Eating from a Nutrition Point of View
KeywordsHealthy Eating Nutritional Guideline Healthful Food Healthful Eating Nutrition Communication
Ample evidence exists on the negative influence on health of eating a diet high in energy, saturated fat, and salt and the onset of diabetes, cardiovascular, and malignant diseases (for an overview, see WHO 2004). The rising problem of obesity fuels the efforts of health promoters, policy makers, the food industry, and other experts concerned with nutrition communication to promote convenient healthful eating. Despite these efforts, promoting healthful eating remains a challenge (see Obesity and Consumer Choice).
At present, two contradictory trends emerge in nutrition promotion. On the one hand, decades of efforts have created awareness and understanding of eating for health, to eat a variety of food, more fruits, vegetables, and fish and avoid too much fatty and sugary food, calories, and salt, and have also created the intention to do so in practice. At the environmental level, great efforts have been put into “making the healthy choice the easy choice.” On the other hand, studies show that, in the Netherlands as well as in other countries, most consumers eat less fruit and vegetables and more products high in energy, saturated fat, and sugar than recommended. This latter type of dietary intake is indicated as one of the main causes of the increasing prevalence of obesity and consequent rise in adult onset of diabetes, nowadays a major public health concern in the Netherlands, as well as globally.
Apparently, knowing what to eat for health is not put into practice by many people. New strategies, therefore, have to be considered to ensure that consumers direct their eating practices toward health.
This entry discusses firstly the current biomedical-oriented strategy of specifying nutritional recommendations on why, how, and what to eat to remain in good health (2). Then, the mismatches between this approach and the way people themselves deal with food and health in their everyday lives are presented (3) and discussed in relation to ethical considerations (4). The next section introduces the salutogenic perspective (5) and the evidence regarding its value for application to the promotion of healthier eating practices (6). The last part of this entry discusses implications and examples of using this perspective for nutrition research and promotion (7) and conclusions (8).
Existing Efforts: Nutritional Specification
Nutritional research is increasingly capable of identifying the relation between specific nutrients and physical health. The insights are translated into guidelines for healthful eating and communicated to consumers through educational and marketing efforts. The rising problem of obesity fuels the efforts of health promoters, policy makers, the food industry, and other experts concerned with nutrition communication to facilitate convenient healthful eating.
The further specification of advice on why, what, and how to eat for physical health is fuelled by three developments. Firstly, behavioral research supports the idea that specific advice is more successful than general advice in motivating healthful eating because individuals view it as more personally relevant (Eyles and Mhurchu 2009). This so-called tailored advice provides individuals with highly specific information on individual health risks and benefits of their current eating habits and the desirable changes (see Food Risk Communication). In addition, rapid developments in interactive computer technology (ICT), especially the Internet, allow for the provision of tailored advice on a larger scale than possible through face-to-face consults (Broekhuizen et al. 2012). A third development is that of nutrigenomics research. This innovative discipline of nutritional research studies the interaction between food, genes, and health at the molecular level. A genetic test for vulnerability to diet-related disease, such as cardiovascular disease, could be added to a personal risk assessment, one that is currently comprised of indicators such as body mass index and blood cholesterol (German et al. 2005).
In addition to individually tailored advice, making healthy choices is facilitated by a growing variety of convenient, tasty, and healthful foods and meals available to consumers. These may facilitate uncomplicated healthful and pleasurable food choice. And, if needed, consumers can buy functional foods, in the form of health-claim-carrying products or natural foods that offer convenient, instant compensation for potential damage done to health (Bouwman et al. 2009; see Functional Foods).
Nutrition Research and Everyday Eating as a Social Practice
The key idea that drives a lot of nutrition research and promotion is that eating for attaining or maintaining good individual physical health is a central goal in life. This biomedical notion of health drives the search in nutritional studies for a better understanding of the risks and benefits of certain nutrients for physical health (see Nutritionism). It is related to that of “healthism,” a concept introduced by Crawford (1980) to describe a new form of health consciousness that refers to a preoccupation with personal health as the primary focus for the achievement of health and well-being. Health behavior thereby became the paradigm for good living.
The studies based on this biomedical approach orient toward pathogenesis, the study of disease origins and causes. It starts by considering disease and infirmity and then works retrospectively to determine how individuals can avoid, manage, and/or eliminate that disease or infirmity. This risk-oriented, pathogenic view underlies the search in nutritional research and promotion for nutrients, foods, and meals that prevent, treat, or manage diet-related diseases.
A parallel can be drawn between nutritional research and behavioral food research, the research areas that provide the scientific basis for nutrition promotion strategies. Both areas study how interactions between humans and their social and cultural context impact physical health. The areas also share the difficulties involved in exploring contextual variables that often cannot be controlled in research studies (Fischer 2006). If humans are studied without considering contextual influences, the validity of the research results for everyday life situations is limited. This applies to nutritional research, where issues about contextual influences are threefold: (1) limitations of studying single nutrients while people consume food products, (2) studying specific food products while people consume diets composed of many foods, and (3) studying diets without considering other lifestyle components. This perspective causes a gap between healthy eating guidelines (e.g., eat polyunsaturated fats and avoid sugar) and concrete action rules for real-life eating practices.
The review of the literature on health behavior change and health communication on this aspect of Bouwman and van Woerkum (2012) indicates mismatches between the focus on physical health in nutrition promotion and consumers’ own view.
Firstly, that healthful eating is not solely a matter of conscious personal choices for the benefit of maintaining or attaining physical health. Studies show that eating involves other functions such as taste, convenience, costs, moral concerns, and the maintenance of relationships (Sobal et al. 2006) that often take precedence over biomedical health. Scrinis (2008) argues that the narrow focus on physical health, so-called nutritionism, may have limited value in everyday life (see Medicalization of Eating and Feeding). The scant attention paid to the social and cultural circumstances in which attitudes or intentions are formed in the dominant, cognitive perspective on health behavior more generally is widely addressed in literature (Fischer 2006; Green 2006).
The second issue concerns the absence of the social dimension of eating in nutritional guidelines. Decisions and actions regarding food habits are embedded in a range of other social activities. Following nutritional guidelines in daily life is therefore not a matter of course (cf. van Woerkum and Bouwman 2012). Yet, nutritional guidelines are oriented toward the physical side of health and the concurrent denial of the social embeddedness of food and health behavior and thus seem to ignore that aspect. Food is often shared with others and provides opportunities for making social contacts. Within these social interactions, it may function as a marker of culture and as an expression of affection, attachment, or identity (see You are What You Eat). Apart from being a social activity in itself, eating behavior is also influenced by the broader social context. This social environment has been proven influential in stimulating or inhibiting consumers’ capacity to eat more healthfully. A recent review of qualitative studies confirms that healthy eating reflects people’s personal, social, and cultural experiences, as well as their environment (Bisogni et al. 2012).
A third issue concerns the increasing specificity, and thereby the complexity, of what to eat and what not to eat for the benefit of health. Healthful eating requires a well-organized life, but many consumers are unable to achieve this. Dealing with complexity seems to become more important than eating in accord with nutritional guidelines itself. This complexity is only partly taken care of by health promoters, policy makers, the food industry, and other experts in nutrition communication who facilitate convenient, healthful eating. For instance, a growing variety of convenient, tasty, and healthful foods and meals are available to consumers. These may facilitate uncomplicated healthful and pleasurable food choice. And, if needed, consumers can buy functional foods, in the form of health-claim-carrying products or natural foods that offer convenient, instant compensation for potential damage done to health. It may however lead to the idea that critical thinking by individuals on how to organize healthful eating in everyday life can be handed over to experts. As a consequence, consumers themselves may deal with healthful eating as uncomplicated and unproblematic, as not requiring thoughtful consideration, because someone else is already taking care of it (Bouwman et al. 2009).
Besides questions regarding the everyday relevance and applicability of biomedical-informed nutrition promotion strategies, ethical issues arise as well. A first question is whether the biomedical, pathogenic route toward specification sufficiently addresses autonomy and, hence, will indeed enable healthier eating practices. The second question relates to the increasing specificity and whether this route will exclude those who are in most need for support.
The first issue concerns the tension between the expert-driven nature of the current approach toward food and health and autonomy, the capacity to self-govern and self-control, and being able to act in an independent manner in relation to eating. Health promotion and, hence, nutrition promotion aim for the human rights value of enabling people to lead an autonomous, active, and productive life, a “good life” or quality of life (WHO 1986). Yet, the expert-driven nature of the current food arena reduces the need for self-governance and self-control and hence autonomy in relation to food choice. It can be questioned who is in the drivers’ seat in the food-health arena, where complex nutritional information is simplified by experts and presented in claims, logos, and guidelines on health and sustainability. “You are what you are told to eat” seems to replace “You are what you eat,” signaling distance between people and the way food is produced and “served” in television programs and advertisements and on the food itself.
The availability of specified nutrition advice may also induce societal attribution of extended individual responsibility for one’s health (Korthals 2011). It is however questionable whether the singular focus on attaining biomedical health (Nutritionism) enables increased accountability (Nordström et al. 2013). Enabling the “good life” requires an integration of social and spiritual life ambitions and actions, especially in relation to food. Without consideration of these values, the biomedical route may compromise rather than support autonomy and healthier eating practices (see Medicalization of Eating and Feeding).
The second ethical issue concerns that provision of tailored advice on why, what, and how to eat for health presupposes a self-conscious consumer, willing and capable of finding, understanding, and applying the information. It requires a certain level of “nutritional intelligence.” People who do not accomplish this level may ignore, discard, or misinterpret the information. Similar to other health-related issues, unhealthy eating and its consequences are more prevalent among groups with low socioeconomic status. Nutrition education has shown to be relatively ineffective among lower-income groups (Robertson et al. 2007). Further specification and hence complicating information may therefore not reduce yet increase societal inequalities.
The Salutogenic Perspective on Health
The above sketched issues which result from the dominant role of the biomedical route in nutrition promotion can be addressed by adding a complementary, context-sensitive route. Salutogenesis – a theoretical perspective on health – offers an excellent starting point. Antonovsky’s salutogenic approach is centralized around the question “what creates health?” It targets the search for ways to create, enhance, and improve physical, mental, and social well-being. A key difference with the biomedical perspective is that it assumes health-related practices – such as eating for physical health – as a resource for living rather than a central goal of life (Antonovsky 1987). Healthful eating, together with other biological, material, and psychosocial resources, makes it easier for people to perceive their lives as consistent, structured, and understandable. These resources foster repeated life experiences which help to view the world as “making sense,” cognitively, instrumentally, and emotionally. Antonovsky uses here the metaphor of “stimuli bombarding one from the inner and outer environments are perceived as information rather than noise.”
Out of this way of thinking emerged the sense of coherence (SOC) construct. This orientation perceives the world, on a continuum, as comprehensible, manageable, and meaningful. The strength of one’s SOC is a crucial factor in facilitating the movement toward health. Confronted with a stressor, a person with a strong SOC will be motivated to cope (meaningfulness), believe that the challenge is understood (comprehensibility), and believe that resources to cope are available (manageability). Comprehensibility represents the cognitive component, manageability the instrumental or behavioral component, and meaningfulness the motivational component (Lindstrom and Eriksson 2006).
Life experiences that lead to a strong SOC allow one to reach out in any given situation and apply the resources appropriate to that stressor. Three kinds of life experiences shape the strength of one’s SOC: consistency, underload-overload balance, and participation in socially valued decision making. The extent of such experiences is formed by one’s position in the social structure and by one’s culture – e.g., work and family life.
Salutogenesis and Healthy Eating
Antonovsky developed a scale to measure the strength of the SOC, called the Orientation to Life Questionnaire, which included the SOC-29 and a shorter form, the SOC-13 – comprising of 13 questions on meaningfulness, comprehensibility, and manageability. Since these SOC scales were originally devised by Antonovsky in the 1980s, they have been translated into at least 33 languages in 32 countries with at least 15 different modified versions of the questionnaire available. These scales measure the strength of the three traits which compromise the SOC: meaningfulness, comprehensibility, and manageability. These SOC scales have been found to be highly reliable, valid, and cross-culturally applicable instruments to gauge how people cope with stressful situations and as a result stay healthy (Eriksson and Lindström 2005).
In an extensive systematic review, Eriksson and Lindström (2006) found that a high SOC score was strongly associated with a better perceived physical and mental health and it has a main, moderating, and mediating role in the explanation of positive health. Several studies have also proposed that a strong SOC is associated with healthier eating patterns and lifestyle choices than those with a weaker SOC. Lindmark et al. (2005) found in a cross-sectional study of Swedish adults that both men and women with a high SOC score reported higher intake of healthier food choices such as vegetables and whole grains. They further found that those with lower SOC scores reported higher intakes of unhealthier food choices such as pizza, French fries, and hamburgers. Moreover, research from a population-based cohort study in the United Kingdom found that men and women with a strong SOC were less likely to smoke cigarettes; less likely to be physically inactive; reported higher intake of fruits, vegetables, and fiber; and had a 20 % reduced risk of all-cause mortality than those with a lower SOC, independent of social class and education level (Wainwright et al. 2007). Ray et al. (2009) further found that a strong parental SOC was associated with their children having more regular child eating patterns, lower intake of energy-dense foods, and higher intake of nutrient-rich foods. Their evidence further suggested that parent’s SOC and children’s intake of nutrient-rich foods were mediated by factors from the social and physical context such as providing access to fruits and vegetables at home, having better awareness of recommendations on healthy eating, acting as a role model for their child by eating fruits and vegetables, and eating regular meals together as a family.
Salutogenic research goes beyond only measuring SOC and its association with health and lifestyle behaviors. As Lindström and Eriksson described, salutogenesis is “much more than only the measurement of the Sense of Coherence, it is a much broader concept focusing on resources, competencies, abilities; assessed on different levels, the individual, the group, families and also societies, of which the concept of resilience is one of these assets to health that falls under the salutogenic umbrella” (Lindström and Eriksson 2010). Resilience can be described as a positive capacity to cope with stress and adversity. Qualities of resilience such as flexibility, resourcefulness, and coping with adversities are very similar to GRRs which create the prerequisites for developing a strong SOC as described by Antonovsky. Further, resilience is just like salutogenesis in that it is not a trait, but rather a dynamic process that illustrates how the availability and use of resources can be used to promote well-being (salutogenic) or protect people from adversities (resilience) to set people on the continuum of positive health.
In the past, the concept of resilience had been mostly applied within only child development, mental health, and psychology; however in recent years the concept has been applied to a variety of topics. Australian researchers have begun to apply the concept to study the phenomenon of “obesity resilience” among populations with high levels of health disparities. This research has suggested that characteristics such as perceived social support from family and friends for healthy eating and physical activity, perceived self-control for healthy eating, self-efficacy for regulating eating and physical activity, social participation, and neighborhood access to healthy foods all explained variations in BMI in woman living in disadvantaged neighborhoods (Ball et al. 2012). Moreover, Williams et al. (2011) identified personal, social, and environmental factors that promote healthy eating and healthy weight among families from economically disadvantaged neighborhoods in Australia. These included parental control, moderation and support for healthy eating, parental role modeling, and limiting access to unhealthy foods. American researchers have also recently begun to examine the obesity resilience phenomenon. Lim et al. (2011) found that among families from deprived neighborhoods in urban Detroit, a higher parental capacity for resilience was associated with healthy weight maintenance and lower soft drink consumption in their 3–5-year-old children over a 4-year follow-up period.
In sum, the salutogenic research paradigm strives to ultimately answer the question “what creates health” rather than “what causes disease” and, hereby, complements the biomedical route in multiple ways. The salutogenic view toward health complements the biomedical route by adding the everyday life dimension where people strive not only to avoid disease yet also for quality – “goodness” – in life. People need to be aware of not only risks that keep them from achieving good health but also how they can use resources within and outside themselves to guide them successfully toward positive health. It includes all aspects of health, being in line with the way people themselves experience health: as resulting from an interplay between bodily, mental, social, and spiritual well-being. It is embedded in the social context; it studies the dynamics between people and environment and how health develops from this interaction – or not. It aims to identify the patterns and mechanisms underlying health processes, rather than factors bound to people, as is characteristic to biomedical-oriented research. Disjointedly studying and enacting upon people and context may be easier but does not do justice to reality. Society can be rich in resources; the outcome depends on how people make sense, interpret, and give meaning to these resources in relation to health.
Implications for Research and Practice
In summary, the evidence emerging from salutogenic research suggests that a higher SOC score is associated with better perceived physical and mental health and it has a main, moderating, and mediating role in positive health outcomes. Findings from the salutogenic literature suggest that those with a higher SOC make healthier food choices, eat less energy-dense foods, have healthier physical activity patterns, and tend not to be smokers. Such research has been important to gain initial insight into the resources that promote healthful eating and resilience to obesity at the individual, family, and community levels. However, we have only just begun to scratch the surface. In-depth qualitative research has yet to be applied to study the mechanisms and patterns behind the phenomenon of eating well. In future research, it will be important to examine how healthy eaters adapt and utilize resources in health-promoting ways despite such overwhelming influences of the “obesogenic” environment. For instance, what types of life experiences with healthy eating and lifestyle have shaped the development of a high SOC and resilience to obesity?
The use of the salutogenic perspective has several implications for research. The target groups are those who do manage to sustain in their intentions to eat healthfully and find out why they are doing well. The questions should centralize around the life experiences that have led to their strong SOC, their ability to cope with a “challenging” environment in relation to eating for health. With respect to eating, one can think of how they deal with the abundance of food, “seductive” marketing efforts, pricing strategies, as well as negative social norms – e.g., the health freak image mentioned above. What are the knowledge, tools, or skills, on a biomedical (as provided by existing nutrition advice), practical, as well as social level, required to effectively deal with these challenges in everyday life?
Secondly, research should not be limited to topics directly related to the food chain process of buying, preparing, and consuming food. Peoples’ other, interlinked ambitions and actions should be considered as well. The aim is to identify how eating for health is linked with other resources that contribute to health and well-being, for instance, experiencing nature, playing, or child rearing (see Childhood Obesity and Parent Responsibility). In line with this, care farms, natural playgrounds, or city gardens may serve as excellent settings for promoting eating for health.
A third aspect is the question how the complexity that characterizes advice on why, how, and what to eat relates to the element of comprehensibility, the understanding of one’s environment. We propose that nutrition promotion, besides considering the impact of (un)healthful food choice on personal health, also includes other levels (from local to global) and domains linked with food (e.g., animal welfare and natural resource management).
The complex nature of eating advice may also hinder the opportunity for positive life experiences required to establish a strong SOC. As mentioned above, these life experiences should be characterized by consistency, an underload-overload balance and participation in socially valued decision making. The fast changing insights on food-health relations may not provide for consistency. And the enormous attention paid to food-health may lead to an overload of information. The importance of the aspect of “participation” is widely recognized in health promotion and central to human rights. Yet, current nutrition promotion efforts insufficiently allow for active involvement of people themselves (Bouwman 2009). We therefore wish to emphasize the need for a change from expert-driven nutrition promotion toward a coevolutionary development process. In this process, people themselves are actively involved, issues and solutions can be exchanged between consumers and experts, and new ways to establish eating for health may be devised.
The biomedical specification route provides valuable insights on risk factors and strategies to avoid disease. Yet, its complex nature and distance to the everyday context of eating practices may limit the impact of nutrition promotion efforts and compromise the values of autonomy and health equity. Complementing this route with the salutogenic approach will be relevant for public health practice in developing interventions that enhance and develop personal, social, and environmental resources which foster healthy eating practices. Through coordinated action with relevant societal actors, findings could also be used to propose and develop “salutogenic” public health interventions which fit within current frameworks and policies. Furthermore, the research findings can help develop new tools for practitioners to assist people that are struggling with their weight in designing a “personalized health trajectory” that enables and empowers them to utilize personal, social, and physical resources for health. Most importantly, such action-oriented approaches form part of the solution and help people in accomplishing lifestyle changes in the context of their everyday lives (van Woerkum and Bouwman 2012).
It can be expected that salutogenic research findings will be highly valuable not only for practitioners but also for policy makers and industry. The knowledge gained from salutogenic research can be used to design more holistic, context-sensitive, and solution-oriented obesity and lifestyle-related policies, as well as develop socially driven technologies and devices which emphasize enabling and facilitating resources within people’s social and physical contexts as a means to promote health and prevent obesity. Health promotion has a long tradition of arranging enabling contexts to mobilize human and material resources to promote and protect health.
This does not require a complete paradigm shift to using only salutogenic methods, rather that there should be more of a balance between pathogenic and salutogenic methods in obesity research. Introducing more salutogenic approaches to obesity research can complement the existing knowledge by identifying the “determinants of success” in those coping well with the obesogenic environment and comparing these to the established “determinants of failure” in people who struggle with overweight and obesity due to unhealthful dietary and lifestyle practices. By widening the research perspective to encompass both approaches, one can better understand how the complex interplay between physical, mental, social, and contextual factors can support the maintenance of a healthy weight and promote well-being. This understanding can ultimately aid science and practice in creating supportive and enabling social and physical contexts which promote healthy eating, lifestyle practices, obesity prevention, and overall health.
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