up to 2001 (when the review was completed).

Full reports of potentially relevant studies identified from the literature search were obtained and classified (e.g. in terms of specific topic area, context, characteristics of young people, research design and methodological attributes).

Inclusion screening

Inclusion criteria were developed and applied to each study. The first round of screening was to identify studies to populate the map. To be included, a study had to (i) focus on healthy eating; (ii) include young people aged 11–16 years; (iii) be about the promotion of healthy eating, and/or the barriers to, or facilitators of, healthy eating; (iv) be a relevant study type: (a) an outcome evaluation or (b) a non-intervention study (e.g. cohort or case control studies, or interview studies) conducted in the UK only (to maximize relevance to UK policy and practice) and (v) be published in the English language.

The results of the map, which are reported in greater detail elsewhere [ 23 ], were used to prioritize a subset of policy relevant studies for the in-depth systematic review.

A second round of inclusion screening was performed. As before, all studies had to have healthy eating as their main focus and include young people aged 11–16 years. In addition, outcome evaluations had toFor a non-intervention study to be included it had to

(i) use a comparison or control group; report pre- and post-intervention data and, if a non-randomized trial, equivalent on sociodemographic characteristics and pre-intervention outcome variables (demonstrating their ‘potential soundness’ in advance of further quality assessment);

(ii) report an intervention that aims to make a change at the community or society level and

(iii) measure behavioural and/or physical health status outcomes.

(i) examine young people's attitudes, opinions, beliefs, feelings, understanding or experiences about healthy eating (rather than solely examine health status, behaviour or factual knowledge);

(ii) access views about one or more of the following: young people's definitions of and/or ideas about healthy eating, factors influencing their own or other young people's healthy eating and whether and how young people think healthy eating can be promoted and

(iii) privilege young people's views—presenting views directly as data that are valuable and interesting in themselves, rather than only as a route to generating variables to be tested in a predictive or causal model.

Non-intervention studies published before 1990 were excluded in order to maximize the relevance of the review findings to current policy issues.

Data extraction and quality assessment

All studies meeting inclusion criteria underwent data extraction and quality assessment, using a standardized framework [ 24 ]. Data for each study were entered independently by two researchers into a specialized computer database [ 25 ] (the full and final data extraction and quality assessment judgement for each study in the in-depth systematic review can be viewed on the Internet by visiting http://eppi.ioe.ac.uk ).

Outcome evaluations were considered methodologically ‘sound’ if they reported:Only studies meeting these criteria were used to draw conclusions about effectiveness. The results of the studies which did not meet these quality criteria were judged unclear.

(i) a control or comparison group equivalent to the intervention group on sociodemographic characteristics and pre-intervention outcome variables.

(ii) pre-intervention data for all individuals or groups recruited into the evaluation;

(iii) post-intervention data for all individuals or groups recruited into the evaluation and

(iv) on all outcomes, as described in the aims of the intervention.

Non-intervention studies were assessed according to a total of seven criteria (common to sets of criteria proposed by four research groups for qualitative research [ 26–29 ]):

(i) an explicit account of theoretical framework and/or the inclusion of a literature review which outlined a rationale for the intervention;

(ii) clearly stated aims and objectives;

(iii) a clear description of context which includes detail on factors important for interpreting the results;

(iv) a clear description of the sample;

(v) a clear description of methodology, including systematic data collection methods;

(vi) analysis of the data by more than one researcher and

(vii) the inclusion of sufficient original data to mediate between data and interpretation.

Data synthesis

Three types of analyses were performed: (i) narrative synthesis of outcome evaluations, (ii) narrative synthesis of non-intervention studies and (iii) synthesis of intervention and non-intervention studies together.

For the last of these a matrix was constructed which laid out the barriers and facilitators identified by young people alongside descriptions of the interventions included in the in-depth systematic review of outcome evaluations. The matrix was stratified by four analytical themes to characterize the levels at which the barriers and facilitators appeared to be operating: the school, family and friends, the self and practical and material resources. This methodology is described further elsewhere [ 20, 22, 30 ].

From the matrix it is possible to see:

(i) where barriers have been modified and/or facilitators built upon by soundly evaluated interventions, and ‘promising’ interventions which need further, more rigorous, evaluation (matches) and

(ii) where barriers have not been modified and facilitators not built upon by any evaluated intervention, necessitating the development and rigorous evaluation of new interventions (gaps).

Figure 1 outlines the number of studies included at various stages of the review. Of the total of 7048 reports identified, 135 reports (describing 116 studies) met the first round of screening and were included in the descriptive map. The results of the map are reported in detail in a separate publication—see Shepherd et al. [ 23 ] (the report can be downloaded free of charge via http://eppi.ioe.ac.uk ). A subset of 22 outcome evaluations and 8 studies of young people's views met the criteria for the in-depth systematic review.

The review process.

Outcome evaluations

Of the 22 outcome evaluations, most were conducted in the United States ( n = 16) [ 31–45 ], two in Finland [ 46, 47 ], and one each in the UK [ 48 ], Norway [ 49 ], Denmark [ 50 ] and Australia [ 51 ]. In addition to the main focus on promoting healthy eating, they also addressed other related issues including cardiovascular disease in general, tobacco use, accidents, obesity, alcohol and illicit drug use. Most were based in primary or secondary school settings and were delivered by teachers. Interventions varied considerably in content. While many involved some form of information provision, over half ( n = 13) involved attempts to make structural changes to young people's physical environments; half ( n = 11) trained parents in or about nutrition, seven developed health-screening resources, five provided feedback to young people on biological measures and their behavioural risk status and three aimed to provide social support systems for young people or others in the community. Social learning theory was the most common theoretical framework used to develop these interventions. Only a minority of studies included young people who could be considered socially excluded ( n = 6), primarily young people from ethnic minorities (e.g. African Americans and Hispanics).

Following detailed data extraction and critical appraisal, only seven of the 22 outcome evaluations were judged to be methodologically sound. For the remainder of this section we only report the results of these seven. Four of the seven were from the United States, with one each from the UK, Norway and Finland. The studies varied in the comprehensiveness of their reporting of the characteristics of the young people (e.g. sociodemographic/economic status). Most were White, living in middle class urban areas. All attended secondary schools. Table I details the interventions in these sound studies. Generally, they were multicomponent interventions in which classroom activities were complemented with school-wide initiatives and activities in the home. All but one of the seven sound evaluations included and an integral evaluation of the intervention processes. Some studies report results according to demographic characteristics such as age and gender.

Soundly evaluated outcome evaluations: study characteristics (n = 7)

RCT = Randomized Controlled Trial; CT = controlled trial (no randomization); PE = process evaluation.

Separate evaluations of the same intervention in two populations in New York (the Bronx and Westchester County).

The UK-based intervention was an award scheme (the ‘Wessex Healthy Schools Award’) that sought to make health-promoting changes in school ethos, organizational functioning and curriculum [ 48 ]. Changes made in schools included the introduction of health education curricula, as well as the setting of targets in key health promotion areas (including healthy eating). Knowledge levels, which were high at baseline, changed little over the course of the intervention. Intervention schools performed better in terms of healthy food choices (on audit scores). The impact on measures of healthy eating such as choosing healthy snacks varied according to age and sex. The intervention only appeared possibly to be effective for young women in Year 11 (aged 15–16 years) on these measures (statistical significance not reported).

The ‘Know Your Body’ intervention, a cardiovascular risk reduction programme, was evaluated in two separate studies in two demographically different areas of New York (the Bronx and Westchester County) [ 45 ]. Lasting for 5 years it comprised teacher-led classroom education, parental involvement activities and risk factor examination in elementary and junior high schools. In the Bronx evaluation, statistically significant increases in knowledge were reported, but favourable changes in cholesterol levels and dietary fat were not significant. In the Westchester County evaluation, we judged the effects to be unclear due to shortcomings in methods reported.

A second US-based study, the 3-year ‘Gimme 5’ programme [ 40 ], focused on increasing consumption of fruits and vegetables through a school-wide media campaign, complemented by classroom activities, parental involvement and changes to nutritional content of school meals. The intervention was effective at increasing knowledge (particularly among young women). Effects were measured in terms of changes in knowledge scores between baseline and two follow-up periods. Differences between the intervention and comparison group were significant at both follow-ups. There was a significant increase in consumption of fruit and vegetables in the intervention group, although this was not sustained.

In the third US study, the ‘Slice of Life’ intervention, peer leaders taught 10 sessions covering the benefits of fitness, healthy diets and issues concerning weight control [ 41 ]. School functioning was also addressed by student recommendations to school administrators. For young women, there were statistically significant differences between intervention and comparison groups on healthy eating scores, salt consumption scores, making healthy food choices, knowledge of healthy food, reading food labels for salt and fat content and awareness of healthy eating. However, among young men differences were only significant for salt and knowledge scores. The process evaluation suggested that having peers deliver training was acceptable to students and the peer-trainers themselves.

A Norwegian study evaluated a similar intervention to the ‘Slice of Life’ programme, employing peer educators to lead classroom activities and small group discussions on nutrition [ 49 ]. Students also analysed the availability of healthy food in their social and home environment and used a computer program to analyse the nutritional status of foods. There were significant intervention effects for reported healthy eating behaviour (but not maintained by young men) and for knowledge (not young women).

The second ‘North Karelia Youth Study’ in Finland featured classroom educational activities, a community media campaign, health-screening activities, changes to school meals and a health education initiative in the parents' workplace [ 47 ]. It was judged to be effective for healthy eating behaviour, reducing systolic blood pressure and modifying fat content of school meals, but less so for reducing cholesterol levels and diastolic blood pressure.

The evidence from the well-designed evaluations of the effectiveness of healthy eating initiatives is therefore mixed. Interventions tend to be more effective among young women than young men.

Young people's views

Table II describes the key characteristics of the eight studies of young people's views. The most consistently reported characteristics of the young people were age, gender and social class. Socioeconomic status was mixed, and in the two studies reporting ethnicity, the young people participating were predominantly White. Most studies collected data in mainstream schools and may therefore not be applicable to young people who infrequently or never attend school.

Characteristics of young people's views studies (n = 8)

All eight studies asked young people about their perceptions of, or attitudes towards, healthy eating, while none explicitly asked them what prevents them from eating healthily. Only two studies asked them what they think helps them to eat healthy foods, and only one asked for their ideas about what could or should be done to promote nutrition.

Young people tended to talk about food in terms of what they liked and disliked, rather than what was healthy/unhealthy. Healthy foods were predominantly associated with parents/adults and the home, while ‘fast food’ was associated with pleasure, friendship and social environments. Links were also made between food and appearance, with fast food perceived as having negative consequences on weight and facial appearance (and therefore a rationale for eating healthier foods). Attitudes towards healthy eating were generally positive, and the importance of a healthy diet was acknowledged. However, personal preferences for fast foods on grounds of taste tended to dominate food choice. Young people particularly valued the ability to choose what they eat.

Despite not being explicitly asked about barriers, young people discussed factors inhibiting their ability to eat healthily. These included poor availability of healthy meals at school, healthy foods sometimes being expensive and wide availability of, and personal preferences for, fast foods. Things that young people thought should be done to facilitate healthy eating included reducing the price of healthy snacks and better availability of healthy foods at school, at take-aways and in vending machines. Will-power and encouragement from the family were commonly mentioned support mechanisms for healthy eating, while teachers and peers were the least commonly cited sources of information on nutrition. Ideas for promoting healthy eating included the provision of information on nutritional content of school meals (mentioned by young women particularly) and better food labelling in general.

Table III shows the synthesis matrix which juxtaposes barriers and facilitators alongside results of outcome evaluations. There were some matches but also significant gaps between, on the one hand, what young people say are barriers to healthy eating, what helps them and what could or should be done and, on the other, soundly evaluated interventions that address these issues.

Synthesis matrix

Key to young people's views studies: Y1 , Dennison and Shepherd [ 56 ]; Y2 , Harris [ 57 ]; Y3 , McDougall [ 58 ]; Y4 , Miles and Eid [ 59 ]; Y5 , Roberts et al. [ 60 ]; Y6 , Ross [ 61 ]; Y7 , Watt and Sheiham [ 62 ]; Y8 , Watt and Sheiham [ 63 ]. Key to intervention studies: OE1 , Baranowski et al. [ 31 ]; OE2 , Bush et al. [ 32 ]; OE3 , Coates et al. [ 33 ]; OE4 , Ellison et al. [ 34 ]; OE5 , Flores [ 36 ]; OE6 , Fitzgibbon et al. [ 35 ]; OE7 , Hopper et al. [ 64 ]; OE8 , Holund [ 50 ]; OE9 , Kelder et al. [ 38 ]; OE10 , Klepp and Wilhelmsen [ 49 ]; OE11 , Moon et al. [ 48 ]; OE12 , Nader et al. [ 39 ]; OE13 , Nicklas et al. [ 40 ]; OE14 , Perry et al. [ 41 ]; OE15 , Petchers et al. [ 42 ]; OE16 , Schinke et al. [ 43 ]; OE17 , Wagner et al. [ 44 ]; OE18 , Vandongen et al. [ 51 ]; OE19 , Vartiainen et al. [ 46 ]; OE20 , Vartiainen et al. [ 47 ]; OE21 , Walter I [ 45 ]; OE22 , Walter II [ 45 ]. OE10, OE11, OE13, OE14, OE20, OE21 and OE22 denote a sound outcome evaluation. OE21 and OE22 are separate evaluations of the same intervention. Due to methodological limitations, we have judged the effects of OE22 to be unclear. Y1 and Y2 do not appear in the synthesis matrix as they did not explicitly report barriers or facilitators, and it was not possible for us to infer potential barriers or facilitators. However, these two studies did report what young people understood by healthy eating, their perceptions, and their views and opinions on the importance of eating a healthy diet. OE2, OE12, OE16 and OE17 do not appear in the synthesis matrix as they did not address any of the barriers or facilitators.

In terms of the school environment, most of the barriers identified by young people appear to have been addressed. At least two sound outcome evaluations demonstrated the effectiveness of increasing the availability of healthy foods in the school canteen [ 40, 47 ]. Furthermore, despite the low status of teachers and peers as sources of nutritional information, several soundly evaluated studies showed that they can be employed effectively to deliver nutrition interventions.

Young people associated parents and the home environment with healthy eating, and half of the sound outcome evaluations involved parents in the education of young people about nutrition. However, problems were sometimes experienced in securing parental attendance at intervention activities (e.g. seminar evenings). Why friends were not a common source of information about good nutrition is not clear. However, if peer pressure to eat unhealthy foods is a likely explanation, then it has been addressed by the peer-led interventions in three sound outcome evaluations (generally effectively) [ 41, 47, 49 ] and two outcome evaluations which did not meet the quality criteria (effectiveness unclear) [ 33, 50 ].

The fact that young people choose fast foods on grounds of taste has generally not been addressed by interventions, apart from one soundly evaluated effective intervention which included taste testings of fruit and vegetables [ 40 ]. Young people's concern over their appearance (which could be interpreted as both a barrier and a facilitator) has only been addressed in one of the sound outcome evaluations (which revealed an effective intervention) [ 41 ]. Will-power to eat healthy foods has only been examined in one outcome evaluation in the in-depth systematic review (judged to be sound and effective) (Walter I—Bronx evaluation) [ 45 ]. The need for information on nutrition was addressed by the majority of interventions in the in-depth systematic review. However, no studies were found which evaluated attempts to increase the nutritional content of school meals.

Barriers and facilitators relating to young people's practical and material resources were generally not addressed by interventions, soundly evaluated or otherwise. No studies were found which examined the effectiveness of interventions to lower the price of healthy foods. However, one soundly evaluated intervention was partially effective in increasing the availability of healthy snacks in community youth groups (Walter I—Bronx evaluation) [ 45 ]. At best, interventions have attempted to raise young people's awareness of environmental constraints on eating healthily, or encouraged them to lobby for increased availability of nutritious foods (in the case of the latter without reporting whether any changes have been effected as a result).

This review has systematically identified some of the barriers to, and facilitators of, healthy eating with young people, and illustrated to what extent they have been addressed by soundly evaluated effective interventions.

The evidence for effectiveness is mixed. Increases in knowledge of nutrition (measured in all but one study) were not consistent across studies, and changes in clinical risk factors (measured in two studies) varied, with one study detecting reductions in cholesterol and another detecting no change. Increases in reported healthy eating behaviour were observed, but mostly among young women revealing a distinct gender pattern in the findings. This was the case in four of the seven outcome evaluations (in which analysis was stratified by gender). The authors of one of the studies suggest that emphasis of the intervention on healthy weight management was more likely to appeal to young women. It was proposed that interventions directed at young men should stress the benefits of nutrition on strength, physical endurance and physical activity, particularly to appeal to those who exercise and play sports. Furthermore, age was a significant factor in determining effectiveness in one study [ 48 ]. Impact was greatest on young people in the 15- to 16-year age range (particularly for young women) in comparison with those aged 12–13 years, suggesting that dietary influences may vary with age. Tailoring the intervention to take account of age and gender is therefore crucial to ensure that interventions are as relevant and meaningful as possible.

Other systematic reviews of interventions to promote healthy eating (which included some of the studies with young people fitting the age range of this review) also show mixed results [ 52–55 ]. The findings of these reviews, while not being directly comparable in terms of conceptual framework, methods and age group, seem to offer some support for the findings of this review. The main message is that while there is some evidence to suggest effectiveness, the evidence base is limited. We have identified no comparable systematic reviews in this area.

Unlike other reviews, however, this study adopted a wider perspective through inclusion of studies of young people's views as well as effectiveness studies. A number of barriers to healthy eating were identified, including poor availability of healthy foods at school and in young people's social spaces, teachers and friends not always being a source of information/support for healthy eating, personal preferences for fast foods and healthy foods generally being expensive. Facilitating factors included information about nutritional content of foods/better labelling, parents and family members being supportive; healthy eating to improve or maintain one's personal appearance, will-power and better availability/lower pricing of healthy snacks.

Juxtaposing barriers and facilitators alongside effectiveness studies allowed us to examine the extent to which the needs of young people had been adequately addressed by evaluated interventions. To some extent they had. Most of the barriers and facilitators that related to the school and relationships with family and friends appear to have been taken into account by soundly evaluated interventions, although, as mentioned, their effectiveness varied. Many of the gaps tended to be in relation to young people as individuals (although our prioritization of interventions at the level of the community and society may have resulted in the exclusion of some of these interventions) and the wider determinants of health (‘practical and material resources’). Despite a wide search, we found few evaluations of strategies to improve nutritional labelling on foods particularly in schools or to increase the availability of affordable healthy foods particularly in settings where young people socialize. A number of initiatives are currently in place which may fill these gaps, but their effectiveness does not appear to have been reported yet. It is therefore crucial for any such schemes to be thoroughly evaluated and disseminated, at which point an updated systematic review would be timely.

This review is also constrained by the fact that its conclusions can only be supported by a relatively small proportion of the extant literature. Only seven of the 22 outcome evaluations identified were considered to be methodologically sound. As illustrated in Table III , a number of the remaining 15 interventions appear to modify barriers/build on facilitators but their results can only be judged unclear until more rigorous evaluation of these ‘promising’ interventions has been reported.

Finally, it is important to acknowledge that the majority of the outcome evaluations were conducted in the United States, and by virtue of the inclusion criteria, all the young people's views studies were UK based. The literature therefore might not be generalizable to other countries, where sociocultural values and socioeconomic circumstances may be quite different. Further evidence synthesis is needed on barriers to, and facilitators of, healthy eating and nutrition worldwide, particularly in developing countries.

The aim of this study was to survey what is known about the barriers to, and facilitators of, healthy eating among young people with a view to drawing out the implications for policy and practice. The review has mapped and quality screened the extant research in this area, and brought together the findings from evaluations of interventions aiming to promote healthy eating and studies which have elicited young people's views.

There has been much research activity in this area, yet it is disappointing that so few evaluation studies were methodologically strong enough to enable us to draw conclusions about effectiveness. There is some evidence to suggest that multicomponent school-based interventions can be effective, although effects tended to vary according to age and gender. Tailoring intervention messages accordingly is a promising approach which should therefore be evaluated. A key theme was the value young people place on choice and autonomy in relation to food. Increasing the provision and range of healthy, affordable snacks and meals in schools and social spaces will enable them to exercise their choice of healthier, tasty options.

We have identified that several barriers to, and facilitators of, healthy eating in young people have received little attention in evaluation research. Further work is needed to develop and evaluate interventions which modify or remove these barriers, and build on these facilitators. Further qualitative studies are also needed so that we can continue to listen to the views of young people. This is crucial if we are to develop and test meaningful, appropriate and effective health promotion strategies.

We would like to thank Chris Bonell and Dina Kiwan for undertaking data extraction. We would also like to acknowledge the invaluable help of Amanda Nicholas, James Thomas, Elaine Hogan, Sue Bowdler and Salma Master for support and helpful advice. The Department of Health, England, funds a specific programme of health promotion work at the EPPI-Centre. The views expressed in the report are those of the authors and not necessarily those of the Department of Health.

Google Scholar

Google Preview

• healthy diet

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1465-3648
• Print ISSN 0268-1153
• Copyright © 2024 Oxford University Press
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Fruits, vegetables, and health: A comprehensive narrative, umbrella review of the science and recommendations for enhanced public policy to improve intake

Affiliations.

• 1 Department of Nutrition and Food Studies, George Mason University, Fairfax, Virginia, USA.
• 2 Think Healthy Group, Inc., Washington, DC, USA.
• 3 Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA.
• 4 Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA.
• 5 Center for Nutrition Research, Institute for Food Safety and Health, Illinois Institute of Technology, Bedford Park, Illinois, USA.
• 6 Biofortis Research, Merieux NutriSciences, Addison, Illinois, USA.
• 7 Department of Human Nutrition, University of Alabama, Tuscaloosa, Alabama, USA.
• 8 Department of Epidemiology, University of Washington, Seattle, Washington, USA.
• 9 School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California, USA.
• 10 Bone and Body Composition Laboratory, College of Family and Consumer Sciences, University of Georgia, Athens, Georgia, USA.
• 11 College of Education and Human Ecology, The Ohio State University, Columbus, Ohio, USA.
• 12 Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA.
• 13 D&V Systematic Evidence Review, Bronx, New York, USA.
• PMID: 31267783
• DOI: 10.1080/10408398.2019.1632258

Fruit and vegetables (F&V) have been a cornerstone of healthy dietary recommendations; the 2015-2020 U.S. Dietary Guidelines for Americans recommend that F&V constitute one-half of the plate at each meal. F&V include a diverse collection of plant foods that vary in their energy, nutrient, and dietary bioactive contents. F&V have potential health-promoting effects beyond providing basic nutrition needs in humans, including their role in reducing inflammation and their potential preventive effects on various chronic disease states leading to decreases in years lost due to premature mortality and years lived with disability/morbidity. Current global intakes of F&V are well below recommendations. Given the importance of F&V for health, public policies that promote dietary interventions to help increase F&V intake are warranted. This externally commissioned expert comprehensive narrative, umbrella review summarizes up-to-date clinical and observational evidence on current intakes of F&V, discusses the available evidence on the potential health benefits of F&V, and offers implementation strategies to help ensure that public health messaging is reflective of current science. This review demonstrates that F&V provide benefits beyond helping to achieve basic nutrient requirements in humans. The scientific evidence for providing public health recommendations to increase F&V consumption for prevention of disease is strong. Current evidence suggests that F&V have the strongest effects in relation to prevention of CVDs, noting a nonlinear threshold effect of 800 g per day (i.e., about 5 servings a day). A growing body of clinical evidence (mostly small RCTs) demonstrates effects of specific F&V on certain chronic disease states; however, more research on the role of individual F&V for specific disease prevention strategies is still needed in many areas. Data from the systematic reviews and mostly observational studies cited in this report also support intake of certain types of F&V, particularly cruciferous vegetables, dark-green leafy vegetables, citrus fruits, and dark-colored berries, which have superior effects on biomarkers, surrogate endpoints, and outcomes of chronic disease.

Keywords: Fruit; health; nutrition; produce; vegetable.

Publication types

• Diet, Healthy*
• Nutrition Policy*
• Observational Studies as Topic
• Systematic Reviews as Topic
• United States
• Vegetables*

• Reference Manager
• Simple TEXT file

People also looked at

Original research article, students' knowledge of healthy food and their actual eating habits: a case study on the university of granada (spain).

• Department of Sociology, Faculty of Political Sciences and Sociology, University of Granada, Granada, Spain

This article focuses on an analysis of the discourses produced during 34 semi-structured interviews (17 men and 17 women) conducted at the University of Granada (Spain) with undergraduate, Master, and Ph.D. students. The interviewees were between 20 and 44 years old. It was observed that the fact of having a high educational level did not prevent University students from eating unhealthily. There is a gap between the fact that 97.1% of 34 students interviewed (that is, 33 of them) know what healthy food is and their self-perception about whether or not what they are eating is healthy, since in 41.2% of them said self-perception is negative. This gap narrows as the interviewees' age increases and their socio-economic and vital situation is stabilizing which favors that their eating habits become more regular and healthier. Thus, all the interviewees aged 27 or over self-perceived that they were eating healthily. But the biggest differences are those that have to do with the gender of interviewees. Thus, while 23.5% of women interviewed perceived that they were not eating healthy, 76.5% of them felt that they were eating healthy. However, among the men interviewed, these percentages were somehow reversed, in such a way that 58.8% of them believed that they were not eating healthy, compared to 41.2% of them who indicated that they were eating healthy. Therefore, the investigation revealed that women tend to have the best chances of assuming healthy eating habits. Male students living outside the family home or without female partners exhibited greater feeding problems, while females living under similar conditions tended to display healthier eating habits. This is related to the fact that women have traditionally been in charge of acquiring and preparing food. So, women's food education has not been restricted to the mere transmission to them of knowledge about what healthy food is, but from their childhood they were food trained through their active involvement in practical experiences. Obviously, the solution proposed to this male disadvantage is to not perpetuate macho gender stereotypes that assign women the role of home caregivers, but to seek that both women and men have the opportunity and the duty to experience equally those practical experiences that involve the tasks of the acquisition and preparation of food. Working to achieve a situation like this, not only promotes progress in gender equality, but also helps to overcome the lower training of men to perform the tasks inherent in their diet.

Introduction

Beyond being an action, whose only purpose is to satisfy one of the most primitive needs of human beings, feeding should be understood as a social practice that is socially constructed and/or reconstructed over time ( Berger and Luckmann, 1979 ; Verplanken and Faes, 1999 ; García-Cardona et al., 2008 ). The family home is the first environment of socialization and personality formation ( Isaza, 2012 ). Thus, the family home constitutes the primary social space in which individuals' practices, customs, gender identity/roles and social habits begin to develop; particularly, individuals' eating habits. Such habits are understood here as the set of feeding-related social customs that influence the way people prepare, consume, or even select food. Therefore, preparing and consuming food are cultural behaviors that provide individuals with an identity ( Fischler, 1980 ; FAO, 2008 ; Barilla Center for Food Nutrition, 2009 ; Almerico, 2014 ; Cox, 2014 ; Silva et al., 2014 ; The Nielsen Company, 2015 ; Levine et al., 2016 ). The food people consume and how the food is consumed are essential determinants of health. Regarding this matter, here we mention only a few references from an abundant bibliography ( Willett et al., 1995 ; Martín Criado, 2004 ; Díaz-Méndez and Gómez-Benito, 2008 ; Gracia-Arnáiz, 2010 ; Guenther et al., 2013 ; Martinez-Lacoba et al., 2018 ).

Growing concerns about eating healthy foods have emerged as the consumption of industrially produced foods has augmented, and the negative consequences of industrially produced foods are increasingly acknowledged. Obesity is among the most widespread consequences. For instance, according to the Organization for Economic Co-operation and Development ( OECD, 2017a ), obesity has rapidly increased in OECD countries from 2010 and not only among adults, since children constitute 24.6% of the overweight population. Additionally, the OECD (2017a) reported that 19.5% of the population in Europe was overweight or obese in 2015, and this percentage exceeded that in other countries, such as Korea and Japan (6%), but was less than that in New Zealand, Mexico, and the United States (30%). Therefore, unsurprisingly, ischemic heart disease (10.6% in women and 12.8% in men) and heart attacks (8.2% in women and 7% in men) are currently among the main causes of death in Europe.

In the Spanish context, people are attempting to acquire better eating habits, as indicated by the Organization of Consumers and Users ( OCU, 2017 ). According to data from an OCU interview, the respondents reduced their consumption of sugar-sweetened beverages by 56%, pastries and sweets by 47%, and alcohol by 38%, while the consumption of fruits has increased by 30% and vegetables by 31%. Among all explanations given by the interviewees about these changes, their concern regarding their health was the most frequent, which is in line with the growing awareness that food plays a key role in people's health ( Cubero-Juánez et al., 2017 ; De Ridder et al., 2017 ; Dernini et al., 2017 ; Grosso et al., 2017 ; Oliffe et al., 2017 ; WHO, 2018 ). However, despite efforts to improve their eating habits, Spanish people have not yet managed to consume the healthiest possible diets ( OCU, 2019 ).

According to the National Institute of Statistics ( INE ), in 2019 , 18.7% of Spaniards aged 16 years and over reported that their health was “very good,” while 56.6% of the respondents described their health as “good.” Only 5.6% of the population considered their health “bad,” and 1.5% of the population considered their heath “very bad.” Regarding the healthiness of food, a report by OCU (2017) pointed out that 6% of Spaniards consumed more sweets and sweetened beverages, 7% of Spaniards consumed less fruit, and 5% of Spaniards consumed fewer vegetables than 2 years before. Among the reasons given in the report, the Spaniards indicated that they did not changed their bad eating habits due to the lack of time or will. However, Spaniards are not the only individuals who show the consequences of adopting unhealthy eating habits. Thus, regarding the percentage of individuals who are obese or overweight due to inadequate nutrition, some European Union countries are even above the Spanish average (16.7%), such as the United Kingdom (26.9%), Germany (23.6%), and Luxembourg (22.6%) ( OECD, 2017b ).

In these circumstances, as this article shows, even the fact of having a high level of studies, does not guarantee the strengthening of good and healthy eating practices among the University students interviewed ( Entrena-Durán et al., 2020 ). Thus, as revealed by the research “Effects of Age and Gender Identity on the Healthiness of University Students' Eating Habits in Spain” on which the writing of this article has been based, all the interviewees know what constitutes healthy food because of their elevated educational level. However, this knowledge does not always lead them to eat healthy. Achieving a healthy diet also requires the internalization and implementation of daily healthy eating habits. For that reason, the subsequent analysis focuses on the role that age and gender identity play in facilitating or hindering the acquisition of such habits to young men and women interviewed for this study.

Materials and Methods

This research study analyzed the eating habits reported in the interviews with a group of students at Granada University (Spain). In this regard, we clarify here that we have focused our research on University students because this social group is very appropriate to study how life crises (these usually appear as a consequence of the change processes in which people are involved) affect to eating patterns and habits. Thus, when young students enter the University, they usually undergo a deep change and an important life crisis, since many of them have to leave their home and move away from their families. As a consequence, these students experience the loss of the relatively stable living environment where they have resided until then, in which their diet, analogous to the generality of their life, has usually been regulated by their parents; mainly by their mothers, who have been responsible for the tasks of acquisition and preparation of food for the family.

All these sudden changes explain that a series of eating problems, such as the irregularity in meal times, the excessive consumption of fast food, the follow-up of nutritionally inadequate diets or the high incidence of eating disorders, are frequent among the University population ( Ruiz-Moreno et al., 2013 ).

A qualitative study, based on semi-structured interviews, was carried out in order to understand the knowledge the subjects analyzed have about the motivations behind the aforementioned eating problems. The qualitative methodology of our research has allowed us to comprehend, through the analysis of discourses produced by the students interviewed, how these students experience and explain their eating disorders.

We selected our sample among students of the University of Granada, but this should not be understood in the sense that we have limited ourselves to doing research with local students. In fact, this limitation has not occurred because the University of Granada has an outstanding national and international position. Thus, the 2020 edition of the Academic Ranking of World Universities (ARWU), also known as the Shanghai Ranking, has placed the University of Granada among the 300 best Universities in the world. In this Ranking, as has been happening in the last 5 years, the UGR appears in positions 201–300, where the Autonomous University of Barcelona, the Complutense University of Madrid and the University of Valencia are also located. This circumstance, together with the fact that the University of Granada has a long tradition of international academic cooperation, explains that many students come to Granada from all over Spain, as well as from very different countries abroad; mainly, from the European Union (EU). Particularly, with regard to the EU, the University of Granada is the Spanish University that accepts more foreign students within the framework of the Erasmus Program. So, as can be seen in Table 1 , in the selected sample for this study only 14 students are from the municipality of Granada or its province, while the remaining 20 students interviewed came from other Spanish provinces or even from abroad. In other words, 41.2% of those interviewees are from Granada or its province and 58.8% of them came from other parts of Spain, and even some of these students are from foreign countries.

Table 1 . List of interviewees.

The selected sample contained a group of 14 undergraduate, 18 Master, and 2 Ph.D. students which were chosen using a non-probability purposive sampling method. Therefore, we interviewed 34 students (17 women and 17 men) who were between the ages of 20 and 44. The leading reason for deciding to conclude the fieldwork with 34 interviews was because we saw no additional information was obtained from the new interviews done.

The 34 students interviewed were not told that we were going to investigate the influence of their age and gender identity on the healthiness of their eating habits. They were only told that our interviews were intended to both know their self-perception about their own eating behaviors and their opinions regarding the healthiness of eating habits in Spain.

The interviews lasted between 45 and 60 min, depending on the respondents' motivation in answering the questions. Most participants in this study were highly receptive and communicative. All interviews were recorded with the prior consent of the interviewees.

After all interviews were done, we analyzed all collected information. First, we focused on assessing whether the interviewees were aware of the need to adopt healthy eating habits and how to identify healthy food. Once we verified that 97.1% of 34 interviewees (that is, 33 of them) were aware of these feeding issues (mainly due to their educational level), we investigated the reasons why this awareness or conscience did not motivate many of them to change their eating habits to healthier ones, so that, there is a gap between what the interviewees thought they knew and their real eating behaviors.

As just said, there is a gap between the fact that 33 of 34 students interviewed (that is, 97.1% of them) know what healthy food is and their self-perception about whether or not what they are eating is healthy (see Table 1 ). So, in 14 of them said self-perception is negative; that is in 41.2% of the selected sample. This gap narrows as the interviewees' age increases and their socio-economic and vital situation is stabilizing, which favors that their eating habits become more regular and healthier. Thus, all the interviewees aged 27 or over self-perceived that they were eating healthily. But the biggest differences are those that have to do with the gender of interviewees.

Likewise, Table 1 shows how only 4 of the 17 women interviewed perceive that they do not eat healthy, while 13 of them perceive that they eat healthy. As for men, there are 10 who perceive that they do not eat healthy and 7 who think that they eat healthy. But, it should be noted the fact that four of these men live with their parents, two with their female romantic partners and only one lives alone, but he is 42 years old and, therefore, he is more aware of the need to eat healthy. In other words, there are important differences according to gender in the perceptions of the interviewees about the healthiness of their diet. Thus, while 23.5% of women interviewed perceived that they were not eating healthy, 76.5% of them felt that they were eating healthy. However, among the men interviewed, these percentages were somehow reversed, in such a way that 58.8% of them believed that they were not eating healthy, compared to 41.2% of them who affirmed that they were eating healthy.

Moreover, one significant thing we note in this research is that, due to their high educational level, the generality of interviewees, regardless of their gender, show an absolute distrust of advertisements. Therefore, all University students analyzed seemed to be aware of the “tricks” used by advertising to cajole and attract consumers toward their products regardless of whether such products are healthy. Both women and men revealed some distrust of food ads.

“Often, the labeling of products is pure marketing, selling methods that companies have to create new demands for consumers. For instance, people want to be healthier, and the response of companies is offering milk with added calcium or omega 3, which was not initially demanded by the people. All our lives, we have taken untreated milk that was healthy, but now, they are selling us Premium milk, which is milk with new additives. So, a demand that you did not have before is now being produced” (Man, 37 years old).

However, surprisingly, only 7 of 34 interviewed students (that is, 20.6% of them) openly stated that they usually read the labels of the foods they consume. Only two of these seven students were men, but they were especially motivated to verify these labels since they were both vegans.

“I look at the labels of products, their images, their presentation. I try not to buy many packaged products because they put many images of trees and/or fruits. and so, they try to deceive us. However, sometimes, I have bought these kinds of products, and when I think about it later, I say to myself ‘I've let myself be cajoled’, but anyway. I think so many products are being sold to us in this way now” (Man, 22 years old).

The importance of regulating food advertising was also noted by the interviewees with an emphasis on advertising targeting children.

“It is necessary to intensify and improve the regulations of industrial food advertising (industrial bakery, sugary soft drinks and so on) above all in children's programs since children are very vulnerable. Although, often, children are not the ones who buy the food they see in the ads of the supermarket, but their parents buy it.” (Man, 42 years old).

As shown in Table 1 , the aforementioned fact that 97.1% of 34 interviewed (that is, 33 of them) clearly distinguished between healthy and unhealthy food does not mean that 97.1% of students eat healthily. So, 32 interviewees (namely, 94.1% of them) confessed that they allowed themselves one or another “whim” in their everyday lives. For instance, the respondents consumed precooked foods, such as pizza and lasagna, and industrially manufactured sweets and ice cream. Furthermore, while 22 interviewees (namely, 64.7% of interviewees) said that they had some concern about their diet, the fact is that only 15 students (44.1% of them) expressed a settled intention to get a healthy diet. Most of these students were women, although the case of some men is also significant, such as this 27-year-old man, for whom a healthy diet is the one that is as varied as possible.

“I am quite influenced by my grandmother's meals; so, what I usually prepare to eat is traditional meals, such as lentil soups or stews… I do not usually repeat the meal in the same week; so, what I understand for a healthy diet is to eat as much variety as possible” (Man, 27 years old).

In particular, 14 students (41.2% of the sample), of which 8 were women, said they were selective regarding the foods they consumed, and they attempted to review the labels and composition of each product. Nevertheless, most interviewees (58.8% of them) said that they do not usually review the labels of products because they do not understand them, or they lack the time. Moreover, when they review the labels, they are rushed and only superficially read them.

“I don't pay attention to labels basically because I cannot understand them. There are all ingredients, but when you start reading something called ‘E’ and this kind of things… I cannot understand them” (Man, 27 years old).

“Sometimes when I buy frozen foods, I see the labels… When the freezing process began, the expiration date, if it has saturated fats. but the truth is that it is not something that I usually do” (Woman, 24 years old).

“The truth is that I do not look at the label in detail. I do not look at all the components that the product has” (Woman, 33 years old).

Additionally, as shown in Table 1 , we try to find out if the place where the interviewees lived significantly influenced their eating habits. In this sense, the analysis of 34 conducted interviews revealed that 8 University students (23.5% of them) were still living with their parents (3 women and 5 men), 18 University students (52.9% of them) shared housing with other students (9 women and 9 men), 6 University students (17.6% of them) lived with their romantic partners (4 women and 2 men), and only 2 University students (5.9% of them) lived single (1 woman and 1 man). In this regard, those 8 students who still lived with their families were the ones who ate more healthily, mainly because, in this case, their mothers were the ones who acquired and cooked the food.

The Decisive Influence of Age and Gender

However, what decisively influenced the interviewees' eating behaviors was their age and gender. Firstly, we observed that the concern in buying healthy foods grew as the age of the interviewees increased. Particularly, students aged 27 years or older (that is, 35.3% of the interviewees) showed great interest in maintaining the type of diet that they thought was most beneficial to their health.

“I do not drink milk anymore. Some people have told us that it is not recommendable to drink so much milk at a certain age. My partner has high cholesterol, and we had to change our diet …I think that is also due to the fact that we are getting older… hahaha … We try to do some exercise as well” (Woman, 44 years old).

Those University students who showed a lower degree of involvement in the tasks of buying and cooking food were aged between 20 and 26 years; namely, 64.7% of the selected sample. These students, who are the youngest of this sample, are highly dependent on their parents for performing tasks, especially their mothers. Thus, these often continue providing containers with frozen food they had prepared to their sons even after they have left the family home. Focusing on the gender variable, we observed that the said dependency is lower among women, and only three of nine women students sharing housing with other students (33.3% of them) admitted that they received meals prepared by their mothers, even though they no longer resided under the same roof. However, only one of nine male students in the aforementioned residential situation (11.1% of them) said that he prepares his own food without any help, while most young male interviewees showed that they were strongly dependent not only on their mothers but also on other women (romantic partners or female companions with which they shared housing) in terms of buying and/or cooking food. In other words, 88.9% of these students used to ignore these tasks and leave them in female hands.

“I have been living out of my parents' home for 3 years. My first year was a bit disastrous in terms of my feeding… I lost 10 kg because I only ate some pasta and rice… it was definitely a critical point in my feeding. Fortunately, my nourishment improved when I started living with a woman flatmate, but, when she left the floor, I lost weight again. Now, I'm trying to improve my diet a bit” (Man, 20 years old).

Unfortunately, this situation does not change significantly as the interviewees age. Those male students aged over 27 years who reside with their romantic partners continue to show a strong dependence on women for activities, such as purchasing food and cooking.

“When I eat alone, I do not have control over the food that I eat. When I lived with my parents, they used to manage everything about feeding, and my partner currently helps me. I thought that it is because of this kind of life in which we need to do lots of things and all them so quickly that we do not have time enough to eat” (Man, 33 years old).

Justifications to Explain Eating Habits

One of justifications used by some students to explain why they are not eating healthily is the lack of time in their daily lives. So, 7 of the 34 interviewees (20.6% of selected sample) said that they did not have enough time to eat a healthy diet. Two of these students were women and the remaining five were men. Besides, 14 students said that they had time to prepare all their meals; that is, 41.2% of the selected sample. Ten of these 14 students (namely, 71.4% of them) were women and the remaining four were men, including the two aforementioned men who were vegans; thus, they were strongly motivated to devote enough daily time to prepare their food.

“The great majority of my friends eat really unhealthy; they do not do exercise, and they eat a lot of fried food. I think that it is because they are lazy or maybe because of the stress of working all day, and they directly think, ‘Well, for just one day in which I can allow a whim, I'm going to eat a soup? Not at all” (Man, 25 years old).

Nevertheless, the remaining 13 students (38.2% of the selected sample) openly stated that they had no time problems related to feeding, either because they were living with their parents or because they often received frozen food cooked by their mothers. In particular, with reference to these 13 students (5 women and 8 men) it should be noted that, in addition to the key role played by mothers, men mentioned that their female partners are mainly responsible for preparing and cooking food. Therefore, these female partners could be perpetuating the same role in some way that they see their mothers perform, i.e., the main individual responsible for feeding the family. In fact, these mothers assume and internalize the function that “male domination” ( Bourdieu, 2001 ) has assigned to them so intensely that they often do not allow their daughters to work in the kitchen while they are inside it.

“When I live with my mother, I do not make my own meal, but when I live alone, I do everything by myself. This is not because I do not want to do it, but it is because my mother prefers doing all household tasks without any sort of help. She told me, ‘no, no, get out of the kitchen!’; so… how can I learn?” (Woman, 21 years old).

Furthermore, 26.5% of interviewees (5 men and 4 women) mentioned direct and conscious social pressure as an influential factor on their eating habits.

“Maybe, if you go out with your friends on weekends, you are more exposed to eat some inappropriate food, such as burgers or some fried food… And, in case you prefer another healthier meal, they automatically look at you as weird or something like this…” (Man, 25 years old).

“I do not usually eat snacks. I eat them when I meet with some friends” (Man, 22 years old).

In addition to friends, social pressure may also come from some relatives, romantic partners, or even flatmates. In all these cases, the way social pressure is exercised varies according to the age of those who experience it. Primarily, age determines the settings where such pressure is exerted. In this regard, although students older than 30 years refer to such settings as “small meetings with friends,” younger students talk about getting together in an apartment to play video games or going to bars to “take tapas.”

“I usually buy snacks, but it is because my husband and my little son like them. I do not like snacks; so, I do not eat them. I mostly prefer doing varied meals for them, such as fruits or vegetables… This is what I understand for healthy diet” (Woman, 33 years old).

“I usually eat some snacks just when I meet with some friends to watch a football match or dinner. but I do not consume them on my own. With these products, it happens to me, I think, what happens to us all. this feeling of saying ‘take them away from me because otherwise I cannot stop eating them!’ It is true; they are good. I suppose that is because of the additives or aromas they have.” (Man, 37 years old).

Last but not least, the price of the products was another of the interviewees' arguments to justify their unhealthy eating habits. Thus, most students agreed that the healthiness of a food product is lower when the price is cheaper. Consistently, 19 of the 34 interviewees (55.9% of the selected sample) explicitly said that they had more or less difficulties (depending on their respective living standards) to eat healthy due to the high prices of organic or natural products compared to the prices of industrially processed foods, which they perceived as less healthy. Nine of these 19 students were men aged between 20 and 28 years, while the other 10 students were women aged between 21 and 27 years.

“When I was a degree student, I ate lots of pre-cooked food because I preferred to save my money for other things, such as going out with friends, for example” (Man, 26 years old).

However, the importance of price decreases as the University students become economically independent from their parents and their age and purchasing power increase. This change is particularly observed among those female students who are 27 years old or older.

“I usually buy organic/local food products, such as vegetables or meat, in local markets or corner shops… I do not usually take into account their price, but what drives me to purchase these products is that they inspire more confidence in me than those from great supermarkets because you meet the owner, and you can know everything about the product just by asking him/her” (Woman, 44 years old).

Particularly, the students most interested in eating a healthy diet are also those who are the most concerned about buying food products whose healthiness they trust. But, even in this case, price continues to have much influence on deciding what to buy or what can be bought. Some students suggested the need to implement policies to solve this problem.

“I think that we should encourage more local products. that is, that people consume more of this type of product than foreign ones. Perhaps governments should encourage more consumption of local foods by subsidizing them or establishing certain norms for the market” (Woman, 27 years old).

The authors of this work are fully aware that the discussion on the factors that influence eating habits and affect their greater or lesser healthiness does not end with age, gender and other factors that we have considered in this research. In this regard, numerous studies have demonstrated that the educational status, the income level, the role of agri-food supply chains and the lesser or greater accessibility to these by people, the occupation and even social class are factors that can influence people's feeding habits ( De Irala-Estévez et al., 2000 ; Trichopoulou et al., 2002 ; Darmon and Drewnowski, 2008 ; Cobb-Clark et al., 2012 ; Horská et al., 2020 ). However, these factors are not the only ones that determine individuals' eating habits, since other external or environmental factors alter these habits and are beyond an individual's control. Examples of these factors include the characteristic cultures of the social and/or geographical context in which a person lives or has grown and food advertising ( Troncoso and Amaya, 2009 ; Saucedo et al., 2010 ; Ganasegeran et al., 2012 ; Robinson et al., 2013 ; Becerra et al., 2015 ; WHO, 2018 ; Higgs and Ruddock, 2020 ).

Currently, concerns about people's health since childhood and throughout their entire adulthood are increasing. Demands for natural and healthy foods by consumers are growing ( De Ridder et al., 2017 ; Dernini et al., 2017 ; Oliffe et al., 2017 ; Parham et al., 2017 ; Vallejo-Alviter and Martínez-Moctezuma, 2017 ). In this context, in which daily lives of people take place, the said demands are often manipulated by marketing strategies used by the food industry. Thus, a series of foods that are actually industrial products are presented as natural and/or ecological and, therefore, good for health, which has become an advertising hook for this type of processed foods.

Usually, advertising, rather than reliably reporting the quality and characteristics of the products offered or promoting a healthy diet, reflects marketing strategies that create symbolic necessities in a consumption society. Now, in this society, individuals seek to face new experiences and feelings or simply publicly show their identities by purchasing certain material goods ( Ibáñez, 1997 ). Thus, unsurprisingly, the WHO (2014 , 2018 , 2020) openly criticized current advertising campaigns for promoting food products without being entirely honest with consumers, and subsequently, the WHO noted the urgency of persuading governmental institutions to take action to address this issue.

Regarding the control of food advertising in Spain, the Spanish Ministry of Health (SPH) published the so-called PAOS code in 2005 (Advertising (Publicidad), Activity (Actividad), Obesity (Obesidad), and Health (Salud) [PAOS]) ( SPH, 2005 ; AECOSAN, 2012 ). In collaboration with a group of companies voluntarily committed to the cause, the Ministry intended to co-regulate the food and drink products advertised to children to prevent obesity and promote health among them ( González-Díaz, 2013 ). Nonetheless, despite all the ethical rules established in this code for the development, creation and dissemination of advertising messages to children, there exists still a high degree of non-compliance with the PAOS code, at least regarding television commercials. Thus, as shown in a recent article ( León-Flández et al., 2017 ), up to 88.3% of television advertisements for foods and beverages targeting minors violated the code in some way in 2012, while in 2008, the degree of noncompliance was 49.3%. Notably, non-compliance was greater in the commercials aired on children's channels (92.3%) than in commercials airing on channels targeting the entire population (81.5%). In this context, the aforementioned article proposed more restrictive and legal measures for food advertising to children, with healthy products being the only suitable products that can be advertised to minors.

Nonetheless, the problems caused by unhealthy feeding practices cannot be solved only by the enactment of prohibitive or restrictive new laws or measures that are often not complied with. Furthermore, this issue cannot only be resolved by doctors and nutritionists prescribing highly strict diets that are demoralizing to those who are unable to follow them ( Pérez-Rodrigo and Aranceta, 2001 ; Worsley, 2002 ; Bandura, 2004 ; Kupolati et al., 2015 ; Nguyen et al., 2015 ; OECD, 2017b ; Rush and Yan, 2017 ). Of course, both the regulation of food advertising and the work of nutritionists or doctors are essential factors for expanding and strengthening healthy eating habits among the population ( Worsley, 2002 ; Maixé-Altés, 2009 ; Robinson et al., 2013 ; Perveen, 2017 ; Rush and Yan, 2017 ; Schneider et al., 2017 ). Nevertheless, even though these factors may have an undeniable impact on the improvement in food health, they alone do not ensure that progress toward healthier eating practices is achieved. Even improving people's education cannot guarantee the strengthening of such practices, such as we have shown in this article ( Entrena-Durán et al., 2020 ).

The University students interviewed here have reached a high educational level, and consequently they engage in critical thinking that allows them to clearly discern between healthy and unhealthy food. However, this fact does not guarantee that all these students eat healthily. On the contrary, there is a gap between what the students know and how a significant proportion of them actually behave, and between what they express in their discourses and the concrete practices or eating habits they perceive or say they follow in their daily lives ( Martín Criado, 1998 ).

Our study has helped to reveal some of the causes behind this gap. So, the fact of focusing exclusively on University students has allowed this research to demonstrate that the circumstance of having a high educational level is not enough to ensure that there will be healthy eating habits. In addition to the educational level, a decisive element in order to achieve a healthy diet is to internalize food habits that make it possible. We have seen that these habits are strengthened as the interviewees' age increases. We have also found that most of women interviewed show healthier eating habits.

In the first place, we have observed that, as their age increases, the socio-economic and vital situation of interviewees is stabilizing, which favors that their eating habits become more regular and healthier, and this happens at the same time that the interviewees' awareness of the need to lead a more regulated and healthy lifestyle augments.

Secondly, with respect to gender, our research has shown that food education is more effective among women. This is so because women have traditionally been in charge of acquiring and preparing food at their homes. In other words, women's food education has not been restricted to the mere transmission to them of knowledge about what healthy food is, but from their childhood they were food trained through their active involvement in practical experiences. All this explains both why healthy eating habits are more strongly rooted in women and why these tend to have the best chances of assuming such habits.

Regarding Bourdieu's Concepts and the Assumption of Healthy Eating Habits

To understand eating habits shaping and assumption by individuals and the implementation of these habits, we can be inspired by the habitus and field concepts of Bourdieu (1991) . Therefore, the present study reveals that the reason why people eat healthily does not only depend on their knowledge of healthy food, but healthy eating is strongly influenced (hindered or furthered) by the habitus acquired by individuals. Moreover, in the case of the University students studied here, the strength of their eating habitus fluctuates according to their age and gender. These two variables, together with the specific contexts in which they act, constitute the particular circumstances under which people's eating habits develop day-by-day. In turn, the said circumstances play a key role in the processes of shaping, assuming and implementing eating habits and, according to Bourdieu, they create a sort of field (i.e., a social game space or scenario ) in which the production and reproduction of feeding-related discourses, practices and habits occur. Particularly, in the case of women, their socialization in the procurement and preparation of food has created a very optimal field for their internalization and effective assumption of a healthy food habitus , which according to Bourdieu, could be understood as the assumption of a set of durable dispositions or predispositions to buy, prepare and eat healthy food. We make this assertion based on the fact that, for Bourdieu (1991) , the habitus can be understood as a system of durable and transposable predispositions and dispositions that operate as schemes that generate and organize social practices. Simultaneously, these schemes incline people to act, perceive, value, feel and think in a certain way.

So understood, the habitus concept is very fruitful in explaining women's predisposition to assume the gender role of performing the tasks of buying, cooking and feeding their family group. Thus, women internalize a gender role that is nothing more than a product of history, i.e., a social construction. They assume this role as inherent to their gender identity, as if it were innate to their female nature and accept their supposed natural-psychological aptitudes for the said tasks. By acting in this way, women contribute to the reproduction of “male domination” over them while such domination is simultaneously legitimized as being grounded in biology ( Bourdieu, 2001 ).

According to this logic, the biological nature of men renders them better prepared than women to function outside the home. Thus, a fact whose causes are merely social tends to be legitimized as natural because men often have greater access to and control over the material and symbolic resources that underpin their predominance in the public sphere. Consistently, men—and society at large—think that when they are responsible for household chores, such as feeding the family, they are performing an exceptional task that is not inherent to their masculine nature. Men improve their self-esteem by assuming this role and achieve a social recognition that is based on a macho thought regardless of their intentions. This thought could be formulated as “what a good person that man is who help his wife with domestic chores and taking responsibility for these tasks when she is not at home or is sick.”

In contrast, even upon entering the public sphere, women have fewer opportunities to avoid their role as home caregivers. This role has been strongly internalized by most women as an inherent obligation due to their gender; thus, they tend to be highly self-demanding and blame themselves when they feel that they have failed their main responsibility when their home is not working well.

In particular, Bourdieu's (1991 ; 2001 ) conceptual framework and theories of gender socialization can be very useful tools for explaining the guilt that many women experience when they work outside the home and cannot exclusively dedicate themselves to household tasks. Some authors have noted that as long as home care is understood as a process associated with and undertaken by women, our society will not overcome labor, social and political segregation ( Doucet, 2009 ; Skærbæk, 2011 ). These authors emphasize that home caregiving should be understood as an existential condition of life that affects both men and women.

Unfortunately, the present study has shown that gender inequalities persist even among University students. Thus, both students sharing the same apartment and heterosexual couples living together, share a common situation in which the women continue to perform most of the domestic chores. In consequence, improving individuals' educational levels is insufficient. In addition, working on relations between genders is necessary for achieving a complete and effective redefinition of their habitus ( Bourdieu, 1991 ) in such a way that any predisposition or inclination that tends to legitimize or naturalize gender inequalities disappears. To achieve this goal, we must seek to inculcate egalitarian habits of behavior and relationship between both sexes from childhood. Undoubtedly, this task requires family socialization, training for gender equality at the different educational levels, and the media in general to stop the macho portrayals and stereotypes.

Consistently, men must be educated to be equally involved in domestic responsibilities and particularly to believe that the time devoted to feeding is not lost but instead is beneficial in terms of improving their health and because of the creativity it entails.

Some Limitations of Our Study and Suggestions for Future Research

The qualitative methodology of our research has permitted us to see, through the analysis of their discourses, how the interviewees experience and explain their food problems. The analysis of these discourses has allowed us to collect comprehensive information regarding the perceptions of both healthy food and healthy eating habits in Spain. Such depth of information could not have been obtained through a quantitative survey. However, this research has some limitations.

Interviewing an entire group of students who live together in the same flat could be beneficial, since this could allow us to contrast all information provided by each student. Nevertheless, it was not possible for the interviewees to bring their roommates to the interview, likely because of the lack of strong relational links between the flatmates.

Moreover, a comparative investigation that involved samples from different universities could have been intriguing. Nonetheless, such a study would require financial resources, which we lack. However, while it is true that the interviews were conducted exclusively at the University of Granada, as explained above, we selected a sample of interviewees in which we included a majority of students from outside Granada. Therefore, in some way, our sample is something representative to allow a certain degree of extrapolation of the results obtained here to other University contexts.

Recommendations for Policy Makers

Public policies can contribute by creating conditions that enable people to more easily develop healthy eating habits. For instance, by forcing the food industry to put clearer labeling. Moreover, such policies must ensure a sufficient supply of healthy food at affordable prices and they should promote and/or support food education. This education should focus not only on transmitting knowledge regarding healthy food, but also on training people to develop predispositions toward this type of food and acquire a healthy food habitus ( Bourdieu, 1991 ). Thus, it is very necessary to inculcate healthy eating habits in people through practical experiences. For example, by means of promoting access to rural environments and contact with nature from early childhood (through visits to school farms, field trips, etc.) not only to encourage greater physical exercise, but also to favor both knowledge of traditional and/or ecological products and some practical knowledge about sustainable and healthy food ( Paddock, 2017 ).

Educational actions, such as those abovementioned, favor the incorporation of healthy eating habits, which are best achieved when an adequate field or social game space is created for this purpose. This field has to be built by implementing policies, such as the creation of employment and improvements in wages and quality of work, which could increase people's purchasing power. These policies should be combined with all these other measures aimed at facilitating accessibility to healthy foods.

Furthermore, the consolidation of healthy food habits can be greatly favored by implementing policies that encourage the creation of conditions under which both men and women have more time to live with their families and perform household chores. Overall, these conditions could contribute to facilitating all members of the family to assume the responsibilities inherent in the acquisition and purchasing of food regardless of their gender.

The present study suggests that, in their position, women have some advantages over men in developing healthy food habits. Obviously, a solution is to not perpetuate macho gender stereotypes that assign women the role of home caregivers, but to seek the establishment of a society in which the economic value of domestic labor is recognized and women and men should have the opportunity, and the duty, to experience equally those practical experiences that involve the tasks of the acquisition and preparation of food. The fact of working for the achievement of a socioeconomic situation in which this is possible, not only has a positive impact on the advancement of gender equality, but also it contributes to creating more adequate conditions to overcome the disadvantages men have due to their lack of training to perform the home care services and, in particular, the tasks of buying and preparing food, either for themselves or for their families.

Data Availability Statement

The datasets on which the writing of this article has been based are not made available to readers. The main reason for this is to prevent the people interviewed for this research from being identified. Any additional clarification about the interviews conducted may be requested from the corresponding author of this paper. Requests to access the datasets should be directed to fentrena@ugr.es .

Ethics Statement

The studies involving human participants were reviewed and approved by the Ethics Committee in Human Research of the University of Granada. The participants provided their written informed consent to participate in this study.

Author Contributions

FE-D and HB-L: conception, conceptualization, design, original draft, methodology, research, and analysis. FE-D and J-MV-G: methodology, analysis, writing, and final review. All authors have read and agreed to the published version of the manuscript.

No scholarship or financial aid was requested or granted specifically for conducting the research on which this study is based. However, such research was carried out within the framework of the Research Group Social Problems in Andalusia (SEJ-129), which is financed by the Regional Government of Andalusia and the Government of the Spanish State.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We thank all those University students who kindly participated in this research.

AECOSAN (2012). Código de Corregulación de la Publicidad de Alimentos y Bebidas Dirigida a Menores, Prevención de la Obesidad y Salud . 1–18. Available online at: http://www.aecosan.msssi.gob.es/AECOSAN/docs/documentos/nutricion/Nuevo_Codigo_PAOS_2012_espanol.pdf (accessed November 25, 2020).

Google Scholar

Almerico, G. M. (2014). Food and identity: food studies, cultural, and personal identity. J. Int. Bus. Cult. Stud. 8, 1–7. Available online at: https://www.aabri.com/manuscripts/141797.pdf (accessed January 25, 2021).

Bandura, A. (2004). Health promotion by social cognitive means. Heal. Educ. Behav. 31, 143–164. doi: 10.1177/1090198104263660

PubMed Abstract | CrossRef Full Text | Google Scholar

Barilla Center for Food and Nutrition (2009). La Dimens. Cult. del cibo, 36 . Available online at: https://www.barillacfn.com/m/publications/pp-dimensione-culturale-cibo.pdf (accessed February 2, 2021).

Becerra, F., Pinzón, G., and Vargas, M. (2015). Practicas alimentarias de un grupo de estudiantes universitarios y las dificultades percibidas para realizar una alimentación saludable. Rev. Fac. Med. 63, 457–463. doi: 10.15446/revfacmed.v63n3.48516

CrossRef Full Text | Google Scholar

Berger, P. L., and Luckmann, T. (1979). La Construcción Social de la Realidad . Buenos Aires: Amorrortu.

Bourdieu, P. (1991). El Sentido Práctico . Madrid: Taurus.

Bourdieu, P. (2001). Masculine Domination . Palo Alto, CA: Stanford University Press.

Cobb-Clark, D. A., Kassenboehmer, S. C., and Schurer, S. (2012). Healthy habits: the connection between diet, exercise, and locus of control. SSRN Electron. J. doi: 10.2139/ssrn.2146274. Available online at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2146274# (accessed January 20, 2021).

Cox, R. (2014). Food and eating: an anthropological perspective. Soc. Issues Res. 1–22. Available online at: http://www.sirc.org/publik/foxfood.pdf (accessed on December 22, 2020).

Cubero-Juánez, J., Franco-Reynolds, L., Calderón, M., Caro, B., Rodrigo, M., and Ruiz, C. (2017). El desayuno escolar; una intervención educativa en alimentación y nutrición saludable. Didáctica las Ciencias Exp. Soc. 32, 171–182. doi: 10.7203/dces.32.4546

Darmon, N., and Drewnowski, A. (2008). Does social class predict diet quality? Am. J. Clin. Nutr. 87, 1107–1117. doi: 10.1093/ajcn/87.5.1107

De Irala-Estévez, J., Groth, M., Johansson, L., Oltersdorf, U., Prättälä, R., and Martínez-González, M. A. (2000). A systematic review of socio-economic differences in food habits in Europe: consumption of fruit and vegetables. Eur. J. Clin. Nutr. 54, 706–714. doi: 10.1038/sj.ejcn.1601080

De Ridder, D., Kroese, F., Evers, C., Adriaanse, M., and Gillebaart, M. (2017). Healthy diet: health impact, prevalence, correlates, and interventions. Psychol. Heal. 32, 907–941. doi: 10.1080/08870446.2017.1316849

Dernini, S., Berry, E. M., Serra-Majem, L., La Vecchia, C., Capone, R., Medina, F. X., et al. (2017). Med Diet 4.0: the mediterranean diet with four sustainable benefits. Public Health Nutr. 20, 1322–1330. doi: 10.1017/S1368980016003177

Díaz-Méndez, C., and Gómez-Benito, C., (eds.). (2008). Alimentación, Consumo y Salud (Colección Estudios Sociales, num. 24) . Barcelona: Fundación “la Caixa”.

Doucet, A. (2009). Gender equality and gender differences: parenting, habitus and embodiment. Can. Rev. Sociol. 48, 99–117. doi: 10.1111/j.1755-618x.2009.01206.x

Entrena-Durán, F., Baldan-Lozano, H., and Valdera-Gil, J. M. (2020). “La salubridad de los hábitos alimenticios de los estudiantes universitarios: un estudio de caso,” in Análisis y Enfoques Novedosos Para Contenidos Culturales , ed M. Rodorigo (Valencia: Tirant lo Blanch).

FAO (2008). Doc. apoyo para la Asign. Ciencia, Salud y Medio Educ. en Nutr. Segur. y huertos Esc. , 84. Food and Agriculture Organization of the United Nations. Available online at: http://www.fao.org/3/a-am278s.pdf (accessed February 1, 2021).

Fischler, C. (1980). Food habits, social change and the nature/culture dilemma. Soc. Sci. Inf. 19, 937–953. doi: 10.1177/053901848001900603

Ganasegeran, K., Al-Dubai, S. A. R., Qureshi, A. M., Al-Abed, A. A. A., Am, R., and Aljunid, S. M. (2012). Social and psychological factors affecting eating habits among University students in a Malaysian medical school: a cross-sectional study. Nutr. J. 11:48. doi: 10.1186/1475-2891-11-48

García-Cardona, M., Pardío-López, J., Arroyo-Acevedo, P., Fernández-García, V., and García, M. (2008). Dinàmica familiar y su relaciòn con hàbitos alimentarios. Estud. sobre las Cult. Contemp. XIV , 27, 9–46. Available online at: https://www.redalyc.org/articulo.oa?id=31602702 (accessed January 20, 2021).

González-Díaz, C. (2013). La publicidad dirigida a niños en el sector de la alimentación: un estudio atendiendo al tipo de producto/Food advertising targeted to children: a study on type product. Hist. Comun. Soc. 18, 175–187. doi: 10.5209/rev_HICS.2013.v18.44235

Gracia-Arnáiz, M. (2010). Alimentación y cultura en España: una aproximación desde la antropología social. Phys. Rev. Saúde Colet. 20, 357–386. doi: 10.1590/S0103-73312010000200003

Grosso, G., Bella, F., Godos, J., Sciacca, S., Del Rio, D., Ray, S., et al. (2017). Possible role of diet in cancer: systematic review and multiple meta-analyses of dietary patterns, lifestyle factors, and cancer risk. Nutr. Rev. 75, 405–419. doi: 10.1093/nutrit/nux012

Guenther, P. M., Casavale, K. O., Reedy, J., Kirkpatrick, S. I., Hiza, H. A. B., Kuczynski, K. J., et al. (2013). Update of the Healthy Eating Index: HEI-2010. J. Acad. Nutr. Diet. 113, 569–580. doi: 10.1016/j.jand.2012.12.016

Higgs, S., and Ruddock, H. (2020). “Social influences on eating,” in Handbook of Eating and Drinking (Cham: Springer International Publishing), 277–291. doi: 10.1007/978-3-030-14504-0_27

Horská, E., Petrilák, M., Šedík, P., and Nagyová, L. (2020). Factors influencing the sale of local products through short supply chains: a case of family dairy farms in Slovakia. Sustainability 12:8499. doi: 10.3390/su12208499

Ibáñez, J. (1997). Por Una Sociología de la Vida Cotidiana . Madrid: Siglo XXI.

INE (2019). Indicadores Calid. Vida Salud autopercibida . INE (Instituto Nacional de Estadística). Available online at: https://www.ine.es/ss/Satellite?L=es_ESandc=INESeccion_Candcid=1259944485720andp=1254735110672andpagename=ProductosYServicios%2FPYSLayoutandparam1=PYSDetalleFichaIndicadorandparam3=1259937499084andrendermode=pr+eviewnoinsite (accessed February 2, 2021).

Isaza, L. (2012). El contexto familiar: un factor determinante en el desarrollo social de los niños y las niñas. Rev. Electrón. Psicol. Soc. 23, 1–6. Available online at: https://www.funlam.edu.co/revistas/index.php/poiesis/article/view/332/305 (accessed February 14, 2021).

Kupolati, M. D., Gericke, G. J., and MacIntyre, U. E. (2015). Teachers' perceptions of school nutrition education's influence on eating behaviours of learners in the Bronkhorstspruit District. South African J. Educ. 35:1049. doi: 10.15700/saje.v35n2a1049

León-Flández, K., Rico-Gómez, A., Moya-Geromin, M., Romero-Fernández, M., Bosqued-Estefania, M. J., Damián, J., et al. (2017). Evaluation of compliance with the Spanish Code of self-regulation of food and drinks advertising directed at children under the age of 12 years in Spain, 2012. Public Health 150, 121–129. doi: 10.1016/j.puhe.2017.05.013

Levine, C. S., Miyamoto, Y., Markus, H. R., Rigotti, A., Boylan, J. M., Park, J., et al. (2016). Culture and healthy eating: the role of independence and interdependence in the United States and Japan. Personal. Soc. Psychol. Bull. 42, 1335–1348. doi: 10.1177/0146167216658645

Maixé-Altés, J. (2009). La modernización de la distribución alimentaria en España, 1947-1995. Rev. Hist. Ind. 18, 125–160. Available online at: https://revistes.ub.edu/index.php/HistoriaIndustrial/article/view/20486 (accessed January 20, 2021).

Martín Criado, E. (1998). Los decires y los haceres. Pap. Rev. Sociol. 56, 57–71. doi: 10.5565/rev/papers.1944

Martín Criado, E. (2004). El valor de la buena madre: oficio de ama de casa, alimentación y salud entre las mujeres de clases populares. Rev. Espan. Sociol . 93–118. Available online at: https://recyt.fecyt.es/index.php/res/article/view/64944/39354 (accessed February 18, 2021).

Martinez-Lacoba, R., Pardo-Garcia, I., Amo-Saus, E., and Escribano-Sotos, F. (2018). Mediterranean diet and health outcomes: a systematic meta-review. Eur. J. Public Health 28, 955–961. doi: 10.1093/eurpub/cky113

Nguyen, B. H., Nguyen, C. P., McPhee, S. J., Stewart, S. L., Bui-Tong, N., and Nguyen, T. T. (2015). Cognitive interviews of vietnamese americans on healthy eating and physical activity health educational materials. Ecol. Food Nutr. 54, 455–469. doi: 10.1080/03670244.2015.1015119

OCU (2017). OCU Inf. Los Españoles Quieren Aliment. Mejor. Pero no lo Consiguen . OCU (Organization of Consumers and Users). Available at: https://www.ocu.org/organizacion/prensa/notas-de-prensa/2017/habitos-alimentarios-250817 (accessed December 28, 2020).

OCU (2019). “ 10% menos de azúcar, grasas saturadas y sal en alimentos procesados? #NoCuela. OCU (Organization of Consumers and Users). Available online at: https://www.ocu.org/alimentacion/alimentos/noticias/alimentos-procesados-reducir-grasa-azucar-plan (accessed November 29, 2020).

OECD (2017a). Obes. Updat. 2017 . OECD (Organization for Economic Co-operation and Development). Available at: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf (accessed November 27, 2020).

OECD (2017b). Heal. a Glance 2017 OECD Indic . OECD (Organization for Economic Co-operation and Development). Available online at: https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2017_health_glance-2017-en (accessed October 25, 2020).

Oliffe, J. L., Bottorff, J. L., Sharp, P., Caperchione, C. M., Johnson, S. T., Healy, T., et al. (2017). Healthy eating and active living: rural-based working men's perspectives. Am. J. Mens. Health 11, 1664–1672. doi: 10.1177/1557988315619372

Paddock, J. (2017). Household consumption and environmental change: rethinking the policy problem through narratives of food practice. J. Consum. Cult. 17, 122–139. doi: 10.1177/1469540515586869

Parham, S. C., Kavanagh, D. J., Gericke, C. A., King, N., May, J., and Andrade, J. (2017). Assessment of motivational cognitions in diabetes self-care: the motivation thought frequency scales for glucose testing, physical activity and healthy eating. Int. J. Behav. Med. 24, 447–456. doi: 10.1007/s12529-016-9607-2

Pérez-Rodrigo, C., and Aranceta, J. (2001). School-based nutrition education: lessons learned and new perspectives. Public Health Nutr. 4, 131–139. doi: 10.1079/PHN2000108

Perveen, R. (2017). Assessing the influence of nutrition education among adolescent girls (13-16 years). Adv. Obesity, Weight Manag. Control 6, 144–147. doi: 10.15406/aowmc.2017.06.00167

CrossRef Full Text

Robinson, E., Blissett, J., and Higgs, S. (2013). Social influences on eating: implications for nutritional interventions. Nutr. Res. Rev. 26, 166–176. doi: 10.1017/S0954422413000127

Ruiz-Moreno, E., Del-Pozo-de-la-Calle, S., Valero-Gaspar, T., Ávila-Torres, J. M., and Varela-Moreiras, G. (2013). Estudio de Hábitos Alimentarios y Estilos de Vida de los Universitarios Españoles. Patrón de consumo de bebidas fermentadas. Fund. Española la Nutr . 1–32. Available online at: http://www.fen.org.es/storage/app/media/imgPublicaciones/30092014131915.pdf (accessed November 24, 2020).

Rush, E. C., and Yan, M. R. (2017). Evolution not revolution: nutrition and obesity. Nutrients 9:519. doi: 10.3390/nu9050519

Saucedo, T., Peña, A., Fernández, L., García, A., and Jiménez, R. (2010). Identificación de factores de riesgo asociados a trastornos de la conducta alimentaria y su relación con el Índice de Masa Corporal en universitarios del Instituto de Ciencias de la Salud. Rev. Med. UV 10, 16–23. Available online at: https://www.medigraphic.com/pdfs/veracruzana/muv-2010/muv102c.pdf (accessed December 16, 2020).

Schneider, S., Diehl, K., Görig, T., Schilling, L., De Bock, F., Hoffmann, K., et al. (2017). Contextual influences on physical activity and eating habits-options for action on the community level. BMC Public Health 17:760. doi: 10.1186/s12889-017-4790-x

Silva, T. H., Vaz De Melo, P. O. S., Almeida, J., Musolesi, M., and Loureiro, A. (2014). “You are what you eat (and Drink): identifying cultural boundaries by analyzing food and drink habits in foursquare,” in Proceedings of the 8th International Conference on Weblogs and Social Media, ICWSM 2014 (Palo Alto, CA: The AAAI Press), 466–475.

Skærbæk, E. (2011). Navigating in the landscape of care: A critical reflection on theory and practise of care and ethics. in Health Care Analysis (Kluwer Academic Publishers) , 41–50. doi: 10.1007/s10728-010-0157-5

SPH (2005). SPH (Spanish Ministry of Health). Mañana entra en vigor el Código PAOS autorregulación la Public. Destin. a menores para Combat. la Obes. Infant . Available online at: http://www.fundaciondiabetes.org/upload/noticias/4694/23.pdf (accessed January 18, 2021).

The Nielsen Company (2015). We Are What We Eat, 27 . Available online at: https://www.nielsen.com/wp-content/uploads/sites/3/2019/04/Nielsen20Global20Health20and20Wellness20Report20-20January202015-1.pdf (accessed January 26, 2021).

Trichopoulou, A., Naska, A., and Costacou, T. (2002). Disparities in food habits across Europe. Proc. Nutr. Soc. 61, 553–558. doi: 10.1079/PNS2002188

Troncoso, P. C., and Amaya, P. J. P. (2009). Factores sociales en las conductas alimentarias de estudiantes universitarios. Rev. Chil. Nutr. 36, 1090–1097. doi: 10.4067/S0717-75182009000400005

Vallejo-Alviter, N. G., and Martínez-Moctezuma, E. (2017). Impacto de la promoción de estilos de vida saludable para mejorar la calidad de vida. Drugs Addict. Behav. 2, 225–235. doi: 10.21501/24631779.2442

Verplanken, B., and Faes, S. (1999). Good intentions, bad habits, and effects of forming implementation intentions on healthy eating. Eur. J. Soc. Psychol. 29, 591–604. doi: 10.1002/(SICI)1099-0992(199908/09)29:5/6<591::AID-EJSP948>3.0.CO;2-H

WHO (2014). “European food and nutrition action plan 2015 – 2020,” in Regional Committee For Europe 64th Session (Copenhagen).

WHO (2018). Better Food and Nutrition in Europe: A Progress Report Monitoring Policy Implementation in the WHO European Region . World Heal. Organ. Reg. Off. Eur., 51.

WHO (2020). World Health Statistics 2020: Monitoring Health for the SDGs, Sustainable Development Goals .

Willett, W. C., Sacks, F., Trichopoulou, A., Drescher, G., Ferro-Luzzi, A., Helsing, E., et al. (1995). Mediterranean diet pyramid: a cultural model for healthy eating. Am. J. Clin. Nutr. 61, 14025–14065. doi: 10.1093/ajcn/61.6.1402S

Worsley, A. (2002). Nutrition knowledge and food consumption: can nutrition knowledge change food behaviour? Asia Pac. J. Clin. Nutr. 11(Suppl 3), S579–S585. doi: 10.1046/j.1440-6047.11.supp3.7.x

Annex: Questionnaire Used to Do the Interviews

We asked the interviewees open questions. Before starting the interviews, we read them the following paragraph:

“Dear student,

We invite you to participate in this project on the eating habits of the University's student population, whose basic objective is to analyze these habits and the greater or lesser healthiness of them from the self-perception that the own students have. Your participation is totally voluntary. We need you to answer a semi-structured interview, which you are free to interrupt when you deem it convenient or to refuse to answer any of the questions. To enable the analysis of the results, the interview must be recorded. However, this audio will not be used to disclose your personal data at any time. In fact, you will not even be asked your name during the recording and you will only be asked to indicate your age, the type of studies you do, if you live with your parents or with other students, as well as other information. The objective of this is that we who do this research can classify and then study the information you provide us, which will be considered in an aggregate manner, without linking it to your name or any other data from which you can be identified. The recording will be used exclusively to extract the information provided with the aforementioned study purpose. Your participation in the interview, voluntary, and unpaid, assumes that you authorize the use of the information you provide us. However, at any time you can decide to withdraw from the survey and demand that the information you have up to that moment be destroyed. Your participation in the current investigation, or your refusal to do so, will not affect in any way the qualification of any of the matters you are currently studying or your possibilities of academic promotion.”

Next, we made the interviews in which we asked the following open questions:

Summary of the interview guide

Opening questions: How old are you? What are you studying at University? Where do you live? Who do you live with?

Topic 1: Daily routine related to eating habits.

Do you make your own purchases? If you do not , why? Who makes the purchases in your home? If you do , how much time do you spend making purchases on average? Do you cook in your house? If you do not , who cooks in your house? Why? If you do , how much time do you spend cooking on average daily? Do you pay attention to the labels on eating products? In the case that you do not live with your parents, do you need any help preparing your own meals? If yes, who usually helps you and how? The interviewees have to explain their answers .

Topic 2: Personal knowledge of and putting into practice healthy eating habits.

I am going to mention some eating products, and you [interviewee] have to say which product is healthy and which is not. Any answer provided by an interviewee must be explained . What would you consider a healthy diet? Do you consider your eating habits healthy? Regardless of his/her answer, he/she must explain .

Topic 3: Problems found by interviewees and possible solutions.

In your opinion, what social, cultural, economic or political problems can hinder the strengthening of healthy eating habits within Spanish society? Please, describe and explain these problems in greater depth. What types of solutions do you think can help solve these problems? Please, explain in greater depth.

Keywords: food healthiness, students, feeding, self-perception of food, effects of age and gender, discourse analysis

Citation: Entrena-Durán F, Baldan-Lozano H and Valdera-Gil J-M (2021) Students' Knowledge of Healthy Food and Their Actual Eating Habits: A Case Study on the University of Granada (Spain). Front. Sustain. Food Syst. 5:687574. doi: 10.3389/fsufs.2021.687574

Received: 29 March 2021; Accepted: 25 May 2021; Published: 18 June 2021.

Reviewed by:

Copyright © 2021 Entrena-Durán, Baldan-Lozano and Valdera-Gil. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Francisco Entrena-Durán, fentrena@ugr.es

This article is part of the Research Topic

Consumer Behavior and Sustainability in the Food Chain

•   Weather

Search location by ZIP code

An imbalance of two healthy fats affects your early death risk, study finds.

• Copy Link Copy {copyShortcut} to copy Link copied!

GET LOCAL BREAKING NEWS ALERTS

The latest breaking updates, delivered straight to your email inbox.

Eating enough healthy fats is great for brain and heart health , but new research has possibly provided even more evidence for adding them — particularly omega-3s — to your diet.

Video above: How to control junk food cravings in order to reach health goals

"We found that a higher omega-6 to omega-3 ratio is associated with a greater risk of dying," said Yuchen Zhang, lead author of the April study published in the journal eLife, in a news release. Zhang is a doctoral student in the Department of Epidemiology and Biostatistics at the University of Georgia's College of Public Health.

Omega-3 fatty acids are naturally found in foods including fish — especially fatty fish such as salmon, tuna and sardines — as well as flaxseed, walnuts, chia seeds and in dietary supplements such as fish oil .

The three main omega-3 fatty acids are alpha-linolenic acid, or ALA; eicosapentaenoic acid, or EPA; and docosahexaenoic acid, known as DHA, according to the National Institutes of Health . The body must obtain all three from foods, and omega-3s contribute to the health of the heart, blood vessels, lungs, immune system and endocrine system.

Foods high in omega-6 fatty acids, on the other hand, include nuts, seeds, corn and soy — and the oils and preservatives produced from these foods, the authors said. Linoleic acid is the most common omega-6 fatty acid.

"There is some evidence to suggest that the high omega-6 to omega-3 fats ratio typical of Western diets — 20:1 or even higher, compared to an estimated 1:1 during most of human evolution — contributes to many chronic diseases, including cardiovascular disease, cancer and autoimmune disorders," Zhang said.

But the results of past studies have been mixed, she added, and few have investigated the role of an imbalance in mortality. Also, accurately measuring fatty acid intake is difficult, partly due to reliance on participants' own recollections of their dietary intake.

Zhang and the other researchers looked into the associations between the omega-3/omega-6 ratio in blood plasma — a more objective measure — and death from any cause and specifically from cancer or cardiovascular disease, the top two leading causes of death worldwide.

They used data from 85,425 people who had participated in the U.K. Biobank study , which has followed the health outcomes of more than half a million people between ages 40 and 69 in the United Kingdom for at least a decade.

Participants, whose plasma samples were collected between 2007 and 2010, had answered questionnaires about their diet, including whether they took fish oil supplements.

After nearly 13 years of follow-up, the authors found participants with the highest ratios of omega-6 to omega-3 were 26% more likely to die early from any cause, 14% more likely to die from cancer and 31% more likely to die from heart disease than those with the lowest ratios. Considered individually, both high levels of omega-6 and omega-3 were linked with a lower risk of premature death. But the protective effects of omega-3 were greater, likely explaining "why having a high ratio of omega-6s to omega-3s was linked to harm," the authors said.

Despite the findings, the study is "only one 'snapshot' in time of biomarkers and dietary intake of omega 3s and 6s. This is correlation, not causation," said Dr. Lauren R. Sastre, director of the Farm to Clinic Program and assistant professor in the department of nutrition science at East Carolina University, via email. Sastre wasn't involved in the study.

"And even that relationship cannot be strongly supported due to methodological flaws in not considering other dietary components to the overall health/clinical outcomes," Sastre added. "There are many anti-inflammatory food components (nutrients, phytochemicals, etc.) that are associated with reducing all-cause, cancer and (cardiovascular disease) mortality, and to only evaluate omega 3s and 6s — strong confounders may be present that would bias the results."

Managing healthy fat intake

If the omega-6/omega-3 balance actually does have more to do with premature death risk than the study has the capacity to prove, it could be due to the possible function of arachidonic acid, an omega-6 fatty acid, said Kristin Kirkpatrick, a registered dietitian nutritionist at the Cleveland Clinic and author of " Regenerative Health: Discover Your Metabolic Type and Renew Your Liver for Life ."

Arachidonic acid is what the body converts from linoleic acid. It's a "building block for molecules that can promote inflammation, blood clotting, and the constriction of blood vessels," according to Harvard Health . But this fatty acid can also be converted into molecules that fight inflammation and blood clots.

Omega-6s aren't inherently bad, but having too many may offset the anti-inflammatory factors associated with omega-3, Kirkpatrick said, so "a more balanced approach … may be favorable."

"The source of the omega 6s may also be a factor in offsetting the balance as well," she added via email. "Processed seed oils may also contain high amounts of omega 6s for example."

Focusing on this balance and increasing your intake of foods rich in omega-3s can be more important than simply limiting those high in omega-6s, Kirkpatrick said.

"I would also look at the quality of the omega 6 foods in the diet," she added, "aiming for whole foods … rather than more processed products that may contain large amounts via the addition of seed oils."

If you're curious what your blood plasma ratio of omega-6 to omega-3 is, ask your physician about testing for it. In Kirkpatrick's practice, she often works with her patients' doctors for this purpose. Some patients request it with the goal of improving their mental health , heart health or risk of dementia , she said.

Overall, "it's important to note that an unbalanced ratio is only one chapter in our story of better or worse health span," Kirkpatrick said.

"Getting a variety of fiber-rich foods (beneficial to the microbiome) and other nutrient-dense foods, as well as adequate, good-quality sleep, stress management and physical activity play a large role in how long we will enjoy good health within our lifetime."

• Open access
• Published: 05 May 2024

Healthy eating among people on opioid agonist therapy: a qualitative study of patients’ experiences and perspectives

• Einar Furulund 1 , 2 , 3 ,
• Karl Trygve Druckrey-Fiskaaen 2 , 3 ,
• Siv-Elin Leirvåg Carlsen 2 , 3 ,
• Tesfaye Madebo 2 , 4 , 5 ,
• Lars T. Fadnes 2 , 3 &
• Torgeir Gilje Lid 1  

BMC Nutrition volume  10 , Article number:  70 ( 2024 ) Cite this article

251 Accesses

16 Altmetric

Metrics details

People with substance use disorders often have unhealthy diets, high in sweets and processed foods but low in nutritious items like fruits and vegetables, increasing noncommunicable disease risks. This study investigates healthy eating perceptions and barriers among individuals with opioid use disorder undergoing opioid agonist therapy. Interviews with 14 participants at opioid agonist therapy clinics in Western Norway, using a semi-structured guide and systematic text condensation for analysis, reveal that most participants view their diet as inadequate and express a desire to improve for better health. Barriers to healthy eating included oral health problems, smoking habits, and limited social relations, while economic factors were less of a concern for the participants. Participants did find healthy eating easier when they were in social settings. This study underscores the importance of understanding and addressing these barriers and facilitators to foster healthier eating patterns in this population, potentially enhancing overall health and well-being.

Peer Review reports

Introduction

Substance use disorder (SUD), particularly opioid use disorder (OUD), is complex and extends beyond the risk of overdose, suicide, and infection. Noncommunicable diseases, such as chronic lung diseases, cancer, and cardiovascular diseases, all contribute to increased morbidity and mortality [ 1 , 2 ]. Nutrition is an important but often overlooked aspect of SUD recovery [ 3 ]. Individuals, particularly those with OUD, often report unhealthy eating habits consisting of a high consumption of sweets, sugar-sweetened and processed foods and a low consumption of fruits and vegetables [ 4 , 5 , 6 , 7 , 8 ]. Comorbidities might arise or worsen because of an unhealthy eating behavior [ 9 , 10 ]. Furthermore, substance use can severely impact an individuals’ nutritional habits and diet, as substances are often favored over food [ 11 ]. According to recent Norwegian research [ 12 , 13 ], approximately half of the patients receiving opioid agonist therapy (OAT) are deficient in vitamin D and folic acid.

Despite the established link between dietary habits and health outcomes in the general population, few studies have focused on nutritional interventions for populations with SUD and OUD [ 14 ]. A diet containing a higher intake of fruits and vegetables may reduce morbidity in high-risk populations by improving cardiovascular and mental health, as well as biomarkers of cellular stress defense [ 15 , 16 , 17 , 18 ]. However, it is unclear to what extent interventions aimed at other high-risk groups could be applied directly to OAT patients. This research gap highlights the need for improved understanding of dietary behaviors and attitudes to healthy eating among individuals in OAT.

Materials and methods

This study aims to provide insights into the dietary habits and views of healthy eating among individuals with opioid use disorders receiving opioid agonist therapy. In addition, we intend to lay the framework for the development of dietary interventions that could improve health outcomes and quality of life for individuals receiving OAT by identifying barriers and facilitators.

ATLAS4LAR project aims to improve the health and well-being of individuals with opioid use disorder undergoing OAT [ 19 ]. The project enrols OAT patients from Stavanger and Bergen, two cities in Western Norway, into a cohort and a health registry. This article was based on participants in this cohort. A semi-structured interview guide on dietary habits and perceptions of and barriers to healthy eating was developed as a collaboration between the study group, research nurses, clinicians, and user representatives. The interview guide covers topics of physical activity, smoking cessation [ 20 ] and healthy eating; this article focuses on healthy eating. A COREQ checklist [ 21 ] was applied and is included in the supplementary file.

Study sample and setting

Interviews were conducted with 14 patients at OAT clinics in Stavanger and Bergen, the two largest cities in Western Norway. All patients who completed an annual health assessment and willing to complete an interview about lifestyle were eligible to participate in the study. There were no specific exclusion criteria. Most patients receive follow-up on a weekly basis from multidisciplinary teams, including monitoring of OAT medication intake such as buprenorphine and methadone. For more information regarding the included outpatient clinics, see Fadnes et al. (2019) [ 22 ]. The research nurses collaborated with OAT clinicians to recruit a purposive sample from four different clinics in Bergen and Stavanger. Our goal was to recruit participants from various OAT clinics and ages and genders; the study sample characteristics are outlined in Table  1 .

Data collection

Among the 14 participants, thirteen completed the full interview guide, with one participant leaving the interview after twelve minutes with an incomplete interview. All the 14 participants consented to the interviews being audio recorded. All interviews were conducted during the ongoing COVID-19 pandemic in January and February 2021. Necessary precautions were taken to minimise the risk of transmitting viruses during the interview. This included symptom checklists for COVID-19, maintaining distance, and occasionally wearing facemasks. Three research nurses with training in qualitative interviewing contacted patients by phone or when they had an appointment at the clinic and conducted the interviews. They were instructed to move between topics and questions based on interview dynamics. The final interview guide included three nutrition-related issues: (1) reflections on their daily diets, (2) opportunities to prioritise healthy eating in their daily lives, and (3) reflections on the need to change their diets. See the supplementary file for the interview guide. A total of forty to sixty minutes were spent on each interview.

Data analysis

Due to COVID-19 and geographical distances between researchers, we conducted our meetings through Microsoft Teams for video conferencing and used NVivo 20 for the data analysis A pseudonym reflecting the gender of the participants was assigned to each recording, and it was transcribed verbatim by the study’s authors (EF, SELC, and KTDF). The analysis followed the four steps of systematic text condensation [ 23 , 24 ]. At first, the authors spent extensive time reading the transcripts to better understand what was being said. This thorough reading led to identifying preliminary themes, their presentation, and a collaborative discussion in a workshop. As a result of this discussion, some central themes were agreed upon for further analysis. Afterwards, a second reading was conducted to identify meaningful units, which were then categorized under the earlier themes. The lead author led the data analysis in close collaboration with SELC, KTDF, and TGL. TM and LTF also contributed significantly, ensuring a collective analysis effort. This collaborative approach facilitated the generation of condensed versions that captured the essence of the categorized themes. Ongoing discussions on terminology and limitations among all co-authors ensured clarity and coherence throughout the process. In the end, these condensed insights formed the basis of an overall narrative that addressed the aim of the study.

14 participants were interviewed, 11 male and three females, and all receiving OAT (Table  1 ). All participants had relatively stable housing conditions, and six lived alone. Five had injected drugs within the past six months before the interview. Thirteen reported smoking at least three times a week. The median debut age for tobacco, alcohol and cannabis was 13 to 14 years, while for stimulants it was 23 years and for opioids 25 years.

In this analysis, the researches extracted three themes and several subthemes reflecting the complex interactions between personal health, social environment, and dietary practices. For instance, the theme “Dietary Patterns and Health Practices” explored varied dietary habits among participants, from structured meals incorporating traditional Norwegian foods to periods of unhealthy eating dominated by fast foods and convenience items. Sub-themes include the impact of drug use on dietary habits and the role of smoking in influencing taste and appetite. The theme “Barriers and facilitators to healthy eating” discussed factors influencing patients’ ability to maintain a healthy diet, including economic constraints, access to cooking facilities, and treatment facilities’, and physical and social environment. Sub-themes highlighted the role of oral health in dietary choices and the potential of nutritional interventions within OAT clinics. The last theme, “Social and psychological dimensions of eating”, addressed the social context, focusing on how living arrangements and social interactions influence dietary choices. This theme also delves into the stigma associated with substance use and its impact on participants’ nutritional choices and self-perception.

Participants differed greatly in their eating patterns. Most participants acknowledged the importance of increasing fruit and vegetable consumption and expressed a wish to eat healthier. Some perceived their diet as well-balanced, which included multiple meals of traditional Norwegian foods. Others reported having unstable dietary habits, expressed as having healthy periods of eating nutritious foods, and less healthy periods with mainly intake of unhealthy foods such as fast foods. Additionally, some said they almost did not eat for long periods. Some participants felt they needed more knowledge to implement a nutritious diet into their daily lives.

Economy and access to a kitchen were not important barriers to healthy eating

Although most participants said they could afford healthy food and maintain a healthy diet, some highlighted that they could not afford high-priced food like fresh fish or meat several times a week. Nevertheless, it was possible to cook nutritious food despite having little money. Some participants also mentioned vitamin supplements as a means of enhancing their nutrition.

“Yes, I want to eat healthier food. Much of what is healthy is not that expensive. Buy some tomatoes, cucumber, lemon, and salad. Then, we look for where there is an offer, and we go to each store and pick what is on offer”. - Thomas.

For many participants, the kitchen was a space of both opportunity and challenge. While some engaged in regular meal preparations, others found themselves limited to heating pre-processed foods. Living in treatment facilities posed challenges due to their strict schedules and predetermined diets. Some participants had experienced being responsible for prepare food for the institution and other patients. These routines could be quite demanding, and they could become tired of cooking. An interesting introduction to smoothies was noted in some substance use treatment facilities, for making smoothies accessible where the institutions did buy the fruits and vegetables and stood with available equipment. This was without any cost to the patients. The participants expressed appreciation for the smoothies, citing their taste and feeling healthy as key reasons for the positive reception. After discharge from these institutions, none of the participants regularly continued to make or purchase smoothies.

“If you live in an institution or in those places where you are not completely in charge and do not have your own apartment, then it is probably more difficult to inspire yourself to cook and eat healthy …” - Thomas.

Struggling with stigma related to substance use

Several participants knew of food distribution centres that provided free food. Some said it was a helpful initiative to distribute free food to people in need. In contrast, others experienced barriers such as the stigma of being seen at these centres, or the risk of meeting people under the influence of drugs.

“And I do not like going to those Salvation Army [having a food provision service] centres, because I meet so many weird people [trying to sell drugs] … It can be tough to say no [offers for drugs] to those people sometimes”. - Erik.

Some participants mentioned the drug-related stigma linked to low weight. Some participants did not view their weight as crucial to their overall well-being. However, a few participants reported that their family members focused on the participant’s weight and associated this with their life situation, specifically their substance use.

“… about the kilos. It is not something like that, I think I’m very thin or something like that, but I hear from family members that I have now lost weight. Then, I know that they associate it with illicit drugs and that things are not going well. That probably affects me more than just those kilos”. - Kristian.

Some participants stated that they struggled to gain weight, even though they wanted a better appetite to increase their body weight. Some also made choices accordingly, such as eating a high-fat diet. Despite this, weight gain remained a constant struggle. While some participants had specific goals to increase their body weight by five to ten kilograms, they faced challenges in achieving this in a healthy manner. Despite their intention to gain weight, the participants expressed concerns about excessive sugar intake and its impact on their overall health. The struggle to balance weight gain with a nutritious diet and a lack of self-confidence in the kitchen made it difficult for them to adhere to balanced and healthy eating.

“To gain more weight, I try to eat fat-rich foods. Yes, it is the usual routine with breakfast, lunch and dinner, and there are also snacks in between, and of course, then I eat supper”. - Peter.

Oral health status and smoking impact negatively on healthy eating

Poor oral health was a major barrier that greatly impacted the participants’ diet. Missing several teeth, poorly adapted dentures and pain in their mouth restricted many from eating many of the fruits and vegetables. Some described hard fruits and vegetables such as apples and carrots as impossible for them to eat. Participants with poorly adapted dentures expressed difficulties in eating and needing to clean their dentures after eating, which were perceived as embarrassing and stigmatising in social settings.

“Meat, yes, and then it gets stuck. So, I always have to take [the denture] out after I finish eating. Then, I need to go to rinse my mouth. It was not how I imagined it when I got it [denture]…. The only thing I have been able to chew is bananas and oranges, because they are soft”. - Jacob.

Several participants reported that smoking negatively impacted their taste, reduced their appetite of food, and affected their daily food consumption. Smokers who reduced or stopped smoking, experienced an increase in appetite and a positive impact on the taste of food.

“When I stopped smoking, my taste returned to normal, and my appetite improved since smoking “killed” some of my taste for food”. - Thomas.

The social context is important for all aspects of eating

Most participants expressed that food has a social function, particularly among those who live alone. Participants who had cohabitants also said their diet would have been negatively affected if they had lived alone. Establishing or maintaining healthy eating habits were challenging to many who regularly were eating alone. Some participants did not see the value of making an entire meal just for themselves. Furthermore, when participants were alone, purchasing unhealthy foods such as doughnuts and fast food was easier.

“I see I have such a good diet only because I live with someone. It is better to be two people eating together rather than alone… yes, it has a lot to say. Many complain and say exactly that [to me]; ‘you are lucky to be two people’ [eating together]”. - Jacob.

Some participants found that creating a shopping list simplified the grocery shopping process. Although many lacked the discipline to organize a shopping list and preferred not to shop alone, they found it more manageable to shop with family or friends. Alone, participants said to buy unhealthy food, high in fat, and sugar. In contrast, shopping with others often led to healthier choices. However, for a few participants, the challenge was not in purchasing nutritious food but in the actual cooking and preparation of meals.

“I go to the store every other day to buy food. Instead of thinking ahead that tomorrow I will have this for dinner, and then I will have that for dinner the next day”, I make a list like that in my head. However, I do this [buys the food], and the food ends up in the freezer, and then it stays there”. - Oliver.

Preferences relevant to nutritional interventions in the clinic

We specifically asked participants about their preferences for establishing nutritional interventions in their OAT clinic. Most participants wanted to consume more fruits and vegetables, recognising their health benefits and appealing taste. They thought the OAT clinics should promote a healthy diet more actively, e.g., with posters in the waiting room. These posters could include basic information about different foods and about the consequences of not eating healthy. Other suggestions were more extensive, with a clinic-initiated patient-oriented educational cooking programme, focusing on easy recipes of affordable and tasty food.

The study offers fresh insights into the viewpoints and choices of patients regarding healthy eating within the context of OAT. Numerous participants highlighted challenges such as oral health concerns, smoking habits, and reduced social interactions that hinder their ability to adhere to a healthy diet. Interestingly, economic constraints were cited by only a minority of participants as barriers. Additionally, some individuals expressed that they found it easier to sustain a healthy diet when they had social support and stressed the importance of having a structured grocery shopping list.

It is essential to acknowledge that several factors play a role in dietary choices among the OAT population [ 25 ]. Our research has shown a notable shift in the average age of individuals in our sample compared to previous studies. This demographic transformation toward an older population is associated with an increased susceptibility to chronic diseases and a higher risk of malnutrition [ 26 ]. Specifically, the average age of patients undergoing Opioid Agonist Therapy (OAT) now stands at 47, with a median age of 49 within our dataset. A decade ago, the typical age for this OAT patient group was 42, marking a significant increase of five years over the past decade. Notably, the proportion of OAT patients aged 60 and above has tripled in 2021 when compared to data from 2015 [ 27 ]. Furthermore, within our sample, we have observed significant variations in dietary habits and meal frequency among this demographic. Nevertheless, in the context of an ageing population, the importance of adopting healthy eating habits becomes even more pronounced to reduce the risk of chronic diseases, including cardiovascular and metabolic disorders.

In Norway, people with SUD have a high level of social support offered by the government in terms of financial help, free or subsidised health care services, and mostly stable living conditions [ 28 ]. Previous studies have found that people with long-term SUD experience economic challenges and unstable living conditions, making it difficult to achieve adequate nutrition [ 4 , 29 ]. Our participants, however, did not see the economy as a primary obstacle to healthy eating. Despite some financial limitations, such as the need to prioritise and adhere to a budget, they were generally able to afford several healthy foods as components for their diets. Interestingly, some participants who lived together with others said they were always looking for reasonable offers on food at the store, almost like a sport. This may support that they do not necessarily have a stable and strong economy but have strategies to manage economic limitations. However, even with a stable living situation and kitchen access, they still found attaining a healthy diet to be difficult.

Poor oral health significantly hinders the ability to maintain a nutritious diet primarily due to missing teeth, oral pain, or dentures. Many participants expressed how their oral health directly influenced their diet. These physical constraints and the potential for social discomfort provide insights into the infrequent consumption of fruits and vegetables, even when individuals are aware of their nutritional benefits. This aligns with findings on older adults [ 30 ], with many reporting poor oral health due to lacking and damaged teeth. As a result, they have fewer choices for food, such as fruits, vegetables, and fibre, increasing their risk of unhealthy food choices [ 30 ]. However, not all the participants in our study described difficulties eating healthy food. Interestingly, some were introduced to smoothies at treatment facilities and found them appealing. After being discharged, however, they did not continue to make or purchase smoothies.

A large study found an inverse relationship emerged between cigarette smoking and eating healthy food. Specifically, as individuals increase their daily smoking, their intake of healthy foods, such as fruits and vegetables, declined. This is in line with our findings, where participants shared that smoking adversely affected their ability to taste the food [ 8 ]. This effect may be attributed to nicotine’s widely recognized capacity to suppress appetite, potentially prompting individuals to turn to smoking as a substitute behavior for eating [ 31 ].

The absence of individuals to share meals with and feelings of loneliness posed a significant obstacle to the participants’ attempts to sustain a nutritious diet. Many conversations centred around the challenges of grocery shopping and meal preparation for solitary individuals. These observations align with previous research, which has shown that people living alone typically consume fewer fruits, vegetables, and fish compared to those who have meal companions [ 32 ]. Although our data do not allow direct comparisons, the narratives from our participants are consistent with these findings. In contrast, those living with others credited their dietary stability to their shared living arrangements. They believed that having someone to share meals with added an extra layer of meaning and purpose to meals.

Many participants were interested in adopting healthier eating habits, a positive and noteworthy finding considering their substance use history. This shift towards healthier diets may indicate an awareness of the correlation between health and nutrition even after prolonged substance use. These individuals recognized the potential for an improved diet to enhance their health. Some associated a healthy diet with weight gain as a sign that their drug problem is under control. Those who wanted to increase their weight said they needed to pay attention to their diet, which could be exhausting. A number of epidemiological studies have investigated the relationship between drug use and body weight, and most of the evidence demonstrates an inverse correlation [ 33 ]. A regular diet can have therapeutic benefits, including improving health, self-esteem and social relationships [ 25 ].

During the interview, participants were asked for intervention preferences relevant to their dietary and nutritional needs. Interestingly, not all participants came up with specific suggestions for this topic, yet some proposed the idea of making information available in the waiting rooms or initiating cooking courses. As an alternative, some participants suggested that smoothies would be beneficial to consume more fruit and vegetables without damaging their teeth. The potential of smoothies as effective dietary interventions has been explored in different populations, including adolescents in schools and older adults [ 34 , 35 ].

The current study has several strengths and limitations. The qualitative design provides an in-depth understanding of participants’ experiences, and of barriers and facilitators to healthy eating. However, one limitation regarding its design is that nutritional status was not measured in our study. The participants described their nutritional status through their eating habits, detailing their behaviour and experiences associated with eating patterns. Research nurses assisted with providing insights into how to perform the interview and the interview guide on how to phrase the questions in an understandable way. User representatives offered valuable insight to ensure the relevance and highlighted cultural and societal factors. Even though research nurses are separate from the clinical care, bias may still occur. Some patients may be more inclined to present themselves rather than express their feelings or give feedback. Through collaboration in frequent digital meetings and using a theoretical framework, we were able to test ideas and interpretations, and thus reduce the influence of investigator bias [ 36 ]. It is likely that social desirability influenced the interview process and results. When data were collected, the study participants were receiving treatment from OAT outpatient clinics where they were interviewed, which may have made them more susceptible to social desirability bias during interviews [ 37 ]. The interview guide was designed to minimise such bias, as well as the choice of interviewer being a research nurse and not their contact person/clinician. The participants could steer the order of the topics in the discussion, which probably enabled them to speak more freely from their perspectives.

Together with earlier work, this study emphasises the importance of understanding patients’ perspectives and needs regarding nutrition [ 25 , 38 ]. According to patients, diet and nutrition are important and bidirectionally interlinked with their substance use. Healthcare providers should address the diet and nutrition of patients to facilitate recovery. However, strategies to improve oral health among OAT patients, and motivational and educational strategies to improve cooking skills, are necessary prerequisites in addition to the more specific interventions, to improve patients’ recovery and their overall health.

The OAT platform facilitates communication between healthcare professionals and hard-to-reach patients. To prioritize nutrition, five key topics have been proposed: incorporating discussions about food and nutrition history into clinical consultations, conducting anthropometric measurements including regular weight monitoring, utilizing biochemical data to identify dietary limitations, evaluating potential health implications of individuals’ nutritional profiles, and tailoring approaches based on clients’ personal histories and perspectives [ 39 ]. The results indicate that a combination of individual, social, and environmental factors influenced participants’ dietary habits and eating patterns.

Conclusions

In conclusion, our findings shed light on several critical aspects of a healthy diet among patients in OAT. Oral health issues, smoking habits, and limited social interaction emerged as significant impediments to upholding a nutritious diet. Healthcare professionals should proactively tackle these obstacles, while future research should prioritize devising effective strategies to overcome these barriers and improve the dietary patterns, nutritional well-being, and overall health of individuals undergoing OAT.

Data availability

Because of data protection regulations, the raw interview data for this study are not publicly available.

Abbreviations

Substance use disorder

Opioid use disorder

opioid agonist therapy

Consolidated criteria for reporting qualitative research

Hser YI, Mooney LJ, Saxon AJ, Miotto K, Bell DS, Zhu Y, et al. High mortality among patients with opioid Use Disorder in a large Healthcare System. J Addict Med. 2017;11(4):315–9.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Lewer D, Jones NR, Hickman M, Nielsen S, Degenhardt L. Life expectancy of people who are dependent on opioids: a cohort study in New South Wales, Australia. J Psychiatr Res. 2020;130:435–40.

Article   PubMed   Google Scholar  

Whatnall MC, Skinner J, Pursey K, Brain K, Collins R, Hutchesson MJ, Burrows TL. Efficacy of dietary interventions in individuals with substance use disorders for illicit substances or illicit use of pharmaceutical substances: a systematic review. J Hum Nutr Diet. 2021;34(6):981–93.

Sæland M, Haugen M, Eriksen FL, Wandel M, Smehaugen A, Böhmer T, Oshaug A. High sugar consumption and poor nutrient intake among drug addicts in Oslo, Norway. Br J Nutr. 2011;105(4):618–24.

Saeland M, Wandel M, Böhmer T, Haugen M. Abscess infections and malnutrition – a cross-sectional study of polydrug addicts in Oslo, Norway. Scand J Clin Lab Investig. 2014;74(4):322–8.

Article   CAS   Google Scholar  

Nolan LJ, Scagnelli LM. Preference for sweet foods and higher body mass index in patients being treated in long-term methadone maintenance. Subst Use Misuse. 2007;42(10):1555–66.

Sæland M, Haugen M, Eriksen FL, Smehaugen A, Wandel M, Böhmer T, Oshaug A. Living as a drug addict in Oslo, Norway – a study focusing on nutrition and health. Public Health Nutr. 2009;12(5):630–6.

Morabia A, Curtin F, Bernstein MS. Effects of smoking and smoking cessation on dietary habits of a Swiss urban population. Eur J Clin Nutr. 1999;53(3):239–43.

Article   CAS   PubMed   Google Scholar  

Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019;393(10170):447–92.

Hendricks K, Gorbach S. Nutrition issues in chronic drug users living with HIV infection. Addict Sci Clin Pract. 2009;5(1):16–23.

Article   PubMed   PubMed Central   Google Scholar  

Nabipour S, Ayu Said M, Hussain Habil M. Burden and nutritional deficiencies in opiate addiction- systematic review article. Iran J Public Health. 2014;43(8):1022–32.

PubMed   PubMed Central   Google Scholar  

Bemanian M, Chowdhury R, Stokke K, Aas CF, Johansson KA, Vold JH, Fadnes LT. Vitamin D status and associations with substance use patterns among people with severe substance use disorders in Western Norway. Sci Rep. 2022;12(1):13695.

Bemanian M, Vold JH, Chowdhury R, Aas CF, Gjestad R, Johansson KA, Fadnes LT. Folate Status as a Nutritional Indicator among people with Substance Use Disorder; a prospective cohort study in Norway. Int J Environ Res Public Health. 2022;19(9).

Mahboub N, Rizk R, Karavetian M, de Vries N. Nutritional status and eating habits of people who use drugs and/or are undergoing treatment for recovery: a narrative review. Nutr Rev. 2021;79(6):627–35.

Furulund E, Bemanian M, Berggren N, Madebo T, Rivedal SH, Lid TG, Fadnes LT. Effects of Nutritional interventions in individuals with chronic obstructive lung disease: a systematic review of Randomized controlled trials. Int J Chron Obstruct Pulmon Dis. 2021;16:3145–56.

Jacka FN, O’Neil A, Opie R, Itsiopoulos C, Cotton S, Mohebbi M, et al. A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’ trial). BMC Med. 2017;15(1):23.

Bøhn SK, Myhrstad MC, Thoresen M, Holden M, Karlsen A, Tunheim SH, et al. Blood cell gene expression associated with cellular stress defense is modulated by antioxidant-rich food in a randomised controlled clinical trial of male smokers. BMC Med. 2010;8(1):54.

Aune D, Giovannucci E, Boffetta P, Fadnes LT, Keum N, Norat T, et al. Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality—a systematic review and dose-response meta-analysis of prospective studies. Int J Epidemiol. 2017;46(3):1029–56.

Fadnes LT. ATLAS4LAR: Kartlegging og behandling av lungesykdom i legemiddelassistert behandling 2019 [updated 18.12.2019; cited 2020 21.09.2020]. https://helse-bergen.no/avdelinger/rusmedisin/rusmedisin-seksjon-forsking/bar/atlas4lar-kartlegging-og-behandling-av-lungesykdom-i-legemiddelassistert-behandling .

Druckrey-Fiskaaen KT, Furulund E, Madebo T, Carlsen S-EL, Fadnes LT, Lid TG, et al. A qualitative study on people with opioid use disorders’ perspectives on smoking and smoking cessation interventions. Front Psychiatry. 2023;14:1185338.

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.

Fadnes LT, Aas CF, Vold JH, Ohldieck C, Leiva RA, Chalabianloo F, et al. Integrated treatment of hepatitis C virus infection among people who inject drugs: study protocol for a randomised controlled trial (INTRO-HCV). BMC Infect Dis. 2019;19(1):943.

Malterud K. Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health. 2012;40(8):795–805.

Malterud K. Kvalitative metoder i medisinsk forskning: en innføring. 3. Utg. ed. Oslo: Universitetsforl.; 2011.

Google Scholar  

Neale J, Nettleton S, Pickering L, Fischer J. Eating patterns among heroin users: a qualitative study with implications for nutritional interventions. Addiction. 2012;107(3):635–41.

Norman K, Haß U, Pirlich M. Malnutrition in older adults-recent advances and remaining challenges. Nutrients. 2021;13(8).

Bech ABBA, Lobmaier P, Skeie I, Lillevold PH, Clausen T, SERAF Statusrapport LAR. 2021. University Oslo, Center for addiction research; 2022. Report No.: 2/2022.

Health Mo, Services C. Se Meg! En Helhetlig Rusmiddelpolitikk, Alkohol–Narkotika–Doping [See me! An overall policy for Alcohol, drugs and Doping]. Helse-og omsorgsdepartementet Oslo; 2012.

Himmelgreen DA, Pérez-Escamilla R, Segura-Millán S, Romero-Daza N, Tanasescu M, Singer M. A comparison of the nutritional status and food security of drug-using and non-drug-using hispanic women in Hartford, Connecticut. Am J Phys Anthropol. 1998;107(3):351–61.

Toniazzo MP, Amorim PSA, Muniz FWMG, Weidlich P. Relationship of nutritional status and oral health in elderly: systematic review with meta-analysis. Clin Nutr. 2018;37(3):824–30.

Audrain-McGovern J, Benowitz NL. Cigarette smoking, nicotine, and body weight. Clin Pharmacol Ther. 2011;90(1):164–8.

Hanna KL, Collins PF. Relationship between living alone and food and nutrient intake. Nutr Rev. 2015;73(9):594–611.

Li J, Yang C, Davey-Rothwell M, Latkin C. Associations between Body Weight Status and Substance Use among African American Women in Baltimore, Maryland: the CHAT study. Subst Use Misuse. 2016;51(6):669–81.

Bates D, Price J. Impact of Fruit smoothies on adolescent Fruit Consumption at School. Health Educ Behav. 2015;42(4):487–92.

Zhang JY, Lo HC, Yang FL, Liu YF, Wu WM, Chou CC. Plant-Based, antioxidant-rich snacks elevate plasma antioxidant ability and alter gut bacterial composition in older adults. Nutrients. 2021;13(11).

Shenton AK. Strategies for ensuring trustworthiness in qualitative research projects. Educ Inform. 2004;22(2):63–75.

Article   Google Scholar  

Latkin CA, Edwards C, Davey-Rothwell MA, Tobin KE. The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland. Addict Behav. 2017;73:133–6.

Matthews H, Diamond JB, Morrison D, Teitelbaum SA, Merlo LJ. Patient experiences with tobacco use during substance use disorder treatment and early recovery: a mixed method analysis of phone interview responses. J Addict Dis. 2022:1–7.

Chavez MN, Rigg KK. Nutritional implications of opioid use disorder: a guide for drug treatment providers. Psychol Addict Behav. 2020;34(6):699–707.

Download references

Acknowledgements

In addition to the participants, we would like to thank the dedicated clinical staff for their enthusiasm during the planning stages of the study. Rannveig Elisabeth Nesse deserves recognition for her assistance with the transcription of the interviews. We also acknowledge the ATLAS4LAR Study Group: In Bergen: Vibeke Bråthen Buljovcic, Jan Tore Daltveit, Trude Fondenes, Per Gundersen, Beate Haga Trettenes, Mette Hegland Nordbotn, Maria Olsvold, Marianne Cook Pierron, Christine Sundal, Jørn Henrik Vold. In Stavanger: Maren Borsheim Bergsaker, Eivin Dahl, Tone Lise Eielsen, Torhild Fiskå, Marianne Larssen, Eirik Holder, Ewa Joanna Wilk, Mari Thoresen Soot.

This study is funded by the Western Norway Regional Health Authority («Strategiske forskningsmidler» through the ATLAS4LAR project - August 3, 2020 to December 31, 2029). Open access funding was provided by the University of Bergen. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Open access funding provided by University of Bergen.

Author information

Authors and affiliations.

Centre for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway

Einar Furulund & Torgeir Gilje Lid

Department of Addiction Medicine, Bergen Addiction Research, Haukeland University Hospital, Bergen, Norway

Einar Furulund, Karl Trygve Druckrey-Fiskaaen, Siv-Elin Leirvåg Carlsen, Tesfaye Madebo & Lars T. Fadnes

Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway

Einar Furulund, Karl Trygve Druckrey-Fiskaaen, Siv-Elin Leirvåg Carlsen & Lars T. Fadnes

Department of Respiratory Medicine, Stavanger University Hospital, Stavanger, Norway

Tesfaye Madebo

Department of Clinical Science, University of Bergen, Bergen, Norway

You can also search for this author in PubMed   Google Scholar

Contributions

All authors (EF, KTDF, SELC, TM, LTF and TGL) were involved in the study’s design, analysis of the data and contributed to the manuscript. EF wrote the first draft and led the writing process. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Einar Furulund .

Ethics declarations

Ethical approval and consent to participate.

As part of the ATLAS4LAR project, the Regional Ethics Committee for Health Research (REC) southeast, Norway (no. 1555386/sørøst) approved this study (dated 23 September 2020). All patients involved in this study provided written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Furulund, E., Druckrey-Fiskaaen, K.T., Carlsen, SE.L. et al. Healthy eating among people on opioid agonist therapy: a qualitative study of patients’ experiences and perspectives. BMC Nutr 10 , 70 (2024). https://doi.org/10.1186/s40795-024-00880-8

Download citation

Received : 19 February 2024

Accepted : 30 April 2024

Published : 05 May 2024

DOI : https://doi.org/10.1186/s40795-024-00880-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Substance-related disorders
• Therapeutics, Methadone
• Behavior and behavior mechanisms

BMC Nutrition

ISSN: 2055-0928

• General enquiries: [email protected]

This paper is in the following e-collection/theme issue:

Published on 14.5.2024 in Vol 8 (2024)

Exploring Children's Knowledge of Healthy Eating, Digital Media Use, and Caregivers’ Perspectives to Inform Design and Contextual Considerations for Game-Based Interventions in Schools for Low-Income Families in Lima, Peru: Survey Study

Authors of this article:

Original Paper

• Bladimir Morales-Cahuancama 1, 2 * , MSc   ; 
• Nervo Verdezoto 3 * , PhD   ; 
• Elena Gonzales-Achuy 1 , BSc   ; 
• Cinthia Quispe-Gala 1 , BSc   ; 
• William Bautista-Olortegui 1 , BSc   ; 
• Paul Hinojosa-Mamani 1 , BSc   ; 
• Juan Pablo Aparco 1, 4 , MSc  

1 Centro Nacional de Alimentación, Nutrición y Vida Saludable, Instituto Nacional de Salud, Lima, Peru

2 Programa Académico de Nutrición y Dietética, Facultad de ciencias de la salud, Universidad Peruana de Ciencias Aplicadas, Lima, Peru

3 School of Computer Science and Informatics, Cardiff University, Cardiff, United Kingdom

4 Escuela Profesional de Nutrición, Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Peru

*these authors contributed equally

Corresponding Author:

Bladimir Morales-Cahuancama, MSc

Centro Nacional de Alimentación, Nutrición y Vida Saludable

Instituto Nacional de Salud

Av Ricardo Tizón y Bueno 276

Jesús María

Lima, 15072

Phone: 51 7480000 ext 6626

Email: [email protected]

Background: The prevalence of overweight and obesity in schoolchildren is increasing in Peru. Given the increased use of digital media, there is potential to develop effective digital health interventions to promote healthy eating practices at schools. This study investigates the needs of schoolchildren in relation to healthy eating and the potential role of digital media to inform the design of game-based nutritional interventions.

Objective: This study aims to explore schoolchildren’s knowledge about healthy eating and use of and preferences for digital media to inform the future development of a serious game to promote healthy eating.

Methods: A survey was conducted in 17 schools in metropolitan Lima, Peru. The information was collected virtually with specific questions for the schoolchild and their caregiver during October 2021 and November 2021 and following the COVID-19 public health restrictions. Questions on nutritional knowledge and preferences for and use of digital media were included. In the descriptive analysis, the percentages of the variables of interest were calculated.

Results: We received 3937 validated responses from caregivers and schoolchildren. The schoolchildren were aged between 8 years and 15 years (2030/3937, 55.8% girls). Of the caregivers, 83% (3267/3937) were mothers, and 56.5% (2223/3937) had a secondary education. Only 5.2% (203/3937) of schoolchildren’s homes did not have internet access; such access was through WiFi (2151/3937, 54.6%) and mobile internet (1314/3937, 33.4%). In addition, 95.3% (3753/3937) of schoolchildren’s homes had a mobile phone; 31.3% (1233/3937) had computers. In relation to children’s knowledge on healthy eating, 42.2% (1663/3937) of schoolchildren did not know the recommendation to consume at least 5 servings of fruits and vegetables daily, 46.7% (1837/3937) of schoolchildren did not identify front-of-package warning labels (FOPWLs), and 63.9% (2514/3937) did not relate the presence of an FOPWL with dietary risk. Most schoolchildren (3100/3937, 78.7%) preferred to use a mobile phone. Only 38.3% (1509/3937) indicated they preferred a computer. In addition, 47.9% (1885/3937) of caregivers considered that the internet helps in the education of schoolchildren, 82.7% (3254/3937) of caregivers gave permission for schoolchildren to play games with digital devices, and 38% (1495/3937) of caregivers considered that traditional digital games for children are inadequate.

Conclusions: The results suggest that knowledge about nutrition in Peruvian schoolchildren has limitations. Most schoolchildren have access to the internet, with mobile phones being the device type with the greatest availability and preference for use. Caregivers’ perspectives on games and schoolchildren, including a greater interest in using digital games, provide opportunities for the design and development of serious games to improve schoolchildren’s nutritional knowledge in Peru. Future research is needed to explore the potential of serious games that are tailored to the needs and preferences of both schoolchildren and their caregivers in Peru in order to promote healthy eating.

Introduction

Food intake provides not only energy but also a variety of nutrients that play a crucial role in human health. The diversity and properties of these nutrients continue to be the subject of study to date [ 1 ]. Importantly, certain dietary patterns are critical for preventing and addressing the development of chronic noncommunicable diseases, such as cardiovascular disease, cancer, stroke, and diabetes [ 2 ] , as well as contributing significantly to the obesity and overweight epidemic [ 3 ]. Risks associated with diet, such as low intake of fruits, vegetables, and whole grains, as well as excessive consumption of red meat, processed meats, and sugar-sweetened beverages, are major contributors to global mortality rates [ 4 ]. In contrast, a healthy diet not only promotes general well-being but also plays an essential role in the prevention of the aforementioned diseases [ 5 ]. Despite the widely recognized benefits of healthy eating for children's health and optimal development, it is concerning to note that many do not meet the established recommendations for fruit and vegetable consumption [ 6 ]. Instead, they tend to overconsume sugars and fats, which represents a significant challenge for the promotion of appropriate eating habits in this population [ 7 ].

The COVID-19 pandemic accelerated the growing trend of digital media use, especially among children and adolescents [ 8 , 9 ]. Consequently, there has been increasing interest in exploring the use of digital resources to address the global epidemic of overweight, as different studies have reported positive effects on weight reduction in children and adolescents especially in higher-income countries [ 10 , 11 ]. Indeed, health promotion interventions to prevent obesity that seek to engage children through, for example, playful strategies (eg, games) can take advantage of the predisposition for entertainment and learning so that the player can make choices or decisions through the game challenges [ 12 ]. In contrast, traditional interventions (eg, weight control in children's centers) may not be appropriate for certain populations with limited mobility, time, or money, especially in low- and middle-income countries (LMICs) [ 10 ].

One type of intervention for children using digital media is digital games for educational purposes, also called serious games, which seek to entertain while supporting serious purposes such as education, training, and improving health [ 13 ]. Compared with traditional digital games, which mostly prioritize fun and entertainment, health-related serious games are intentionally created for learning about topics such as nutrition or to support health prevention and rehabilitation, for example, so that the participant can receive motivation aids and subsequently achieve a healthy target behavior [ 14 ]. In the context of changing eating-related behaviors, some systematic reviews have shown that most studies using serious games had positive results and are suitable to accompany strategies for the prevention and treatment of childhood overweight [ 15 , 16 ]. In recent years, serious games for health promotion, in particular for healthy eating [ 17 ], have been shown to be an appropriate alternative for an audience that is increasingly indifferent to television or printed advertisements; even the cost is comparatively lower [ 18 ].

Currently, there are several models for the development of digital game interventions; these models offer guidance in each part of the development cycle, from the exploration of the user's needs to the implementation of the intervention. Several researchers have pointed out that one of the main barriers to the development of digital health interventions in LMICs remains the lack of evidence regarding contextual issues, such as specific socioeconomic and infrastructural factors, as well as the target population’s use of and preferences for digital devices and media [ 19 - 22 ]. Inclusion of the target audience is recommended for the development of effective interventions [ 23 ]. In that sense, it is important to explore certain characteristics of children and adolescents to identify specific requirements of their context, as well as to establish the learning objectives of the intervention [ 24 ]. For this reason, it is necessary to conduct formative research to engage with participants to better understand their needs and the personal relevance of the messages and activities contributing to better-informed serious game interventions [ 14 ].

Formative research is a necessary step before developing an intervention because it allows understanding of the complexity of implementation projects, analyzing aspects of responses to change, adaptations, and context [ 25 ]. However, not all interventions are developed under a step-by-step implementation scheme. Although effectiveness trials or impact evaluations are required, it is also necessary to publish formative research that serves as a basis to gather design requirements for the development of an intervention [ 24 ]. This is especially true for LMICs such as Peru, where there is less evidence on the context and problems of schoolchildren, which makes it difficult to transform pilot programs into sustainable and scalable interventions [ 26 , 27 ].

Given the potential use of game-based approaches with Peruvian schoolchildren to develop health promotion interventions and prevent overweight and obesity, this formative research aimed to explore primary schoolchildren’s knowledge about healthy eating, as well as access to, use patterns of, and preferences for digital media. This information will elucidate design elements and considerations to inform the future development of health interventions such as serious games to promote healthy eating in schoolchildren in the Peruvian context.

In this cross-sectional, exploratory study, information was collected through online surveys for primary schoolchildren and only one of their caregivers. The child’s father, mother, or other relative in charge of the schoolchild at home was considered as the “caregiver.” Based on the last census, public schools in metropolitan Lima located in districts with higher population density were invited to participate.

Population and Sample

In coordination with the “Regional Directorate of Education of Metropolitan Lima” (RDEML), schoolchildren and their caregivers from the 4th, 5th, and 6th grades of primary school from 17 public schools were invited to participate. A total of 6396 officially registered schoolchildren were invited in 2021. The invitation was sent through WhatsApp groups in which teachers shared the link to the digital questionnaire and a 2-minute informative video to the caregivers. The video presented the study and showed key guidelines for the correct completion of the questionnaire. The data collection took place during October 2021 and November 2021.

Research Context

Data collection occurred during the 2021 school year, during which classes were entirely remote, and following COVID-19 public health restrictions. Communication between teachers and caregivers of schoolchildren took place using online means through WhatsApp groups or emails. Metropolitan Lima is the capital of the country with approximately 11 million citizens, representing 30% of the national population [ 28 ]. Despite the economic development of the country in recent years, even in urban areas, there is a large portion of the population with social vulnerability and scarce economic resources; this population generally uses public schools for the education of their children. The food environment of schoolchildren is disproportionately composed of the availability of ultraprocessed foods, rather than healthy options [ 29 ].

Questionnaire: Development and Design

The first version of the questionnaire was elaborated by the researchers, trying to incorporate the necessary questions for the study variables. The study variables were informed by a literature review. Subsequently, the questionnaire underwent content validation by 8 Peruvian experts from public and private academic institutions with expertise in nutrition, psychology, teaching, engineering, and digital game development. For the content evaluation, the Aiken V coefficient was calculated for each section of the questionnaire, and values > 0.7 were obtained, indicating adequate consensus of the experts [ 30 ]. Likewise, modifications were made to the questionnaire in view of the suggestions made by the experts and considered pertinent by the research team. For the form validation, 3 mothers and their children were interviewed through synchronous video calls via Google Meet; in this phase, the caregivers and children were asked if the questions were understandable and if the categories corresponded adequately to their answers. Based on the feedback from these stages, modifications were made to the questionnaire. Subsequently, the questionnaire was digitized using the SurveyMonkey web platform, and informed consent was added at the beginning of the digital questionnaire. Finally, a pilot was carried out with schoolchildren from 1 school that was not part of the 17 schools selected for the research; the link was sent to a group of 30 schoolchildren to complete the questionnaire, in order to validate the process of entering and storing information and to calculate the time it takes to answer the questionnaire (average: 20 minutes; minimum time: 16 minutes). These responses were excluded from the final analysis.

The questionnaire was designed to be answered by schoolchildren and their main caregiver at the same time. It was divided into questions for the child and questions for the caregiver. The introduction to the 2 sections presented the informed consent for the caregiver and the informed assent for the schoolchild, which included information about the research, voluntary participation, and data protection. The first part of the survey was for the schoolchild, with questions on nutritional knowledge (21 items), digital media preferences (21 items), and serious games (24 items). Most questions for schoolchildren included reference images to improve their understanding. The second part of the questionnaire was intended for the caregiver, with questions about eating habits at home related to the schoolchild (36 items) and perceptions of schoolchildren's use of digital media (12 items). All questions were close ended with multiple or single response options. The questions were short and easy to understand. The questions on nutritional knowledge included the option “I do not know” to prevent incorrect answers. The information gathered through these questions was used to construct the indicators of nutritional knowledge presented in the results (its construction is detailed in Multimedia Appendix 1 ).

Statistical Analysis

Initially, 5331 records were downloaded (survey responses submitted to the Survey Monkey platform). Subsequently, quality control was performed on the downloaded database using a systematic process [ 31 ]. We excluded 338 duplicate questionnaires from the analysis; we identified them through the similarity of the names of the children and caregivers provided during the informed consent. After this procedure, the data were anonymised. Subsequently, 345 questionnaires were excluded because they were completed in less than the minimum time estimated in the pilot (16 minutes). In addition, 26 questionnaires with inconsistencies and 578 questionnaires with unanswered questions were discarded. The responses of the pilot participants were also excluded from the analysis. In addition, 107 questionnaires without caregiver informed consent or informed assent for the schoolchild were excluded. At the end, 3937 questionnaires were included in the analysis ( Figure 1 ).

Descriptive analysis was performed focusing on variables related to the development of serious play: knowledge about nutrition, caregivers' perceptions about the use of schoolchildren's digital media, and schoolchildren's preferences for a digital intervention. Frequencies and percentages were calculated using Microsoft Excel 365 (Microsoft Corp) and SPSS version 25 (IBM Corp).

Ethics Approval

The research protocol was approved by the Institutional Research Ethics Committee of the National Institute of Health (Code OI-002-21). We coordinated with the RDEML to implement the research in all the selected schools. The digital questionnaire included informed consent for the caregiver and informed assent for the child. Participation was completely voluntary and could be stopped at any time; there was no compensation.

Table 1 shows an overview of the characteristics of our participants. The schoolchildren had a mean age of 10.8 years; 51.6% (2030/3937) were female. Most of the caregivers who responded to the survey were the schoolchildren's mothers (3267/3937, 83%) with a mean age of 38.4 years; 56.5% (2223/3937) of the schoolchildren's caregivers had a high school education. During the study period, most of the households had mobile phones (3753/3937, 95.3%) and their own WiFi internet connection (2151/3937, 54.6%).

a The question referred exclusively to the schoolchild’s mother.

b The variables were collected independently for each category, and the participant could choose more than one option.

In Table 2 , we present an overview of schoolchildren’s knowledge about healthy eating from our study: 90.8% (3574/3937) of the schoolchildren were able to distinguish, on 3 occasions, the best food options for a healthy lunchbox, and 42.2% (1663/3937) did not know the recommendation to consume at least 5 servings of fruits and vegetables per day. With respect to the questions asking schoolchildren to identify the foods with the highest sugar and fat content, 18.3% (720/3937) of the participants could not identify the solid food with the highest sugar content, 10.8% (426/3937) did not identify the beverage with the highest sugar content, and 8% (316/3937) did not identify the food with the highest fat content. In addition, 53.3% (2100/3937) of schoolchildren did not identify the front-of-package warning labels (FOPWLs) on the food images displayed. Furthermore, 36.1% (1423/3937) of schoolchildren did not relate the presence of FOPWL with the consequences they would experience if they consumed these products in excess. Finally, 95.5% (3755/3937) of schoolchildren indicated that their parents are the ones who teach them about healthy eating. All questions are shown in Multimedia Appendix 1 .

a “Achieved”: the schoolchild chose 3 appropriate options: cookie versus apple, home-produced traditional drink versus soda, chicken sandwich versus chocolate cake.

b “Identified”: the schoolchild chose the chocolate cake instead of the banana or cookies.

c “Identified”: the schoolchild chose the glass of soda instead of the glass of water or lemonade.

d “Identified”: the schoolchild chose potato chips with sauce instead of boiled potato or potato chips alone.

e “Identified”: the schoolchild selected foods with a nutritional FOPWL twice.

f“ Yes“: the schoolchild associated the most harmful food with the one that had an FOPWL twice.

g Who teaches you to eat healthy?

h The categories were collected independently for each category (Yes/No).

In Table 3 , we present an overview of caregivers’ perceptions about their children’s use of digital media. Parents reported that the most used device by schoolchildren to distract themselves was a mobile phone (2514/3937, 63.9%); likewise, the websites with the highest use were YouTube (1178/3937, 29.9%) and TikTok (723/3937, 18.4%). Regarding the perception of internet use in the education of their children, most caregivers (1885/3937, 47.9%) maintained a cautious position by selecting the option ”It helps, but it can be harmful.“ Regarding attitudes toward the use of devices for entertainment, very few caregivers indicated that they would not give permission for any reason (243/3937, 6.2%). Regarding parental control, many caregivers said that a time limit can be set (2611/3937, 66.3%). Finally, many caregivers (1495/3937, 38%) considered that the use of digital games may be inappropriate for their children.

a According to your perception, which device does your child prefer to be distracted by?

b When your child is out of school hours and connects to the internet, what type of site does he/she visit or prefer the most?

c At present, what is your perception of the internet in your child’s education?

d When your child wants to use the devices for entertainment, what is your attitude?

e When your child is entertained using devices, can you set a time limit?

f What is your perception of digital games used by children?

In Table 4 , we present the schoolchildren’s source of distraction and preferences in relation to digital games. Most schoolchildren were distracted by mobile phone use (3100/3937, 78.7%). Schoolchildren reported using digital games when they are bored (2211/3937, 56.2%) or when they feel like it (1308/3937, 33.2%). Most schoolgirls were interested in using a serious game that teaches them about food (3280/3937, 83.8%). Regarding the digital game character, 31.8% (636/2030) of girls preferred animated animals, while 42.4% (798/1907) of boys preferred superheroes. Regarding the environment of the digital game, many schoolchildren (1715/3937, 44%) preferred a nature environment.

a When you want to be distracted, do you use a computer?

b When you want to be distracted, do you use your mobile phone?

c When you want to be distracted, do you use a tablet?

d At what time do you play on the computer, mobile phone, or tablet?

e The categories were collected independently for each category, and the participant could choose more than one option.

f Would you like to try a digital game that teaches you how to eat well like in the previous figure?

g What kind of character would you like to have in a digital game?

h What kind of environment would you like a digital game to have?

Nutritional Knowledge of Schoolchildren: Challenges to Promoting Healthy Eating

The results suggest that primary schoolchildren have limited knowledge about nutrition. Although most of the schoolchildren from our study knew how to put together a healthy lunch box and identified high-calorie foods, only 42.5% of them knew the recommendation to consume at least 5 portions of fruits and vegetables per day. The “5 a day” message is part of an international campaign recommended by the World Health Organization (WHO) for healthy eating [ 32 ]. Our results show that, although this recommendation is shared by public and private institutions in Peru, through health promotion campaigns, information leaflets at schools, and TV advertisements, this message has not yet improved the knowledge of schoolchildren. Our results are very similar to an educational intervention study with Chilean children in which González et al [ 33 ] showed that, at baseline in 2018, only 45.6% of the children were aware of this message [ 33 ].

Another aspect evaluated was related to the healthy eating policy, which was implemented in Peru in 2019 [ 34 ] and requires that processed foods have FOPWLs. Our study shows that 53.3% of schoolchildren did not identify the FOPWL in the 2 images of ultraprocessed foods presented to them. The FOPWL system is a type of front-of-package (FOP) labeling that aims to make product nutritional information more understandable to consumers [ 35 ] and encourage healthier food choices [ 36 ]. The fact that schoolchildren do not recognize FOPWL means that they have not received sufficient information about nutrition labeling in their schools nor in their homes even though they are able to identify them. It has been shown that children aged 7 years to 13 years understand nutrition information and can use it to classify healthy and unhealthy foods [ 37 , 38 ]. FOPWL focuses on helping consumers make better-informed food-related choices with the aim of potentially discouraging the purchasing and consumption of ultraprocessed foods by highlighting the unhealthy aspects of products by pointing out their health risks (eg, ”High in saturated fats“). According to our results, 36.1% of schoolchildren participants did not associate the presence of FOPWL with unhealthy foods. These results are similar to those of a study with Brazilian schoolchildren in which the FOPWL was the most accepted type of FOP, compared with the Guideline Daily Amount (GDA) label and the nutritional traffic light, but it did not play the expected dissuasive role [ 39 ]. Reducing the intake of ultraprocessed foods is a key factor in the prevention of excess weight and various metabolic diseases [ 40 , 41 ]. Different studies have indicated that ultraprocessed foods, compared with natural or minimally processed foods, are calorie dense; have high concentrations of free sugars, sodium, and saturated fats; and have low concentrations of fiber and micronutrients [ 42 , 43 ].

In this study, the majority of schoolchildren (95%) indicated that their parents teach them about healthy eating. Children's eating habits are closely related to behaviors at home, specifically to the parenting and eating styles of the parents [ 44 ]. For this reason, interventions that can be targeted at parents or involving them could offer many opportunities in enhancing healthy eating practices by children, such as increasing the consumption of fruits and vegetables [ 45 ].

Opportunities for Serious Games: Digital Game Preferences of Schoolchildren

Almost all schoolchildren (83.8%) affirmed their interest in trying a digital game that teaches them about healthy eating. This result relates to the wide acceptability of digital games for children and adolescents, which could influence the use of serious games for health and nutrition. The acceptability of games by children is key to developing effective and better-informed interventions, as the enjoyment and participation of children increase the chances of achieving a change in eating behavior [ 46 ]. Most schoolchildren in our study preferred to play when they are bored (56.2%) or when they are in the mood to play (33.2%); these results are similar to those in the study by Holzmann et al [ 47 ] in which German children and adolescents had a positive emotionally induced digital game experience for pleasure and boredom [ 47 ]. Thus, the fact that most schoolchildren use digital games when they are in a good mood could be exploited to suport active learning in an entertaining way through serious games. Several authors have studied the use of serious games to improve children's nutritional knowledge [ 48 , 49 ]. In order to transmit knowledge using a game, several elements must be considered in the design, such as the character or the environment. In that sense, our study showed that most girls preferred animated animals (31.8%), while boys had a greater affinity for superheroes (42.4%). In relation to the environment of the digital game, the greatest preference of schoolchildren was a context with nature (44%). Formative studies prior to game development have investigated these preferences and had similar findings; for example, in the study by Holzmann et al [ 47 ], the majority of schoolgirls preferred a heroic animated human character, and in the study by Kayali et al [ 50 ], the majority of Austrian children aged 8 years to 14 years preferred animals and a natural environment for the digital game [ 50 ]. This information is essential because children's preferences for characters influences their motivation to use serious games that can support learning about nutrition, as children remember nutritional information when they are presented with a sympathetic character [ 51 ].

The Role of Caregivers in the Development of Serious Games

Taking a human-centered approach [ 52 ], our first step was to include caregivers in the survey because of their clear relevance in the education of schoolchildren [ 53 ]. We inquired about caregivers’ perceptions and attitudes regarding the use of the internet and digital games by schoolchildren. Considering that, during the COVID-19 pandemic, the dependence on digital media at home increased [ 54 ], and this may have affected how parents mediated the use of this technology with their children. For example, caregivers usually share mobile phones with their children; therefore, they can give an informed opinion about certain behaviors of schoolchildren. Most caregivers (47.9%) from our study considered that the internet helps in the education of schoolchildren, but they were aware that it can be harmful. The major concerns include risks such as cyberbullying or inappropriate content [ 55 ]. This concern often causes caregivers to apply restrictive measures such as setting rules for digital media use for their children. In our study, the majority of caregivers (82.7%) indicated that they permitted the use of digital devices by their children for entertainment. In addition, the majority of caregivers noted that schoolchildren complied with the time limits they agreed to for the use of digital devices for entertainment (66.3%). Parental mediation aims for children to achieve self-regulation and digital skills that allow the child to limit the risks related to the use of digital media and thus maximize the benefits digital media offers [ 56 ]. Therefore, the acceptability of a novel digital intervention for caregivers may be contingent on the serious game and careful consideration of the aforementioned risks.

In relation to digital games, 38% of caregivers perceived that the use of digital games for schoolchildren is inadequate. These results are similar to those of a study of schoolchildren and parents in New Zealand [ 57 ], in which parents were involved in the development of a serious game for nutrition education. A major concern was the excessive screen time caused by digital games, which increased sedentary behavior. Recommendations such as the Canadian 24-hour Movement Guidelines state that children have less than 2 hours per day of screen time after school [ 58 ]. Thus, more research is needed to understand whether a digital game for health, such as a serious game, can be incorporated into recreational or educational screen time, especially in LMICs. In addition, our results could be interpreted to mean that parents do not tend to give a positive rating to leisure time activities for 8- to 12-year-olds, compared with early childhood [ 59 ]. Parents tended to pigeonhole the use of digital games into totally playful and interactive purposes, as serious games are not popular in Peruvian society. Future research shall explore the potential value of serious games to support and improve children’s health in the Peruvian context. If parents are involved and become aware of the potential opportunities that serious games for health could offer [ 60 ] , their perceptions may change.

Implications for Serious Game Design in the Peruvian Context

The results of the study indicate that the best device to deploy a serious game would be a mobile phone, since it is the device type most accessible in households (95.5%) and the most used for distraction according to the schoolchildren themselves (78.7%) and their caregivers (63.9%). Due to the growing popularity of mobile phones and apps, several health apps aimed at modifiable risk factors such as children's diet have been developed [ 61 ]. Interventions based on the use of mobile phones are often effective at improving behavioral changes associated with obesity in children aged 8 years to 12 years [ 62 ].

Likewise, our study highlights how feasible it could be to develop an online game in urban areas of Peru, since almost all participant households had internet at home (94.8%) and most participant households were connected to the internet through WiFi (69.9%), which generally has unlimited megabytes. These results are similar to those of the Residential Survey of Telecommunications Services [ 63 ], which indicated that 95% of households in metropolitan Lima have internet access and the main source of internet access was through WiFi (68.5%) and mobile phones (92.3%). The residential survey also reported that 94.6% of households have a smartphone [ 63 ].

Our study suggests that serious games may be used as an educational tool to increase schoolchildren's knowledge about food and nutrition. To date, there have been no large-scale interventions in Peru to improve the nutritional knowledge of schoolchildren. In addition, educational content on nutrition in public schools is almost nonexistent, as it competes with other activities in the school curriculum.

Serious games are more cost-effective for reaching large numbers of participants than traditional interventions, such those using human resources; LMICs generally have limited resources for training and transportation of intervention staff [ 64 ]. In addition, serious games may not disrupt classroom activities and may even fit harmoniously into school curricula, such as the “Fitter Critters” serious game that children play in health classrooms for 1 week [ 65 ]. Finally, serious games can offer flexibility in relation to the location or time of play without negatively affecting the content of the intervention. Future research should further engage with caregivers and schoolchildren to explore the design, feasibility, and acceptability of the games in the Peurivan context.

Importance of Developing Digital Intervention to Improve Schoolchildren's Nutrition

Today's food environment is characterized by increased availability of cheap, tasty, energy-dense foods, coupled with wide-ranging and highly persuasive food marketing [ 66 ]. Most foods intended for children are generally excessive in sugars fat, and sodium [ 67 , 68 ]. In that sense, children and adolescents constitute a vulnerable group that deserves social protection, as they have limited nutritional knowledge, they are unable to perceive the risks of their behaviors, and their choices may be affected by the sociocultural environment such as the marketing of unhealthy foods.

Vulnerability also refers to the socioeconomic level of the students in this study; although a specific indicator was not evaluated to determine socioeconomic level, it is very likely that most students belonged to a low socioeconomic stratum. Students in public schools are generally of low socioeconomic status; this is because private schools in Peru enjoy better prestige and involve high expenses for families. In this sense, socioeconomic status is one of the main determinants of food choice and eating habits; households with lower incomes buy less healthy food [ 69 , 70 ]. For example, adolescents of low socioeconomic status often choose foods for their snacks with higher sugar content compared with their peers of higher socioeconomic status [ 71 ]. It should be noted that most successful experiences at improving nutrition in schoolchildren have been reported mainly in contexts other than LMIC [ 72 ]. It is essential that interventions such as serious games are aligned to promote children's health and development in a digital world, establishing responsible, conscious use of the screen as well as ensuring the participation of caregivers [ 73 ].

Strengths and Limitations

To our knowledge, our study is the first formative research carried out with primary schoolchildren in metropolitan Lima to support future development of a digital intervention to improve nutrition. Despite Peru's economic progress in recent years, the insufficient decentralization of the country has meant that metropolitan Lima represents 30% of the country's total population. For this reason, an attempt was made to cover the largest number of participants in the study (3937 schoolchildren), and schools in the most densely populated districts were included. In addition, the questionnaire was developed by a multidisciplinary team with expertise in health sciences, education, and informatics, disciplines relevant to the type of intervention to be developed. To achieve the best quality of responses, interviews and a pilot were conducted, the results of which served to not only improve the understanding and accuracy of the questions but also establish criteria for quality control of the database.

There are some limitations that should be mentioned. The results may be prone to selection bias, since by using a digital survey, participation may have been limited to those with internet access. In addition, probability sampling was not used, so the results are not representative of metropolitan Lima. Although the questions on nutritional knowledge took into account aspects of the food guide for the Peruvian population [ 74 ], these aspects are not yet considered in the official curriculum. There is no official school curriculum on nutrition in Peru. Finally, considering that a self-administered survey with many questions could fatigue participants and lead to decreased answer quality, we decided to prioritize the most relevant questions to answer the purpose of the research. This led to disregarding questions to better characterize the population, such as those related to socioeconomic status, and we did not include open-ended questions. We believe that this type of information would be better addressed in future research with qualitative methodology. Another limitation of this study lies in the use of self-administered questionnaires, which relied on self-reporting by the schoolchildren and their caregivers.

Conclusions

The results presented indicate that there is limited knowledge about nutrition by schoolchildren, specifically in the consumption of healthy food (fruits and vegetables) and the management of information on nutrition labels of ultraprocessed products. Moreover, the results revealed that schoolchildren are interested in using serious games to improve nutrition education. Although it seems feasible to develop an intervention using the internet, since most households have access to this service, our results higlights that mobile phones might be the most suitable device to develop a digital intervention, since they are the most available and preferred device by schoolchildren. Another aspect to consider for the development of a serious game intervention is to get the acceptance and trust of the caregivers, both in the type of content and time of use of the serious game. Therefore, the development and implementation of a serious game is a feasible alternative for schools to increase nutrition knowledge and promote healthy eating in schoolchildren as long as all the different stakeholers are involved in the design process of the intervention.

Acknowledgments

The authors would like to thank all the students, caregivers, and teachers at the schools for their collaboration. We would also like to highlight the valuable contribution of nutritionists Omaira Cochachin and Mariela Candiotti for their coordination with the teachers who helped to encourage the participation of parents and students.

This research was funded by the National Institute of Health of Peru .

Authors' Contributions

BMC was responsible for the conception, study design, data collection, wrote the interpretation, drafted this manuscript, and provided critical review. NV assisted with the study design, wrote the interpretation, drafted the manuscript, and provided critical review. EGA, CQG, and WBO assisted with data collection, administrative support of the research, and critical revision of the manuscript. PHM assisted with data collection, performed statistical analysis, and critically reviewed the manuscript. JPA assisted with study design, data interpretation, and provided critical revision. All authors approved the final version of the manuscript and assume responsibility for the integrity of the work.

Conflicts of Interest

None declared.

Indicators of nutritional knowledge.

• Jew S, Antoine J, Bourlioux P, Milner J, Tapsell LC, Yang Y, et al. Nutrient essentiality revisited. Journal of Functional Foods. Apr 2015;14:203-209. [ CrossRef ]
• Peters R, Ee N, Peters J, Beckett N, Booth A, Rockwood K, et al. Common risk factors for major noncommunicable disease, a systematic overview of reviews and commentary: the implied potential for targeted risk reduction. Ther Adv Chronic Dis. Oct 15, 2019;10:2040622319880392. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Diet, nutrition and the prevention of chronic diseases : report of a joint WHO/FAO expert consultation, Geneva, 28 January - 1 February 2002. World Health Organization. 2003. URL: https://iris.who.int/handle/10665/42665 [accessed 2024-04-24]
• GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. May 11, 2019;393(10184):1958-1972. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Healthy diet. World Health Organization. Apr 29, 2020. URL: https://www.who.int/en/news-room/fact-sheets/detail/healthy-diet [accessed 2024-02-06]
• Gaona-Pineda EB, Martínez-Tapia B, Arango-Angarita A, Valenzuela-Bravo D, Gómez-Acosta LM, Shamah-Levy T, et al. [Food groups consumption and sociodemographic characteristics in Mexican population]. Salud Publica Mex. 2018;60(3):272-282. [ CrossRef ] [ Medline ]
• López-Olmedo N, Carriquiry A, Rodríguez-Ramírez S, Ramírez-Silva I, Espinosa-Montero J, Hernández-Barrera L, et al. Usual intake of added sugars and saturated fats Is high while dietary fiber is low in the Mexican population. J Nutr. Sep 2016;146(9):1856S-1865S. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Rodrigues D, Gama A, Machado-Rodrigues A, Nogueira H, Silva M, Rosado-Marques V, et al. Screen media use by Portuguese children in 2009 and 2016: a repeated cross-sectional study. Ann Hum Biol. Feb 2021;48(1):1-7. [ CrossRef ] [ Medline ]
• Schmidt SCE, Anedda B, Burchartz A, Eichsteller A, Kolb S, Nigg C, et al. Physical activity and screen time of children and adolescents before and during the COVID-19 lockdown in Germany: a natural experiment. Sci Rep. Dec 11, 2020;10(1):21780. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Qiu L, Sun G, Li L, Zhang J, Wang D, Fan B. Effectiveness of multiple eHealth-delivered lifestyle strategies for preventing or intervening overweight/obesity among children and adolescents: A systematic review and meta-analysis. Front Endocrinol (Lausanne). 2022;13:999702. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Kouvari M, Karipidou M, Tsiampalis T, Mamalaki E, Poulimeneas D, Bathrellou E, et al. Digital health interventions for weight management in children and adolescents: systematic review and meta-analysis. J Med Internet Res. Feb 14, 2022;24(2):e30675. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Przybylski AK, Rigby CS, Ryan RM. A motivational model of video game engagement. Review of General Psychology. Jun 01, 2010;14(2):154-166. [ CrossRef ]
• Baranowski T, Buday R, Thompson DI, Baranowski J. Playing for real: video games and stories for health-related behavior change. Am J Prev Med. Jan 2008;34(1):74-82. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Thompson D. Designing serious video games for health behavior change: current status and future directions. J Diabetes Sci Technol. Jul 01, 2012;6(4):807-811. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Mack I, Bayer C, Schäffeler N, Reiband N, Brölz E, Zurstiege G, et al. Chances and limitations of video games in the fight against childhood obesity-a systematic review. Eur Eat Disord Rev. Jul 03, 2017;25(4):237-267. [ CrossRef ] [ Medline ]
• Lu AS, Kharrazi H, Gharghabi F, Thompson D. A systematic review of health videogames on childhood obesity prevention and intervention. Games Health J. Jun 2013;2(3):131-141. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Selmanovic E, Debattista K, Scarle S, Chalmers A. Obesity in children - a serious game. Proceedings of CESCG 2010: The 14th Central European Seminar on Computer Graphics. 2010.:109-116. [ FREE Full text ]
• Stokes B. Videogames have changed: time to consider "Serious Games". American University Research Archive. 2005. URL: https:/​/aura.​american.edu/​articles/​preprint/​Videogames_have_changed_time_to_consider_Serious_Games_/​23844717/​1 [accessed 2024-04-23]
• Ruyobeza B, Grobbelaar SS, Botha A. Hurdles to developing and scaling remote patients' health management tools and systems: a scoping review. Syst Rev. Aug 30, 2022;11(1):179. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Kruse C, Betancourt J, Ortiz S, Valdes Luna SM, Bamrah IK, Segovia N. Barriers to the use of mobile health in improving health outcomes in developing countries: systematic review. J Med Internet Res. Oct 09, 2019;21(10):e13263. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Till S, Mkhize M, Farao J, Shandu L, Muthelo L, Coleman T, et al. CoMaCH Network. Digital health technologies for maternal and child health in Africa and other low- and middle-income countries: cross-disciplinary scoping review with stakeholder consultation. J Med Internet Res. Apr 07, 2023;25:e42161. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Klingberg S, Motlhatlhedi M, Mabena G, Mooki T, Verdezoto N, Densmore M, et al. CoMaCH network. "Must you make an app?" A qualitative exploration of socio-technical challenges and opportunities for designing digital maternal and child health solutions in Soweto, South Africa. PLOS Glob Public Health. Dec 5, 2022;2(12):e0001280. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Larsson I, Staland-Nyman C, Svedberg P, Nygren JM, Carlsson I. Children and young people's participation in developing interventions in health and well-being: a scoping review. BMC Health Serv Res. Jun 28, 2018;18(1):507. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Whittaker R, Merry S, Dorey E, Maddison R. A development and evaluation process for mHealth interventions: examples from New Zealand. J Health Commun. 2012;17 Suppl 1:11-21. [ CrossRef ] [ Medline ]
• Elwy AR, Wasan AD, Gillman AG, Johnston KL, Dodds N, McFarland C, et al. Using formative evaluation methods to improve clinical implementation efforts: Description and an example. Psychiatry Res. Jan 2020;283:112532. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Calderón TA, Martin H, Volpicelli K, Frasso R, Díaz Arroyo EC, Gozzer E, et al. Understanding potential uptake of a proposed mHealth program to support caregiver home management of childhood illness in a resource-poor setting: a qualitative evaluation. Mhealth. May 11, 2017;3:19-19. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Mechael P, Batavia H, Kaonga N, Searle S, Kwan A, Goldberger A, et al. Barriers and Gaps Affecting mHealth in Low and Middle Income Countries: Policy White Paper . Mobile Active. May 2010. URL: https://www.mobileactive.org/pdfs/mHealth_Barriers_White_Paper.pdf [accessed 2024-04-24]
• Censos Nacionales 2017, Perú. Instituto Nacional de estadistica e Informatica (INEI). 2017. URL: http://censos2017.inei.gob.pe/redatam/ [accessed 2024-04-24]
• Saavedra-Garcia L, Meza-Hernández M, Yabiku-Soto K, Hernández-Vásquez A, Kesar HV, Mejia-Victorio C, et al. Food and beverage supply and advertising in schools and their surroundings in Metropolitan Lima. An exploratory study. Rev Peru Med Exp Salud Publica. Nov 09, 2020;37(4):726-732. [ CrossRef ] [ Medline ]
• Requejo-Salinas N, Lewis J, Michener L, La Touche R, Fernández-Matías R, Tercero-Lucas J, et al. International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study. Braz J Phys Ther. 2022;26(2):100395. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Müller H, Sedley A, Ferrall-Nunge E. Survey research in HCI. In: Olson J, Kellogg W, editors. Ways of Knowing in HCI. New York, NY. Springer; 2014;229-266.
• Fruit and vegetable promotion initiative : a meeting report, 25-27/08/03. World Health Organization. 2003. URL: https://apps.who.int/iris/handle/10665/68395 [accessed 2022-09-16]
• González CG, Domper A, Fonseca L, Lera L, Correa P, Zacarías I, et al. Aplicación y efectividad de un modelo educativo en hábitos saludables con entrega de fruta y programa de actividad física en escolares. Rev. chil. nutr. Dec 2020;47(6):991-999. [ CrossRef ]
• Presidente de la República E. DECRETO SUPREMO - N° 015-2019-SA que modifica el Reglamento de la Ley No 30021, Ley de Promoción de la Alimentación Saludable para niños, niñas y adolescentes, y el Manual de Advertencias Publicitarias. Diario Oficial El Peruano. Jun 15, 2019. URL: https:/​/busquedas.​elperuano.pe/​normaslegales/​decreto-supremo-que-modifica-el-reglamento-de-la-ley-no-3002-decreto-supremo-n-015-2019-sa-1779615-4/​ [accessed 2022-07-03]
• Hawley KL, Roberto CA, Bragg MA, Liu PJ, Schwartz MB, Brownell KD. The science on front-of-package food labels. Public Health Nutr. Mar 22, 2012;16(3):430-439. [ CrossRef ]
• Scrinis G, Parker C. Front‐of‐pack food labeling and the politics of nutritional nudges. Law & Policy. Jul 15, 2016;38(3):234-249. [ CrossRef ]
• Soldavini J, Crawford P, Ritchie LD. Nutrition claims influence health perceptions and taste preferences in fourth- and fifth-grade children. J Nutr Educ Behav. 2012;44(6):624-627. [ CrossRef ] [ Medline ]
• Brierley M, Elliott C. Nutritional components and children's interpretations of packaged food. International Journal of Health Promotion and Education. Feb 17, 2015;53(5):230-243. [ CrossRef ]
• Lima M, de Alcantara M, Martins IBA, Ares G, Deliza R. Can front-of-pack nutrition labeling influence children's emotional associations with unhealthy food products? An experiment using emoji. Food Res Int. Jun 2019;120:217-225. [ CrossRef ] [ Medline ]
• Tavares LF, Fonseca SC, Garcia Rosa ML, Yokoo EM. Relationship between ultra-processed foods and metabolic syndrome in adolescents from a Brazilian Family Doctor Program. Public Health Nutr. Jan 2012;15(1):82-87. [ CrossRef ] [ Medline ]
• Scientific Report of the 2015 Dietary Guidelines Advisory Committee. US Department of Health and Human Services. 2015. URL: https:/​/health.​gov/​our-work/​nutrition-physical-activity/​dietary-guidelines/​previous-dietary-guidelines/​2015/​advisory-report [accessed 2024-04-24]
• Martínez Steele E, Popkin BM, Swinburn B, Monteiro CA. The share of ultra-processed foods and the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional study. Popul Health Metr. Feb 14, 2017;15(1):6. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Moubarac J, Batal M, Louzada ML, Martinez Steele E, Monteiro CA. Consumption of ultra-processed foods predicts diet quality in Canada. Appetite. Jan 01, 2017;108:512-520. [ CrossRef ] [ Medline ]
• Vollmer RL, Mobley AR. Parenting styles, feeding styles, and their influence on child obesogenic behaviors and body weight. A review. Appetite. Dec 2013;71:232-241. [ CrossRef ] [ Medline ]
• Schlechter CR, Rosenkranz RR, Guagliano JM, Dzewaltowski DA. A systematic review of children's dietary interventions with parents as change agents: Application of the RE-AIM framework. Prev Med. Oct 2016;91:233-243. [ CrossRef ] [ Medline ]
• Chow CY, Riantiningtyas RR, Kanstrup MB, Papavasileiou M, Liem GD, Olsen A. Can games change children’s eating behaviour? A review of gamification and serious games. Food Quality and Preference. Mar 2020;80:103823. [ CrossRef ]
• Holzmann SL, Dischl F, Schäfer H, Groh G, Hauner H, Holzapfel C. Digital gaming for nutritional education: a survey on preferences, motives, and needs of children and adolescents. JMIR Form Res. Feb 13, 2019;3(1):e10284. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Mack I, Reiband N, Etges C, Eichhorn S, Schaeffeler N, Zurstiege G, et al. The Kids Obesity Prevention Program: cluster randomized controlled trial to evaluate a serious game for the prevention and treatment of childhood obesity. J Med Internet Res. Apr 24, 2020;22(4):e15725. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Khanana K, Law ELC. Designing children's digital games on nutrition with playability heuristics. 2013. Presented at: CHI Conference on Human Factors in Computing Systems; April 27-May 2, 2013; Paris, France. [ CrossRef ]
• Kayali F, Silbernagl M, Peters K, Mateus-Berr R, Reithofer A, Martinek D, et al. Design considerations for a serious game for children after hematopoietic stem cell transplantation. Entertainment Computing. Jun 2016;15:57-73. [ CrossRef ]
• Putnam MM, Richmond EM, Brunick KL, Wright CA, Calvert SL. Influence of a character-based app on children's learning of nutritional information: should apps be served with a side of media characters? Games Health J. Apr 2018;7(2):121-126. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Holeman I, Kane D. Human-centered design for global health equity. Inf Technol Dev. Sep 29, 2019;26(3):477-505. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Strobl H, Ptack K, Töpfer C, Sygusch R, Tittlbach S. Effects of a participatory school-based intervention on students' health-related knowledge and understanding. Front Public Health. Apr 24, 2020;8:122. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Werling AM, Walitza S, Grünblatt E, Drechsler R. Media use before, during and after COVID-19 lockdown according to parents in a clinically referred sample in child and adolescent psychiatry: Results of an online survey in Switzerland. Compr Psychiatry. Aug 2021;109:152260. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Symons K, Ponnet K, Walrave M, Heirman W. A qualitative study into parental mediation of adolescents' internet use. Computers in Human Behavior. Aug 2017;73:423-432. [ CrossRef ]
• Sciacca B, Laffan D, O'Higgins Norman J, Milosevic T. Parental mediation in pandemic: Predictors and relationship with children's digital skills and time spent online in Ireland. Comput Human Behav. Feb 2022;127:107081. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Leong C, Liesaputra V, Morrison C, Parameswaran P, Grace D, Healey D, et al. Designing video games for nutrition education: a participatory approach. J Nutr Educ Behav. Oct 2021;53(10):832-842. [ CrossRef ] [ Medline ]
• Chaput J, Colley RC, Aubert S, Carson V, Janssen I, Roberts KC, et al. Proportion of preschool-aged children meeting the Canadian 24-Hour Movement Guidelines and associations with adiposity: results from the Canadian Health Measures Survey. BMC Public Health. Nov 20, 2017;17(Suppl 5):829. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Watchman T, Spencer-Cavaliere N. Times have changed: Parent perspectives on children's free play and sport. Psychology of Sport and Exercise. Sep 2017;32:102-112. [ CrossRef ]
• Pappa D, Zoulias E, Mantas J. Effective design of serious games for children with chronic diseases: the role of parents and caregivers. Stud Health Technol Inform. Jun 26, 2020;272:437-440. [ CrossRef ] [ Medline ]
• Schoeppe S, Alley S, Van Lippevelde W, Bray NA, Williams SL, Duncan MJ, et al. Efficacy of interventions that use apps to improve diet, physical activity and sedentary behaviour: a systematic review. Int J Behav Nutr Phys Act. Dec 07, 2016;13(1):127. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Yau KW, Tang TS, Görges M, Pinkney S, Kim AD, Kalia A, et al. Effectiveness of mobile apps in promoting healthy behavior changes and preventing obesity in children: systematic review. JMIR Pediatr Parent. Mar 28, 2022;5(1):e34967. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Organismo Supervisor de Inversión Privada en Telecomunicaciones (Perú). Telecommunications services in Peruvian homes. Residential Survey of Telecommunications Services (ERESTEL) 2021. Osiptel. 2022. URL: https://repositorio.osiptel.gob.pe/handle/20.500.12630/808 [accessed 2024-04-24]
• Snuggs S, Houston-Price C, Harvey K. Healthy eating interventions delivered in the family home: A systematic review. Appetite. Sep 01, 2019;140:114-133. [ CrossRef ] [ Medline ]
• Joyner D, Wengreen H, Aguilar S, Spruance L, Morrill B, Madden G. The FIT Game III: reducing the operating expenses of a game-based approach to increasing healthy eating in elementary schools. Games Health J. Apr 2017;6(2):111-118. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. Aug 27, 2011;378(9793):804-814. [ CrossRef ] [ Medline ]
• Powell LM, Schermbeck RM, Chaloupka FJ. Nutritional content of food and beverage products in television advertisements seen on children's programming. Child Obes. Dec 2013;9(6):524-531. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Torres-Schiaffino D, Saavedra-Garcia L. Relationship between marketing to children on food labeling and critical nutrient content in processed and ultra-processed products sold in supermarkets in Lima, Peru. Nutrients. Nov 28, 2020;12(12):3666. [ FREE Full text ] [ CrossRef ] [ Medline ]
• French S, Tangney C, Crane M, Wang Y, Appelhans B. Nutrition quality of food purchases varies by household income: the SHoPPER study. BMC Public Health. Feb 26, 2019;19(1):231. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Hough G, Sosa M. Food choice in low income populations – A review. Food Quality and Preference. Mar 2015;40:334-342. [ CrossRef ]
• Gangrade N, Figueroa J, Leak TM. Socioeconomic disparities in foods/beverages and nutrients consumed by U.S. adolescents when snacking: National Health and Nutrition Examination Survey 2005-2018. Nutrients. Jul 24, 2021;13(8):1. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Verdonschot A, Follong B, Collins C, de Vet E, Haveman-Nies A, Bucher T. Effectiveness of school-based nutrition intervention components on fruit and vegetable intake and nutrition knowledge in children aged 4-12 years old: an umbrella review. Nutr Rev. Feb 10, 2023;81(3):304-321. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Canadian Paediatric Society‚ Digital Health Task Force. Screen time and young children: Promoting health and development in a digital world. Paediatr Child Health. Nov 2017;22(8):461-468. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Ministerio de Salud. Guías Alimentarias para la Población Peruana. Lima, Perú. MINSA; 2019. URL: https://bvs.minsa.gob.pe/local/MINSA/4832.pdf [accessed 2024-02-29]

Abbreviations

Edited by A Mavragani; submitted 19.05.23; peer-reviewed by A Chwałczyńska, R Ciptaningtyas, T Baranowski; comments to author 25.01.24; revised version received 15.02.24; accepted 19.02.24; published 14.05.24.

©Bladimir Morales-Cahuancama, Nervo Verdezoto, Elena Gonzales-Achuy, Cinthia Quispe-Gala, William Bautista-Olortegui, Paul Hinojosa-Mamani, Juan Pablo Aparco. Originally published in JMIR Formative Research (https://formative.jmir.org), 14.05.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

• News & Analysis on Food & Beverage Development & Technology

Developing Ozempic-era foods, beverages: Mattson shares research on what GLP-1 users crave

14-May-2024 - Last updated on 14-May-2024 at 09:48 GMT

• Email to a friend

GLP-1 drugs — which suppress hormones associated with hunger — have been a  hotly debated solution to the obesity epidemic ​ in the US among health professionals. Given the drugs’ effectiveness in promoting weight loss,  Morgan Stanley forecasts ​ that 24m Americans — or 7% of the population — will be on GLP-1 drugs by 2035. 

In a recent survey, Mattson interviewed more than 100 consumers who were or are on anti-obesity medicine (AOM), like GLP-1 drugs Ozempic and WeGovy, about their experience with the drugs and if they noticed any eating habit changes.  

Most surveyed consumers (69%) had a positive experience on AOM, while 28.2% had a mixed and 2.8% had a negative response to the drugs. Many consumers experienced decreased food noises — thoughts of eating and food — with 24% of respondents saying they spend much less time thinking about food and 37% a little less of the time. 

AOM drugs correlated with healthier eating, drinking

Typically, consumers on AOM ate less processed foods, including sugary drinks and salty snack foods, dairy products, coffee, energy drinks and spices, and ate more high-protein foods, eggs, fruits, vegetables, grains, and legumes. 

Most consumers on AOM drugs (61%) said they ate fewer meals, and 51% ate fewer snacks. Similarly, 93% of respondents said portion sizes decreased while on the drug, while 7% reported no change in portion sizes. 

These healthier eating and drinking behaviors paralleled advice AOM users received from their doctor on how to manage the drug’s side effects, including gastrointestinal issues and muscle loss, Jennifer Pagano, insight manager at Mattson, noted during the webinar.    

"Common advice that [consumers received] was increase your protein because you are going to be eating [fewer] nutrients — and you are going to need more key nutrients when you are eating smaller amounts of food — reduce carbs, drink a lot of water and then reduce portions and meal frequency." 

From hydrating popsicles to quick chicken: What products resonate with AOM users 

To gain the most benefit from GLP-1 drugs, "AOM users have a wish list" of foods and beverages claims, which can be used as inspiration for CPG brands developing products, Katie Hagan, executive VP of insights and innovation for Mattson, shared during the webinar. 

“ Portion control ​ and smaller portion sizes is a really big need. ... The need to hydrate is also really important and hydrating in a low sugar, [and] non-carbonated way as well. Then in addition, increasing their protein intake not only for maintaining muscle mass, which is really important as you are losing large quantities of weight ... but we also learned from our research that consumers found that increasing their protein consumption helped with nausea," Hagan said.  

Mattson used the report insight and AI tools to visualize what a series of 22 AOM-orientated concepts would look like, she added. These concepts focused on need states and occasions for AOM users and include: 

• Grilled Quick Chick Strips ​: An on-the-go pre-portion chicken snack that is fully cooked and designed to be eaten as is or on a salad.
• Greek Yogurt Sneaks ​: This concept is a smaller protein-rich version of the yogurt pouch beverages, which include classic fruit flavors like Strawberry Sensation, Mango Magic, and Blueberry Bliss. 
• Mindful Cups ​: A line of globally inspired mini meals or snacks in a cup — including Savory Thai Coconut Curry, Mexican Chicken Fiesta, and Mediterranean Veggie, — that are ready to eat in three minutes after adding hot water.
• HydroPops ​: HydroPops are low-sugar frozen fruit popsicles with Tropical, Berry and Green varieties, tapping into the demand for healthier hydration. 

Related news

Related products

Gain an edge with our active nutrition expertise

Content provided by ADM | 25-Apr-2024 | White Paper

The intersection of the rising plant-based trend and increasing awareness of gut health has opened new opportunities for market success.

Replacement Isn't the Future. Variety Is.

Content provided by ADM | 22-Mar-2024 | White Paper

Successfully navigating the intersection of food and technology can help your business meet evolving consumer demands.

Some home truths about real prebiotic dietary fibre

Content provided by BENEO | 22-Mar-2024 | Product Presentation

Confused about prebiotics? You’re not the only one! Food developers wanting to work with prebiotic dietary fibre are faced with an abundance of products...

Consumer Attitudes on Ultra-Processed Foods Revealed

Content provided by Ayana Bio | 12-Jan-2024 | White Paper

Ayana Bio conducted the Ultra-Processed Food (UPF) Pulse survey, offering insight into consumers’ willingness to consume UPFs, as well as the variables...

Related suppliers

• Blue Diamond Global Ingredients
• IMBAREX Natural Colors
• Rethink Events Ltd
• Tales of Triumph from the Factory Floor, Vol. 1 QAD Redzone | Download Case Study
• Gain an edge with our active nutrition expertise ADM | Download Technical / White Paper
• Learn more: Future Food-Tech Alternative Proteins Rethink Events Ltd | Download Technical / White Paper
• Sustainably sourced. Naturally versatile. Covation Bio™ PDO | Download Insight Guide
• Replacement Isn't the Future. Variety Is. ADM | Download Technical / White Paper
• Some home truths about real prebiotic dietary fibre BENEO | Watch Product Presentation

Upcoming supplier webinars

• 23 May 2024 Thu Unpacking the Impact: What State Color and Food Additive Bans Mean for Your Products FoodChain ID

Upcoming editorial webinars

• 29 May 2024 Wed Webinar Plant-based 3.0: Emerging from the trough of disillusionment

On-demand webinars

• The easy path to “dry” cleaning & sanitization
• From Labeling to Leading: A Cost-Effective Approach for Empowering Innovation FoodChain ID
• Real-time Brix monitoring - the secret ingredient your process needs for quality and efficiency
• Sweet Solutions: Exploring the Future of Sugar Reduction
• Free-From Webinar
• Food for Kids Webinar

Promotional Features

FoodNavigator-USA

• Advertise with us
• Apply to reuse our content
• Press Releases – Guidelines
• Contact the Editor
• Report a technical problem
• Whitelist our newsletters
• Why Register
• Editorial Calendar
• Event Calendar