thesis statement of healthy eating

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• 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

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• 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.

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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.

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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.

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

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Department of Psychology, University of Konstanz, Konstanz, Germany

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

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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.

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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

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12.4 Annotated Student Sample: "Healthy Diets from Sustainable Sources Can Save the Earth" by Lily Tran

Learning outcomes.

By the end of this section, you will be able to:

• Analyze how writers use evidence in research writing.
• Analyze the ways a writer incorporates sources into research writing, while retaining their own voice.
• Explain the use of headings as organizational tools in research writing.
• Analyze how writers use evidence to address counterarguments when writing a research essay.

Introduction

In this argumentative research essay for a first-year composition class, student Lily Tran creates a solid, focused argument and supports it with researched evidence. Throughout the essay, she uses this evidence to support cause-and-effect and problem-solution reasoning, make strong appeals, and develop her ethos on the topic.

Living by Their Own Words

Food as change.

public domain text For the human race to have a sustainable future, massive changes in the way food is produced, processed, and distributed are necessary on a global scale. end public domain text

annotated text Purpose. Lily Tran refers to what she sees as the general purpose for writing this paper: the problem of current global practices in food production, processing, and distribution. By presenting the “problem,” she immediately prepares readers for her proposed solution. end annotated text

public domain text The required changes will affect nearly all aspects of life, including not only world hunger but also health and welfare, land use and habitats, water quality and availability, energy use and production, greenhouse gas emissions and climate change, economics, and even cultural and social values. These changes may not be popular, but they are imperative. The human race must turn to sustainable food systems that provide healthy diets with minimal environmental impact—and starting now. end public domain text

annotated text Thesis. Leading up to this clear, declarative thesis statement are key points on which Tran will expand later. In doing this, she presents some foundational evidence that connects the problem to the proposed solution. end annotated text

THE COMING FOOD CRISIS

public domain text The world population has been rising exponentially in modern history. From 1 billion in 1804, it doubled to approximately 2 billion by 1927, then doubled again to approximately 4 billion in 1974. By 2019, it had nearly doubled again, rising to 7.7 billion (“World Population by Year”). It has been projected to reach nearly 10 billion by 2050 (Berners-Lee et al.). At the same time, the average life span also has been increasing. These situations have led to severe stress on the environment, particularly in the demands for food. It has been estimated, for example, that by 2050, milk production will increase 58 percent and meat production 73 percent (Chai et al.). end public domain text

annotated text Evidence. In this first supporting paragraph, Tran uses numerical evidence from several sources. This numerical data as evidence helps establish the projection of population growth. By beginning with such evidence, Tran underscores the severity of the situation. end annotated text

public domain text Theoretically, the planet can produce enough food for everyone, but human activities have endangered this capability through unsustainable practices. Currently, agriculture produces 10–23 percent of global greenhouse gas emissions. Greenhouse gases—the most common being carbon dioxide, methane, nitrous oxide, and water vapor— trap heat in the atmosphere, reradiate it, and send it back to Earth again. Heat trapped in the atmosphere is a problem because it causes unnatural global warming as well as air pollution, extreme weather conditions, and respiratory diseases. end public domain text

annotated text Audience. With her audience in mind, Tran briefly explains the problem of greenhouse gases and global warming. end annotated text

public domain text It has been estimated that global greenhouse gas emissions will increase by as much as 150 percent by 2030 (Chai et al.). Transportation also has a negative effect on the environment when foods are shipped around the world. As Joseph Poore of the University of Oxford commented, “It’s essential to be mindful about everything we consume: air-transported fruit and veg can create more greenhouse gas emissions per kilogram than poultry meat, for example” (qtd. in Gray). end public domain text

annotated text Transition. By beginning this paragraph with her own transition of ideas, Tran establishes control over the organization and development of ideas. Thus, she retains her sources as supports and does not allow them to dominate her essay. end annotated text

public domain text Current practices have affected the nutritional value of foods. Concentrated animal-feeding operations, intended to increase production, have had the side effect of decreasing nutritional content in animal protein and increasing saturated fat. One study found that an intensively raised chicken in 2017 contained only one-sixth of the amount of omega-3 fatty acid, an essential nutrient, that was in a chicken in 1970. Today the majority of calories in chicken come from fat rather than protein (World Wildlife Fund). end public domain text

annotated text Example. By focusing on an example (chicken), Tran uses specific research data to develop the nuance of the argument. end annotated text

public domain text Current policies such as government subsidies that divert food to biofuels are counterproductive to the goal of achieving adequate global nutrition. Some trade policies allow “dumping” of below-cost, subsidized foods on developing countries that should instead be enabled to protect their farmers and meet their own nutritional needs (Sierra Club). Too often, agriculture’s objectives are geared toward maximizing quantities produced per acre rather than optimizing output of critical nutritional needs and protection of the environment. end public domain text

AREAS OF CONCERN

Hunger and nutrition.

annotated text Headings and Subheadings. Throughout the essay, Tran has created headings and subheadings to help organize her argument and clarify it for readers. end annotated text

public domain text More than 820 million people around the world do not have enough to eat. At the same time, about a third of all grains and almost two-thirds of all soybeans, maize, and barley crops are fed to animals (Barnard). According to the World Health Organization, 462 million adults are underweight, 47 million children under 5 years of age are underweight for their height, 14.3 million are severely underweight for their height, and 144 million are stunted (“Malnutrition”). About 45 percent of mortality among children under 5 is linked to undernutrition. These deaths occur mainly in low- and middle-income countries where, in stark contrast, the rate of childhood obesity is rising. Globally, 1.9 billion adults and 38.3 million children are overweight or obese (“Obesity”). Undernutrition and obesity can be found in the same household, largely a result of eating energy-dense foods that are high in fat and sugars. The global impact of malnutrition, which includes both undernutrition and obesity, has lasting developmental, economic, social, and medical consequences. end public domain text

public domain text In 2019, Berners-Lee et al. published the results of their quantitative analysis of global and regional food supply. They determined that significant changes are needed on four fronts: end public domain text

Food production must be sufficient, in quantity and quality, to feed the global population without unacceptable environmental impacts. Food distribution must be sufficiently efficient so that a diverse range of foods containing adequate nutrition is available to all, again without unacceptable environmental impacts. Socio-economic conditions must be sufficiently equitable so that all consumers can access the quantity and range of foods needed for a healthy diet. Consumers need to be able to make informed and rational choices so that they consume a healthy and environmentally sustainable diet (10).

annotated text Block Quote. The writer has chosen to present important evidence as a direct quotation, using the correct format for direct quotations longer than four lines. See Section Editing Focus: Integrating Sources and Quotations for more information about block quotes. end annotated text

public domain text Among their findings, they singled out, in particular, the practice of using human-edible crops to produce meat, dairy, and fish for the human table. Currently 34 percent of human-edible crops are fed to animals, a practice that reduces calorie and protein supplies. They state in their report, “If society continues on a ‘business-as-usual’ dietary trajectory, a 119% increase in edible crops grown will be required by 2050” (1). Future food production and distribution must be transformed into systems that are nutritionally adequate, environmentally sound, and economically affordable. end public domain text

Land and Water Use

public domain text Agriculture occupies 40 percent of Earth’s ice-free land mass (Barnard). While the net area used for producing food has been fairly constant since the mid-20th century, the locations have shifted significantly. Temperate regions of North America, Europe, and Russia have lost agricultural land to other uses, while in the tropics, agricultural land has expanded, mainly as a result of clearing forests and burning biomass (Willett et al.). Seventy percent of the rainforest that has been cut down is being used to graze livestock (Münter). Agricultural use of water is of critical concern both quantitatively and qualitatively. Agriculture accounts for about 70 percent of freshwater use, making it “the world’s largest water-consuming sector” (Barnard). Meat, dairy, and egg production causes water pollution, as liquid wastes flow into rivers and to the ocean (World Wildlife Fund and Knorr Foods). According to the Hertwich et al., “the impacts related to these activities are unlikely to be reduced, but rather enhanced, in a business-as-usual scenario for the future” (13). end public domain text

annotated text Statistical Data. To develop her points related to land and water use, Tran presents specific statistical data throughout this section. Notice that she has chosen only the needed words of these key points to ensure that she controls the development of the supporting point and does not overuse borrowed source material. end annotated text

annotated text Defining Terms. Aware of her audience, Tran defines monocropping , a term that may be unfamiliar. end annotated text

public domain text Earth’s resources and ability to absorb pollution are limited, and many current agricultural practices undermine these capacities. Among these unsustainable practices are monocropping [growing a single crop year after year on the same land], concentrated animal-feeding operations, and overdependence on manufactured pesticides and fertilizers (Hamilton). Such practices deplete the soil, dramatically increase energy use, reduce pollinator populations, and lead to the collapse of resource supplies. One study found that producing one gram of beef for human consumption requires 42 times more land, 2 times more water, and 4 times more nitrogen than staple crops. It also creates 3 times more greenhouse gas emissions (Chai et al.). The EAT– Lancet Commission calls for “halting expansion of new agricultural land at the expense of natural ecosystems . . . strict protections on intact ecosystems, suspending concessions for logging in protected areas, or conversion of remaining intact ecosystems, particularly peatlands and forest areas” (Willett et al. 481). The Commission also calls for land-use zoning, regulations prohibiting land clearing, and incentives for protecting natural areas, including forests. end public domain text

annotated text Synthesis. The paragraphs above and below this comment show how Tran has synthesized content from several sources to help establish and reinforce key supports of her essay . end annotated text

Greenhouse Gas and Climate Change

public domain text Climate change is heavily affected by two factors: greenhouse gas emissions and carbon sequestration. In nature, the two remain in balance; for example, most animals exhale carbon dioxide, and most plants capture carbon dioxide. Carbon is also captured, or sequestered, by soil and water, especially oceans, in what are called “sinks.” Human activities have skewed this balance over the past two centuries. The shift in land use, which exploits land, water, and fossil energy, has caused increased greenhouse-gas emissions, which in turn accelerate climate change. end public domain text

public domain text Global food systems are threatened by climate change because farmers depend on relatively stable climate systems to plan for production and harvest. Yet food production is responsible for up to 30 percent of greenhouse gas emissions (Barnard). While soil can be a highly effective means of carbon sequestration, agricultural soils have lost much of their effectiveness from overgrazing, erosion, overuse of chemical fertilizer, and excess tilling. Hamilton reports that the world’s cultivated and grazed soils have lost 50 to 70 percent of their ability to accumulate and store carbon. As a result, “billions of tons of carbon have been released into the atmosphere.” end public domain text

annotated text Direct Quotation and Paraphrase. While Tran has paraphrased some content of this source borrowing, because of the specificity and impact of the number— “billions of tons of carbon”—she has chosen to use the author’s original words. As she has done elsewhere in the essay, she has indicated these as directly borrowed words by placing them within quotation marks. See Section 12.5 for more about paraphrasing. end annotated text

public domain text While carbon sequestration has been falling, greenhouse gas emissions have been increasing as a result of the production, transport, processing, storage, waste disposal, and other life stages of food production. Agriculture alone is responsible for fully 10 to 12 percent of global emissions, and that figure is estimated to rise by up to 150 percent of current levels by 2030 (Chai et al.). Münter reports that “more greenhouse gas emissions are produced by growing livestock for meat than all the planes, trains, ships, cars, trucks, and all forms of fossil fuel-based transportation combined” (5). Additional greenhouse gases, methane and nitrous oxide, are produced by the decomposition of organic wastes. Methane has 25 times and nitrous oxide has nearly 300 times the global warming potential of carbon dioxide (Curnow). Agricultural and food production systems must be reformed to shift agriculture from greenhouse gas source to sink. end public domain text

Social and Cultural Values

public domain text As the Sierra Club has pointed out, agriculture is inherently cultural: all systems of food production have “the capacity to generate . . . economic benefits and ecological capital” as well as “a sense of meaning and connection to natural resources.” Yet this connection is more evident in some cultures and less so in others. Wealthy countries built on a consumer culture emphasize excess consumption. One result of this attitude is that in 2014, Americans discarded the equivalent of $165 billion worth of food. Much of this waste ended up rotting in landfills, comprised the single largest component of U.S. municipal solid waste, and contributed a substantial portion of U.S. methane emissions (Sierra Club). In low- and middle-income countries, food waste tends to occur in early production stages because of poor scheduling of harvests, improper handling of produce, or lack of market access (Willett et al.). The recent “America First” philosophy has encouraged prioritizing the economic welfare of one nation to the detriment of global welfare and sustainability. end public domain text

annotated text Synthesis and Response to Claims. Here, as in subsequent sections, while still relying heavily on facts and content from borrowed sources, Tran provides her synthesized understanding of the information by responding to key points. end annotated text

public domain text In response to claims that a vegetarian diet is a necessary component of sustainable food production and consumption, Lusk and Norwood determined the importance of meat in a consumer’s diet. Their study indicated that meat is the most valuable food category to consumers, and “humans derive great pleasure from consuming beef, pork, and poultry” (120). Currently only 4 percent of Americans are vegetarians, and it would be difficult to convince consumers to change their eating habits. Purdy adds “there’s the issue of philosophy. A lot of vegans aren’t in the business of avoiding animal products for the sake of land sustainability. Many would prefer to just leave animal husbandry out of food altogether.” end public domain text

public domain text At the same time, consumers expect ready availability of the foods they desire, regardless of health implications or sustainability of sources. Unhealthy and unsustainable foods are heavily marketed. Out-of-season produce is imported year-round, increasing carbon emissions from air transportation. Highly processed and packaged convenience foods are nutritionally inferior and waste both energy and packaging materials. Serving sizes are larger than necessary, contributing to overconsumption and obesity. Snack food vending machines are ubiquitous in schools and public buildings. What is needed is a widespread attitude shift toward reducing waste, choosing local fruits and vegetables that are in season, and paying attention to how foods are grown and transported. end public domain text

annotated text Thesis Restated. Restating her thesis, Tran ends this section by advocating for a change in attitude to bring about sustainability. end annotated text

DISSENTING OPINIONS

annotated text Counterclaims . Tran uses equally strong research to present the counterargument. Presenting both sides by addressing objections is important in constructing a clear, well-reasoned argument. Writers should use as much rigor in finding research-based evidence to counter the opposition as they do to develop their argument. end annotated text

public domain text Transformation of the food production system faces resistance for a number of reasons, most of which dispute the need for plant-based diets. Historically, meat has been considered integral to athletes’ diets and thus has caused many consumers to believe meat is necessary for a healthy diet. Lynch et al. examined the impact of plant-based diets on human physical health, environmental sustainability, and exercise performance capacity. The results show “it is unlikely that plant-based diets provide advantages, but do not suffer from disadvantages, compared to omnivorous diets for strength, anaerobic, or aerobic exercise performance” (1). end public domain text

public domain text A second objection addresses the claim that land use for animal-based food production contributes to pollution and greenhouse gas emissions and is inefficient in terms of nutrient delivery. Berners-Lee et al. point out that animal nutrition from grass, pasture, and silage comes partially from land that cannot be used for other purposes, such as producing food directly edible by humans or for other ecosystem services such as biofuel production. Consequently, nutritional losses from such land use do not fully translate into losses of human-available nutrients (3). end public domain text

annotated text Paraphrase. Tran has paraphrased the information as support. Though she still cites the source, she has changed the words to her own, most likely to condense a larger amount of original text or to make it more accessible. end annotated text

public domain text While this objection may be correct, it does not address the fact that natural carbon sinks are being destroyed to increase agricultural land and, therefore, increase greenhouse gas emissions into the atmosphere. end public domain text

public domain text Another significant dissenting opinion is that transforming food production will place hardships on farmers and others employed in the food industry. Farmers and ranchers make a major investment in their own operations. At the same time, they support jobs in related industries, as consumers of farm machinery, customers at local businesses, and suppliers for other industries such as food processing (Schulz). Sparks reports that “livestock farmers are being unfairly ‘demonized’ by vegans and environmental advocates” and argues that while farming includes both costs and benefits, the costs receive much more attention than the benefits. end public domain text

FUTURE GENERATIONS

public domain text The EAT– Lancet Commission calls for a transformation in the global food system, implementing different core processes and feedback. This transformation will not happen unless there is “widespread, multi-sector, multilevel action to change what food is eaten, how it is produced, and its effects on the environment and health, while providing healthy diets for the global population” (Willett et al. 476). System changes will require global efforts coordinated across all levels and will require governments, the private sector, and civil society to share a common vision and goals. Scientific modeling indicates 10 billion people could indeed be fed a healthy and sustainable diet. end public domain text

annotated text Conclusion. While still using research-based sources as evidence in the concluding section, Tran finishes with her own words, restating her thesis. end annotated text

public domain text For the human race to have a sustainable future, massive changes in the way food is produced, processed, and distributed are necessary on a global scale. The required changes will affect nearly all aspects of life, including not only world hunger but also health and welfare, land use and habitats, water quality and availability, energy use and production, greenhouse gas emissions and climate change, economics, and even cultural and social values. These changes may not be popular, but they are imperative. They are also achievable. The human race must turn to sustainable food systems that provide healthy diets with minimal environmental impact, starting now. end public domain text

annotated text Sources. Note two important aspects of the sources chosen: 1) They represent a range of perspectives, and 2) They are all quite current. When exploring a contemporary topic, it is important to avoid research that is out of date. end annotated text

Works Cited

Barnard, Neal. “How Eating More Plants Can Save Lives and the Planet.” Physicians Committee for Responsible Medicine , 24 Jan. 2019, www.pcrm.org/news/blog/how-eating-more-plants-can-save-lives-and-planet. Accessed 6 Dec. 2020.

Berners-Lee, M., et al. “Current Global Food Production Is Sufficient to Meet Human Nutritional Needs in 2050 Provided There Is Radical Societal Adaptation.” Elementa: Science of the Anthropocene , vol. 6, no. 52, 2018, doi:10.1525/elementa.310. Accessed 7 Dec. 2020.

Chai, Bingli Clark, et al. “Which Diet Has the Least Environmental Impact on Our Planet? A Systematic Review of Vegan, Vegetarian and Omnivorous Diets.” Sustainability , vol. 11, no. 15, 2019, doi: underline 10.3390/su11154110 end underline . Accessed 6 Dec. 2020.

Curnow, Mandy. “Managing Manure to Reduce Greenhouse Gas Emissions.” Government of Western Australia, Department of Primary Industries and Regional Development, 2 Nov. 2020, www.agric.wa.gov.au/climate-change/managing-manure-reduce-greenhouse-gas-emissions. Accessed 9 Dec. 2020.

Gray, Richard. “Why the Vegan Diet Is Not Always Green.” BBC , 13 Feb. 2020, www.bbc.com/future/article/20200211-why-the-vegan-diet-is-not-always-green. Accessed 6 Dec. 2020.

Hamilton, Bruce. “Food and Our Climate.” Sierra Club, 2014, www.sierraclub.org/compass/2014/10/food-and-our-climate. Accessed 6 Dec. 2020.

Hertwich. Edgar G., et al. Assessing the Environmental Impacts of Consumption and Production. United Nations Environment Programme, 2010, www.resourcepanel.org/reports/assessing-environmental-impacts-consumption-and-production.

Lusk, Jayson L., and F. Bailey Norwood. “Some Economic Benefits and Costs of Vegetarianism.” Agricultural and Resource Economics Review , vol. 38, no. 2, 2009, pp. 109-24, doi: 10.1017/S1068280500003142. Accessed 6 Dec. 2020.

Lynch Heidi, et al. “Plant-Based Diets: Considerations for Environmental Impact, Protein Quality, and Exercise Performance.” Nutrients, vol. 10, no. 12, 2018, doi:10.3390/nu10121841. Accessed 6 Dec. 2020.

Münter, Leilani. “Why a Plant-Based Diet Will Save the World.” Health and the Environment. Disruptive Women in Health Care & the United States Environmental Protection Agency, 2012, archive.epa.gov/womenandgirls/web/pdf/1016healththeenvironmentebook.pdf.

Purdy, Chase. “Being Vegan Isn’t as Good for Humanity as You Think.” Quartz , 4 Aug. 2016, qz.com/749443/being-vegan-isnt-as-environmentally-friendly-as-you-think/. Accessed 7 Dec. 2020.

Schulz, Lee. “Would a Sudden Loss of the Meat and Dairy Industry, and All the Ripple Effects, Destroy the Economy?” Iowa State U Department of Economics, www.econ.iastate.edu/node/691. Accessed 6 Dec. 2020.

Sierra Club. “Agriculture and Food.” Sierra Club, 28 Feb. 2015, www.sierraclub.org/policy/agriculture/food. Accessed 6 Dec. 2020.

Sparks, Hannah. “Veganism Won’t Save the World from Environmental Ruin, Researchers Warn.” New York Post , 29 Nov. 2019, nypost.com/2019/11/29/veganism-wont-save-the-world-from-environmental-ruin-researchers-warn/. Accessed 6 Dec. 2020.

Willett, Walter, et al. “Food in the Anthropocene: The EAT– Lancet Commission on Healthy Diets from Sustainable Food Systems.” The Lancet, vol. 393, no. 10170, 2019. doi:10.1016/S0140-6736(18)31788-4. Accessed 6 Dec. 2020.

World Health Organization. “Malnutrition.” World Health Organization, 1 Apr. 2020, www.who.int/news-room/fact-sheets/detail/malnutrition. Accessed 8 Dec. 2020.

World Health Organization. “Obesity and Overweight.” World Health Organization, 1 Apr. 2020, www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed 8 Dec. 2020.

World Wildlife Fund. Appetite for Destruction: Summary Report. World Wildlife Fund, 2017, www.wwf.org.uk/sites/default/files/2017-10/WWF_AppetiteForDestruction_Summary_Report_SignOff.pdf.

World Wildlife Fund and Knorr Foods. Future Fifty Foods. World Wildlife Fund, 2019, www.wwf.org.uk/sites/default/files/2019-02/Knorr_Future_50_Report_FINAL_Online.pdf.

“World Population by Year.” Worldometer , www.worldometers.info/world-population/world-population-by-year/. Accessed 8 Dec. 2020.

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Dietary Consumption: Strategies for Healthy Eating Essay (Speech)

General Goal: To persuade.

Specific Goal: At the end of my speech, the audience will be able to differentiate between healthy and unhealthy eating.

Central Idea: People should incorporate healthy eating in their diets contrary to which it increases the risk of developing various diseases.

Introduction

A report by the Centers for Disease Control and Prevention (CDC) indicate that, while eating nutritious food is essential for enhancing your health, most people consume an unhealthy diet thus increasing the risk of contracting various diseases such as cancer, reduced brain functioning, type 2 diabetes, stroke, heart disease, or being generally obese or overweight (CDC, 2021a). Most people fall into this category, not because they lack the knowledge about healthy eating, but because they chose to ignore the recommended nutritious consumption.

Reveal Your Topic

Today, I will highlight some strategies of healthy eating against which failure to follow them would be detrimental to your health.

Motivate the Audience to Listen

Probably, you are thinking that you have been eating unhealthy food and nothing has happened to you. Yet, you may not have experienced some of the risks of poor diet, I am here to illustrate to you why you should always have healthy nutrition to boost your health and avoid common diseases that you could develop in the span of your life.

Credibility Statement

While I am not a qualified doctor or nutritionist, I have conducted ample and elaborate research on the strategies for healthy eating.

Today, I will explore three strategies of healthy eating, their benefits, and consequences if not properly followed.

• I will first talk about vegetables and fruits
• Then, I will talk about proteins and carbohydrates
• Finally, I will discuss saturated fats and sugar

Now that I have given you an overview of my topic today, let’s explore my first major point.

It is recommended that we consume vegetables and fruits regularly to stay healthy.

Consumption of vegetables is integral to the health of our bodies:

• The Dietary Guidelines for Americans states that people should eat more vegetables to boost their health and prevent themselves from chronic diseases (DietaryGuidelines.gov., 2020).
• Surprisingly, only 9% of the people consumed the recommended portions of vegetables in their diet (CDC, 2021b).
• In their book, Vegetables: Importance of Quality Vegetables to Human Health , Asaduzzaman and Asao (2018) illustrate that failure to consume the recommended amounts of vegetables in daily meals is associated with increased risk of cancer and stroke.
• Moreover, Asaduzzaman and Asao (2018) expound that lack of proper intake of vegetables causes vitamin deficiency diseases such as scurvy (lack of vitamin C) and Sclerosis (lack of vitamin A).

Consumption of fruits is highly encouraged as one of the major eating habits that all people should embrace.

• In its 2019 publication, World Health Organization (WHO) explains that fruit intake is associated with disease prevention as it enhances the immunity of our bodies.
• Furthermore, WHO (2019) highlights that fruits reduce the risk of adiposity in adolescents and young children.
• As its publication shows, failure to take appropriate amounts of fruits leads to increased risk for various diseases such as myocardial infarction.
• WHO emphasizes that lack of adequate fruit servings in the meals could cause different types of cancer.
• While fruits are crucial in our nutritious feeding, only 12% of Americans eat the recommended amount of fruits (CDC, 2021b).

TRANSITION: Now that we have talked about vegetables and fruits, let us delve into proteins and carbohydrates.

Proteins and carbohydrates are essential for our bodies

While some people could be vegetarians, the need for proteins in dietary consumption is crucial.

• The Dietary Guidelines for Americans, 2020-2025 indicate that proteins could be obtained from animals such as poultry, meat, seafood, and dairy or plant sources for vegetarians (DietayGuidelines.gov., 2020).
• Nutrition scholars, Shan et al. (2019) state that proteins are essential to repair body cells besides promoting growth and development in pregnant women, children, and teenagers.
• Failure to consume the recommended amounts of protein causes various diseases.
• As Shan et al. (2019) explain, insufficient protein in the body leads to impaired mental health, muscle-tissue shrinkage, weak immune system, marasmus, and ultimately, total organ failure.

Carbohydrates

• In their article, nutritionists, Shan et al. (2019) note that carbohydrates are needed in the body as a source of the energy we use to perform daily activities.
• Therefore, it is important to consume the required portions of carbohydrates for our muscles, brain, and other body parts to function normally.
• According to Shan et al. (2019), failure to meet the recommended carbohydrate intake leads to low blood sugar causing hypoglycemia.
• Furthermore, Shan et al. (2019) present that carbohydrates deficiency results in ketosis, characterized by bad breath, mental fatigue, joint pains, headache, and nausea.

TRANSITION: Let us now talk about the last major point in my speech, saturated fats, and sugars

It is imperative to avoid saturated fats and sugars

The Dietary Guidelines for Americans, 2020-2025 recommend that people should limit the consumption of saturated fats to live healthy lives.

• The food we consume must stay within one’s calorie needs for our bodies to operate normally.
• People are not supposed to eat excess calories beyond the levels recommended in the Dietary Guidelines.
• The Dietary Guidelines call upon Americans to consume foods with the least amounts of saturated fats (less than 10% of the total calories consumed per day, DietaryGuidelines.gov, 2020).
• CDC (2021a) reports that excessive saturated fats cause higher levels of blood cholesterol eventually leading to heart diseases or stroke.

Besides, the Dietary Guidelines recommend that Americans’ choice of beverages and single food should be nutrient-dense but, with no added processed sugars.

• A healthy dietary habit limits the amount of processed sugars to fewer than 10% of the total calories consumed daily (DietaryGuidelines.gov, 2020).
• CDC (2021a) posits that consumption of sugar is the root cause of type 2 diabetes, well as increased risk of heart disease and obesity among Americans.

TRANSITION TO CLOSE: As I conclude my speech today, I would like to remind you that the principal capital asset in our lives in good health.

Re-State Central Idea

Incorporating healthy eating in our diets is critical but, lack of it increases the risk of developing the various disease.

Today we have talked about strategies of healthy eating, their benefits, and consequences if not properly followed.

• First, we talked about vegetables and fruits
• Then, we explored proteins and carbohydrates
• Finally, we discussed about saturated fats and sugar

Tie Back to Audience

I hope as you leave this place today, you have appropriate information that would encourage you to observe healthy eating habits.

Closure Statement

While most people have the necessary information we need about dietary consumption; nutrition-related diseases are on the rise. From today, everyone must take full responsibility for their eating habits.

Asaduzzaman, M., & Asao, T. (Eds.). (2018). Vegetables: Importance of quality vegetables to human health . BoD–Books on Demand.

Centers for Disease Control and Prevention (CDC, 2021a). Poor nutrition. CDC’s National Center for Chronic Disease Prevention and Health Promotion. Web.

Centers for Disease Control and Prevention (CDC, 2021b). Only 1 in 10 adults get enough fruits or vegetables . Division of Nutrition, Physical Activity, and Obesity. Web.

DietaryGuidelines.gov. (2020). Dietary Guidelines for Americans , 2020-2025. Web.

Shan, Z., Rehm, C. D., Rogers, G., Ruan, M., Wang, D. D., Hu, F. B.,… & Bhupathiraju, S. N. (2019). Trends in dietary carbohydrate, protein, and fat intake and diet quality among US adults, 1999-2016 . Jama , 322 (12), 1178-1187. Web.

World Health Organization. (WHO, 2019). Sustainable healthy diets: guiding principles . Food & Agriculture Org. Web.

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IvyPanda . 2022. "Dietary Consumption: Strategies for Healthy Eating." July 21, 2022. https://ivypanda.com/essays/strategies-for-healthy-eating-persuasive-speech/.

1. IvyPanda . "Dietary Consumption: Strategies for Healthy Eating." July 21, 2022. https://ivypanda.com/essays/strategies-for-healthy-eating-persuasive-speech/.

Bibliography

IvyPanda . "Dietary Consumption: Strategies for Healthy Eating." July 21, 2022. https://ivypanda.com/essays/strategies-for-healthy-eating-persuasive-speech/.

• Fats, Carbohydrates, and Proteins
• Saturated Fatty Acids and Coronary or Cardiovascular Disease
• Fats and Proteins in Relation to Type 2 Diabetes
• On the Strategies for Healthy Eating Promotion
• Patient Case Study Analysis. Management of Obesity
• Consequences of Sugar to the Human Body
• Polysaccharides in Foods
• Effects of Food Challenges to Health

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Article Contents

Introduction.

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

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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

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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.

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Food Consumption Determinants and Barriers for Healthy Eating at the Workplace—A University Setting †

João p. m. lima.

1 Politécnico de Coimbra, ESTeSC, Unidade Científico-Pedagógica de Dietética e Nutrição, Rua 5 de Outubro, S. Martinho do Bispo, 3046-854 Coimbra, Portugal

2 GreenUPorto—Sustainable Agrifood Production Research Centre, Campus de Vairão Edifício de Ciências Agrárias (FCV2) Rua da Agrária, 747, 4485-646 Vairão, Portugal; tp.pu.ancf@ahcorada

3 LAQV-Requimte—R. D. Manuel II, Apartado 55142, 4051-401 Porto, Portugal

4 ciTechCare—Center for Innovative Care and Health Technology, R. de Santo André 2410, 2410-541 Leiria, Portugal

Sofia A. Costa

5 Instituto de Saúde de Pública da Universidade do Porto, Rua das Taipas 135, 4050-091 Porto, Portugal; tp.opas@1atsocfos

Teresa R. S. Brandão

6 CBQF—Center for Biotechnology and Fine Chemicals—Associate Laboratory, School of Biotechnology, Catholic University of Portugal, R. de Diogo Botelho 1327, 4169-005 Porto, Portugal; tp.pcu.otrop@oadnarbt

7 Faculty of Nutrition and Food Sciences, University of Porto, Rua do Campo Alegre, 823, 4150-180 Porto, Portugal

Associated Data

The work was a part of João Lima’s doctoral thesis.

Background: A wide variety of social, cultural and economic factors may influence dietary patterns. This work aims to identify the main determinants of food consumption and barriers for healthy eating at the workplace, in a university setting. Methods: A cross-sectional observational study was conducted with 533 participants. Data were obtained through the application of a self-administered questionnaire that included socio-demographic information, food consumption determinants and the main perceived barriers for healthy eating at the workplace. Results: The respondents identified “price” (22.5%), “meal quality” (20.7%), and “location/distance” (16.5%). For women, the determinant “availability of healthy food options” was more important than for men ( p < 0.001). The food consumption determinants at the workplace most referred to by respondents were related to the nutritional value. Smell, taste, appearance and texture, and good value for money, were also considered important for choosing food at the workplace. Respondents referred to work commitments and lack of time as the main barriers for healthy eating at the workplace. Conclusions: Identification of determinants involved in food consumption, and the barriers for healthy eating, may contribute to a better definition of health promotion initiatives at the workplace aiming to improve nutritional intake.

1. Introduction

Globalization has caused drastic changes in food patterns within the last decade. These changes resulted in a reduction in the prevalence of malnutrition along with a widespread increase in prevalence of overweight and obesity [ 1 ]. An unhealthy lifestyle is one of the major risk factors for chronic diseases in developed countries [ 2 ]. Consumer behaviors play a prominent role in the etiology of several chronic non-communicable diseases, including obesity, diabetes mellitus, and cardiovascular diseases, among others, whose prevalence tends to stand still, or even increase [ 1 , 3 , 4 ].

Sedentary habits and unhealthy eating behaviors are responsible for a significant economic burden through absenteeism and presenteeism [ 5 , 6 , 7 , 8 ]. Additionally, for employees, unhealthy lifestyle behaviors and obesity might lead to negative effects related to work [ 9 ]. Research has shown that unhealthy employees and those with an unhealthy lifestyle are less productive at work and have decreased work ability [ 10 , 11 , 12 , 13 , 14 ].

The workplace is recognized as an opportune and fruitful setting for health promotion because of the presence of natural social networks, the possibility of reaching a large number of people, and the amount of time people spend at work [ 15 , 16 ]. Promotion of healthy lifestyles, namely healthy nutritional behavior at the workplace, improves workers’ health and productivity [ 17 ].

The workplace also offers an interesting context for studying eating behaviors. There is often a high level of consistency in people’s working lives, with many workers (particularly those who are office-based, as in this sample) spending most of their time in the same location surrounded by the same group of colleagues [ 18 ]. Partly for this reason, a number of eating-related research studies have been conducted at the workplace [ 19 , 20 , 21 ].

A wide variety of social, cultural, and economic factors may influence dietary patterns. Intra-individual determinants, such as physiological and psychological factors, acquired food preferences, and knowledge about nutrition can be distinguished from interpersonal or social factors, such as family and partners influence [ 21 ].

Food choice determinants are frequently presented in four groups:

• (a) Biologically determined behavioral predispositions, related to an individual’s innate abilities related to food, namely the preference for sweet and salty foods; the mechanisms that control hunger and satiety; and the sensory experience provided by food. These are the most basic determinants of food choice, meaning when choosing food or drinks, people firstly follow their preferences [ 21 ];
• (b) Sensory-affective factors—those related to feelings and emotions in relation to food—acquired familiarity and ability to learn how to like something are at the second level [ 21 ];
• (c) Intrapersonal factors, defined by an individual’s beliefs, attitudes, knowledge, skills and social norms, follow the previous factors in determining the choice of food, just like the interpersonal ones, which involve family, friends and other social networks [ 21 ]. The culture in which each individual was born and raised influences general behavior and food habits [ 21 ]. Interpersonal factors theoretical framework was also described by Rothschild, 1999 [ 22 ], and applied, for example, in Bos, 2016 [ 23 ]. Several authors have ascertained that choices depend on the surrounding environment, and are based on one’s knowledge and experience [ 21 ];
• (d) Environmental factors are the last level determining food consumption. Even though they are the most distant from the individual, environmental factors are the easiest to influence. They include availability and accessibility to food; social, environmental and cultural practices; resources; economic environment; and food marketing practices [ 21 ]. For example, resources and economic environment determine food consumption through food cost or individual income [ 21 ]. According to the literature, low-income population groups are more likely to adopt unbalanced diets [ 21 ].

In addition to the determinants described above, the individual’s psychological state is also assumed as one of the major determinants of the act of eating. Situations of emotional difficulty, states of anxiety and stress, situations of rejection, or loneliness, in more vulnerable individuals, can lead to changes in eating behavior [ 21 ].

Several studies concluded that individuals who identified a higher number of barriers for healthier eating habits correspond to those with worse habits [ 23 , 24 ]. The main factors identified by consumers as barriers for healthy eating were lack of time, poor cooking skills, food price, or the lack of healthy choices at food service units [ 23 , 24 , 25 , 26 ].

Meals eaten at the workplace represent a large contribution to the daily energy intake and influence the balance of the diet [ 27 ]. The study “Food and Portuguese Population Lifestyle” [ 28 ], identified the factors that influence the food choices of Portuguese adults, and their relationship with socio-demographic and health features [ 29 ]. The attribute of “Taste” was the most important factor determining food choice, followed by the “Price” and the “Intention of healthy eating”, according to Poínhos et al. [ 29 ].

Previous research conducted at different workplaces related to food consumption determinants and perceived barriers, identified that structures and systems within the workplace have a significant role in dietary behaviors. These include the facilities available [ 30 , 31 , 32 ], training of staff [ 33 ], long hours worked as a result of high workloads and work pressures, and a culture that encourages working through breaks [ 34 , 35 ]. Lack of time for lunch can affect both health and productivity [ 36 , 37 ]. The conflict between promoting a greater range of healthier foods and business constraints has also been previously identified [ 38 ].

In order to develop effective workplace interventions for healthy eating, researchers must first consider all the known determinants of eating behavior as potential targets for intervention, such as distinct features of working conditions. In a recent systematic review of factors affecting healthy eating among nurses, the majority of studies found that workplaces often create barriers for healthy eating [ 20 ]. Therefore, to define appropriate health promotion initiatives, it is necessary to characterize the determinants involved in food choice, in order to influence food consumption at the workplace. Additionally, to identify perceived barriers for healthier eating habits it is also important for the implementation and assessment of interventions in different scenarios [ 39 , 40 ].

To the best of our knowledge, there are no studies that identify and characterize the determinants involved in food choice in Portugal, especially at the workplace, and it becomes relevant to develop research to better understand this subject. Therefore, this study intends to identify the perceived barriers for healthy eating, and the main determinants of food consumption at the workplace, among university employees.

2. Materials and Methods

2.1. study design and sample.

A cross-sectional observational study was conducted at a Portuguese university through face-to-face interviews by a trained researcher at the participants’ workplace. This university had 3307 employees: 1750 teachers and researchers (academic), 1551 non-teaching staff (non-academic) [ 41 ]. A convenience sample was used, stratified by organic units, aiming to represent the study population, allowing researchers to infer conclusions for the study population. Given that the sample corresponds to approximately 15% of the population, it was stratified into teaching and researcher staff, and non-teaching and non-researcher staff; 533 employees were selected. Data collection was performed during labor hours.

2.2. Ethical Issues

The project was approved by Ethical Commission of the University of Porto, with the number CEFADE 25.2014. The principles of the Helsinki Declaration were respected and the workers under analysis accepted participation in the study through informed consent, after having the purpose and methods involved in the study explained to them individually.

2.3. Questionnaires for Data Collection

Data were obtained through the application of a self-administered questionnaire. It included socio-demographic information and food consumption determinants at the workplace, and a list of barriers for healthy eating at the workplace. The questionnaire included questions such as the employee’s age, gender and marital status. Academic qualifications were also questioned, through a closed answer format composed of nine levels of response (between primary school and PhD or Post-Doc). Employees with academic qualifications higher than bachelor’s degree were asked about the training area. Concerning work practices, respondents were asked about the amount of time they spend working at this institution, and the work regime (full-time or part-time). They were asked about the professional category, function performed, with discrimination between teaching and non-teaching activity, and the establishment where they work.

To assess food consumption determinants, a section of the questionnaire was developed through the adaptation of the Food Choice Questionnaire, developed by Steptoe et al. [ 42 ] after translation and validation for the Portuguese population by Cardoso and Vale [ 43 ]. Steptoe et al. also contributed to the questions of the Food Choice Questionnaire. A Likert Scale of 5 points, from strongly disagree (1) to strongly agree (5) was used in the questions related to determinants. Questions used in the studies “Food and Portuguese Population Lifestyle” and “Food and Portuguese Population Lifestyle” [ 28 , 29 ] were included in the questionnaire. The determinants of the choice of location for lunch in the workplace were also evaluated. Respondents were invited to select the three main factors affecting their choice from a predefined list presented in our results [ 29 , 44 , 45 , 46 , 47 ].

The barriers presented to respondents were selected from the literature, and others were added considering individual perceptions of the researchers. Respondents could select as many options from the list as they wanted.

Food offer, quality of meals, prices and food and nutritional intake of employees were analyzed and published in previous research papers [ 48 , 49 ].

2.4. Statistical Analysis

Data were analyzed using the Statistical Package for Social Sciences version 21.0 ® for Windows. Descriptive analysis was performed, and normality of cardinal variables was tested with Shapiro-Wilk Test. Association between nominal variables was analyzed by chi-square test. Association between ordinals and nominal variables was performed with Kruskal-Wallis tests. Between ordinal variables, or between ordinal and cardinal non-normal, Spearman correlation was performed. Taking into consideration the differentiation of the sample in terms of age, results were analyzed by age groups, through splitting the sample by the median age (43 years old) to identify younger and older respondents. Cut-off of 0.05 was used as the level of statistical significance. Data were also analyzed according to Multiple Correspondence Analysis (MCA) procedures, which allows for exploring the pattern of relationships of several categorical variables and representing them in few dimensions of homogeneous variables. For this model, sociodemographic variables were included, namely gender, educational level, and professional occupation; lunch setting (lunch brought from home, university food services, restaurants and go home), determinants for the lunch place choice and determinants of food consumption identified from Food Choice Questionnaire [ 42 , 43 ].

3.1. Sample Characterization

From 533 assessed individuals, 513 were considered valid answers. Participants were aged between 21 and 80 years old (mean 43.3 ± 10.6), mostly females (65.5%) and married (63.4%). About 94% of respondents were full-time workers. Most workers (80.3%) had a university degree and about 35% had a PhD or a Post-Doc diploma. Only 3.3% of respondents did not complete high school education. Of respondents, 34.2% were Teachers, 63.0% were Non-Academic Staff/Researchers and 2.8% had both activities.

The majority of workers had a sedentary activity since 81.5% of them reported spending most of their time seated, and 74.5% characterized their work as not being “very physically demanding”.

Only 23.1% of respondents reported following an unhealthy diet at the workplace. Hence, only these workers were asked to point out the barriers for adopting a healthier diet.

3.2. Determinants of Choosing the Place for Having Lunch

The majority (96.7%) of respondents had lunch every day, however, only 36.1% of them attended the university food service. Of the respondents, 28% had lunch in local restaurants. About 52% of workers brought lunch from home and only 16.2% had lunch at home.

The respondents identified “price” (22.5%), “meal quality” (20.7), “location/distance” (16.5%), “healthy food options” (13.1%) and “lead time” (10.6%) as the most important determinants used to choose the place for having lunch. For women, the option of having “healthy food options” ( p < 0.001) was more important than for men. Additionally, “location” ( p < 0.001) and “noise” ( p = 0.016) were more important for women than for men ( Figure 1 ).

Food consumption determinants to choose the place for having lunch per gender. N: Number of individuals

“Price” as a determinant for choosing the place for having lunch was more important in younger respondents ( Table 1 ). This determinant was also more important for those with a lower academic degree ( p < 0.001) than for those with a higher level of education. Respondents with a higher academic degree referred more frequently to “Location/Distance” of places for having lunch as a determinant of choice. “Meal quality” ( p = 0.002) and “healthy food options” ( p = 0.049) were considered determinants for choosing the lunch setting more frequently by teaching staff.

Food consumption determinants to choose the place for having lunch per age group.

1 Differences with statistical significance.

Based on results of MCA three main dimensions were identified that explained 33.4% of data variability. The following homogeneous groups of variables were obtained ( Figure 2 ).

Food consumption determinants to choose the setting for having lunch (Multiple Correspondence Analysis (MCA) analysis).

3.3. Determinants of Food Consumption at the Workplace

Determinants of food consumption at the workplace most referred to by respondents (more than 70%) were related to foods rich in vitamins, minerals and fiber, nutritionally balanced, with natural ingredients and no additives, and that contribute to health and weight control. Smell, taste, appearance, texture, and a good value for money were also considered important for choosing food at the workplace.

Based on the results of MCA, two main dimensions were identified that explained 59.9% of data variability, and the following homogeneous groups of variables were obtained ( Figure 3 ).

Food consumption determinants at the workplace (MCA analysis).

3.4. Barriers for Healthy Eating at the Workplace

The participants referred mostly to work commitments and lack of time as barriers for healthy eating at the workplace ( Figure 4 ). From the barriers under analysis, differences between genders were only observed related to knowledge about nutrition. Males identified “Lack of knowledge about nutrition/healthy eating” as a barrier for healthy eating more frequently than women ( Table 2 ). No differences were observed between age groups related to perceived barriers for healthy eating ( Table 3 ).

Frequency of perceived barriers for healthy eating at the workplace.

Perceived barriers for healthy eating at the workplace by gender.

Perceived barriers for healthy eating at the workplace by age group.

In comparing academic with non-academic respondents, significant differences for two distinct barriers were found. It seems that food price is a prohibitive factor for having a healthy diet, essentially for non-academic staff in relation to other individuals ( p = 0.004). Lack of healthy options for breakfast, lunch and dinner were identified by academic staff more frequently than by non-academics ( p = 0.012) ( Table 4 ). Concerning other parameters assessed, ranges of age and marital status did not seem to influence the barriers for healthier eating at the workplace.

Perceived barriers for healthy eating at the workplace by professional occupation.

4. Discussion

Major determinants for choosing a place to have lunch were related to “meal quality”, “price”, and “location”. Working at higher education institutes determines an increased burden of work and responsibilities, most of them extra classes [ 50 ], which contributes to work commitments and lack of time to take breaks, prepare, and have healthy meals. Additionally, sensory aspects of food consumption can influence the choice of lunch place. Sensory aspects are usually observed as determinant of food consumption. The cost of meals is more relevant for younger respondents as observed in a previous study [ 51 ].

Younger, non-teaching female employees with lower academic qualifications are the group who most frequently bring lunch from home. Bringing food from home is likely associated with higher level cooking skills—more common in the female gender [ 25 ]. Additionally, this group also has lower disposable income and hence, bringing food from home allows for more savings.

Lunch location is also determined by other factors. According to other authors, meals outside the home often have a higher energy value and a poorer nutritional profile [ 27 ]. Indeed, of the women who bring lunch from home, some do so to ensure a healthier lunch.

On the other hand, teachers with PhD or Post-Doc Diplomas mentioned waiting time as a key decision driver. This is likely associated with a higher level of responsibility, strong focus on work, and consequently, shorter lunch breaks.

In this study, food availability was identified more frequently by academic staff than other respondents. On the other hand, non-academics reported a higher concern, and identified the lack of storage facilities and food preparation areas at the workplace as a barrier. This parallelism on identified barriers could indicate that academics more frequently use university cafeterias, and non-academics bring food from home and use storage and preparation facilities, when available at the workplace, more frequently. These results are in line with the identification of a third barrier, significantly the difference between individuals with different professional occupations. Effectively, non-academics identified the price of healthy food options as a barrier for healthy eating more frequently than academics. Differences in salary between them could explain this result. The perception of these factors could influence the choice of place for having meals—cafeterias, or storage and preparation facilities.

Attending to the wide availability of information about healthy eating, the number of respondents that identify the lack of knowledge about nutrition or healthy eating as a barrier is unexpected. Men identified this barrier more frequently than women. In addition, Yahia observed that men identified the barrier, lack of knowledge about nutrition or healthy eating, more frequently than women, among university students [ 52 ].

Universities are a captive environment where staff is restricted to a campus where offices, classes and study facilities are located, and where there is limited choice for food provision [ 53 , 54 ]. The workplace can be a strong determinant of food consumption behavior as it provides convenient access to healthy and/or unhealthy food choices. In a population experiencing time constraints having good food choices at the workplace provides an easy option for refueling [ 37 , 48 ]. Food available at, or near workplaces, is more convenient, low in cost, and sells well [ 21 ]. Similar findings were reported by Pinhão et al. in a representative sample of the Portuguese population, where “taste” was the most selected factor, followed by “price” and “trying to eat healthy” [ 29 ] as determinants of food choice.

Our results are in accordance with those found by Kjøllesdal in Norwegian adults, showing that people with higher educational levels and in higher income groups ate in staff canteens more frequently than others [ 55 ].

According to previous literature, access to healthy foods in the workplace is often limited, compared with an abundance of unhealthy foods present in workplace canteens, onsite shops, and vending machines [ 46 , 48 , 56 , 57 ]. According to literature, workers desire a greater variety of healthy and fresh foods compared with the current offerings [ 46 , 57 , 58 , 59 ], which is identified in this research as a barrier for healthy eating. Healthy options also determined workers food choice. Interestingly, some employees felt that food served in the canteen is not balanced with their nutritional needs. The factors that influence food consumption of employees related to healthy options, nutritional value of foods, meal quality, and health and well-being, may be associated with employees’ perception of canteen’ meals being too high in calories and tailored for physically demanding roles [ 46 ].

However, employees also reported that the lunch provided by the work canteen is the only opportunity to have a “proper meal” each day [ 58 ]. In the same way, the workplace could be a provider of healthy foods (such as vegetables and fruit) and increase intake of those foods [ 59 , 60 ]. Availability at the workplace is a determinant for food choice and a barrier for healthy eating, the reasons why the availability of facilities where food can be prepared was considered to be an important facilitator of healthy eating [ 46 , 59 ]. On the other hand, the higher cost of healthy options compared with unhealthy options was identified as one of the most significant barriers to healthy eating [ 46 ].

The determinants that most influence food choice at the workplace in this study are related to the individual. The identification of knowledge about the health benefits of food is commonly observed, followed by biological determinants such as taste, smell, or the texture of the food, and finally, of an environmental nature related to the quality-price ratio of the food.

Food choices of men, with higher academic qualifications and belonging to the teaching staff, are determined by food taste and texture, and by availability and price-quality relationship. Additionally, they value the potential benefits of food, and their food choice is determined by them. The influence that foods can have on well-being is also important, such as choosing foods that help maintain alertness and support emotional health.

Regardless of gender, among professors with higher academic qualifications, food choice is determined by cultural, religious or ethnic beliefs, political ideologies, the clarity and environmental responsibility of packaging products, and medical advice regarding the intake of certain foods. On the other hand, among individuals with lower academic qualifications, these determinants have a reduced importance.

In fact, food choice is a complex result of preferences for sensory characteristics, combined with the influence of non-sensory factors, including food-related expectations and attitudes, health claims, price, ethical concerns and mood, as already reported by other authors [ 47 , 61 ]. Regarding these concerns, the availability of healthy food options at the workplace, namely in cafeterias, is very important. On the other hand, the inability to prepare meals was also identified as a barrier for healthy eating, pointing to a need to improve cooking skills, for example, by the inclusion of this topic in the school curriculum.

Only a small proportion of respondents perceived barriers for adoption of a healthy diet. Other authors observed similar results [ 25 , 26 , 62 ]. Healthier environments should be promoted to facilitate healthy eating and fighting chronic diseases such as obesity [ 63 ]. However, of all variables tested, only the price and lack of knowledge about nutrition/healthy eating showed significant differences between respondents. Some studies have shown that people that identify a higher number of barriers are those that follow unhealthy eating habits more frequently [ 24 , 63 ].

The barriers identified in this research are related only to individuals that are considered as having unhealthy eating at the workplace. Future works should also include those who are considered as having healthy habits.

Strategies to promote healthier food habits aim at reducing barriers to access healthy options and increasing opportunities for employees to make healthier food choices. Implementation includes provision of healthier options, improved accessibility, and establishment of mandatory policies to provide healthy options or restrict less healthy offerings at the workplace [ 16 ].

Some limitations were identified in this study. Lack of information concerning income that impair conclusions potentially explained by this. Another limitation was related to the usage of different tools to access food determinants for choosing the place to have lunch, and the determinants of food consumption in general. However, the fact that the tool used to access the determinants for choosing the place to have lunch was used in another Portuguese study with a national representative sample, motivates the researchers to that procedure. The use of a convenience sample determined a higher proportion of non-academic staff as they were more available for data collection.

5. Conclusions

The most important determinants identified by respondents choosing the place for having meals were “meal quality”, “price”, and “location/distance”. For women, the availability of “healthy food options” was more important than for men.

Our results seem to demonstrate that gender, marital status, academic degree and main professional occupation, are related to the choice of the place for having lunch. Differences were found between gender, marital status and age ranges, in terms of factors-affecting food choice at the workplace. A higher concern with nutritional value of food was observed for younger respondents, individuals living alone, and women.

Gender and academic degree are relevant in food choice. Factors influencing individuals with a low academic degree were previous food habits, price, and quality of meals, in determining the choice of place for having lunch at restaurants or at home. On the other hand, women with a high academic degree prefer to bring meals from home as they find them healthier.

Related to determinants of food choice in general, MCA analysis reported the major differences related to academic degree and main occupation, with lower academic degree individuals being not influenced by external determinants, since their food choice was mainly influenced by previous food habits. Higher academic degree employees in general are influenced by nutritional value of food and its relationship to health and well-being, packaging, and health professional advice, the reason why strategies to promote healthy eating in these scenarios are necessarily different. If we could design a healthy eating program based on information about the nutrition value of food and health, namely through packaging, our results would show clearly that this option could be adequate for teachers and other employees with high academic degrees, but not for others that probably need personal counseling to change previous food habits.

This work also identified lack of time, work commitments, and lack of healthy options for having meals at the workplace as barriers for healthy eating. Educational level, professional occupation, and gender were the socio-economic characteristics evaluated that influenced the perception of barriers for healthy eating.

These results may contribute to a better definition of strategies to promote healthy eating in these scenarios and show that different strategies are needed for different target groups to reduce barriers once they are perceived differently by individuals.

Acknowledgments

Authors thank Graça Neto, English Professional, for English grammar and structure revision of the manuscript.

Author Contributions

Conceptualization, J.P.M.L. and A.R.; formal analysis, S.A.C. and T.R.S.B.; investigation, J.P.M.L. and A.R.; writing—original draft preparation, J.P.M.L.; writing—review and editing, A.R. All authors have read and agreed to the published version of the manuscript.

This research was supported by national funds through FCT—Foundation for Science and Technology within the scope of UIDB/05748/2020 and UIDP/05748/2020.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethical Commission of the University of Porto (protocol code CEFADE 25.2014 at 22/10/2014).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Health Thesis Statemen

Navigating the intricate landscape of health topics requires a well-structured thesis statement to anchor your essay. Whether delving into public health policies or examining medical advancements, crafting a compelling health thesis statement is crucial. This guide delves into exemplary health thesis statement examples, providing insights into their composition. Additionally, it offers practical tips on constructing powerful statements that not only capture the essence of your research but also engage readers from the outset.

What is the Health Thesis Statement? – Definition

A health thesis statement is a concise declaration that outlines the main argument or purpose of an essay or research paper thesis statement focused on health-related topics. It serves as a roadmap for the reader, indicating the central idea that the paper will explore, discuss, or analyze within the realm of health, medicine, wellness, or related fields.

What is an Example of a Medical/Health Thesis Statement?

Example: “The implementation of comprehensive public health campaigns is imperative in curbing the escalating rates of obesity and promoting healthier lifestyle choices among children and adolescents.”

In this example, the final thesis statement succinctly highlights the importance of public health initiatives as a means to address a specific health issue (obesity) and advocate for healthier behaviors among a targeted demographic (children and adolescents).

100 Health Thesis Statement Examples

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Discover a comprehensive collection of 100 distinct health thesis statement examples across various healthcare realms. From telemedicine’s impact on accessibility to genetic research’s potential for personalized medicine, delve into obesity, mental health, antibiotic resistance, opioid epidemic solutions, and more. Explore these examples that shed light on pressing health concerns, innovative strategies, and crucial policy considerations. You may also be interested to browse through our other  speech thesis statement .

• Childhood Obesity : “Effective school-based nutrition programs are pivotal in combating childhood obesity, fostering healthy habits, and reducing the risk of long-term health complications.”
• Mental Health Stigma : “Raising awareness through media campaigns and educational initiatives is paramount in eradicating mental health stigma, promoting early intervention, and improving overall well-being.”
• Universal Healthcare : “The implementation of universal healthcare systems positively impacts population health, ensuring access to necessary medical services for all citizens.”
• Elderly Care : “Creating comprehensive elderly care programs that encompass medical, social, and emotional support enhances the quality of life for aging populations.”
• Cancer Research : “Increased funding and collaboration in cancer research expedite advancements in treatment options and improve survival rates for patients.”
• Maternal Health : “Elevating maternal health through accessible prenatal care, education, and support systems reduces maternal mortality rates and improves neonatal outcomes.”
• Vaccination Policies : “Mandatory vaccination policies safeguard public health by curbing preventable diseases and maintaining herd immunity.”
• Epidemic Preparedness : “Developing robust epidemic preparedness plans and international cooperation mechanisms is crucial for timely responses to emerging health threats.”
• Access to Medications : “Ensuring equitable access to essential medications, especially in low-income regions, is pivotal for preventing unnecessary deaths and improving overall health outcomes.”
• Healthy Lifestyle Promotion : “Educational campaigns promoting exercise, balanced nutrition, and stress management play a key role in fostering healthier lifestyles and preventing chronic diseases.”
• Health Disparities : “Addressing health disparities through community-based interventions and equitable healthcare access contributes to a fairer distribution of health resources.”
• Elderly Mental Health : “Prioritizing mental health services for the elderly population reduces depression, anxiety, and cognitive decline, enhancing their overall quality of life.”
• Genetic Counseling : “Accessible genetic counseling services empower individuals to make informed decisions about their health, family planning, and potential genetic risks.”
• Substance Abuse Treatment : “Expanding availability and affordability of substance abuse treatment facilities and programs is pivotal in combating addiction and reducing its societal impact.”
• Patient Empowerment : “Empowering patients through health literacy initiatives fosters informed decision-making, improving treatment adherence and overall health outcomes.”
• Environmental Health : “Implementing stricter environmental regulations reduces exposure to pollutants, protecting public health and mitigating the risk of respiratory illnesses.”
• Digital Health Records : “The widespread adoption of digital health records streamlines patient information management, enhancing communication among healthcare providers and improving patient care.”
• Healthy Aging : “Promoting active lifestyles, social engagement, and cognitive stimulation among the elderly population contributes to healthier aging and reduced age-related health issues.”
• Telehealth Ethics : “Ethical considerations in telehealth services include patient privacy, data security, and maintaining the quality of remote medical consultations.”
• Public Health Campaigns : “Strategically designed public health campaigns raise awareness about prevalent health issues, motivating individuals to adopt healthier behaviors and seek preventive care.”
• Nutrition Education : “Integrating nutrition education into school curricula equips students with essential dietary knowledge, reducing the risk of nutrition-related health problems.”
• Healthcare Infrastructure : “Investments in healthcare infrastructure, including medical facilities and trained personnel, enhance healthcare access and quality, particularly in underserved regions.”
• Mental Health Support in Schools : “Introducing comprehensive mental health support systems in schools nurtures emotional well-being, reduces academic stress, and promotes healthy student development.”
• Antibiotic Stewardship : “Implementing antibiotic stewardship programs in healthcare facilities preserves the effectiveness of antibiotics, curbing the rise of antibiotic-resistant infections.”
• Health Education in Rural Areas : “Expanding health education initiatives in rural communities bridges the information gap, enabling residents to make informed health choices.”
• Global Health Initiatives : “International collaboration on global health initiatives bolsters disease surveillance, preparedness, and response to protect global populations from health threats.”
• Access to Clean Water : “Ensuring access to clean water and sanitation facilities improves public health by preventing waterborne diseases and enhancing overall hygiene.”
• Telemedicine and Mental Health : “Leveraging telemedicine for mental health services increases access to therapy and counseling, particularly for individuals in remote areas.”
• Chronic Disease Management : “Comprehensive chronic disease management programs enhance patients’ quality of life by providing personalized care plans and consistent medical support.”
• Healthcare Workforce Diversity : “Promoting diversity within the healthcare workforce enhances cultural competence, patient-provider communication, and overall healthcare quality.”
• Community Health Centers : “Establishing community health centers in underserved neighborhoods ensures accessible primary care services, reducing health disparities and emergency room utilization.”
• Youth Health Education : “Incorporating comprehensive health education in schools equips young people with knowledge about reproductive health, substance abuse prevention, and mental well-being.”
• Dietary Guidelines : “Implementing evidence-based dietary guidelines and promoting healthy eating habits contribute to reducing obesity rates and preventing chronic diseases.”
• Healthcare Innovation : “Investing in healthcare innovation, such as telemedicine platforms and wearable health technologies, transforms patient care delivery and monitoring.”
• Pandemic Preparedness : “Effective pandemic preparedness plans involve cross-sector coordination, rapid response strategies, and transparent communication to protect global health security.”
• Maternal and Child Nutrition : “Prioritizing maternal and child nutrition through government programs and community initiatives leads to healthier pregnancies and better child development.”
• Health Literacy : “Improving health literacy through accessible health information and education empowers individuals to make informed decisions about their well-being.”
• Medical Research Funding : “Increased funding for medical research accelerates scientific discoveries, leading to breakthroughs in treatments and advancements in healthcare.”
• Reproductive Health Services : “Accessible reproductive health services, including family planning and maternal care, improve women’s health outcomes and support family well-being.”
• Obesity Prevention in Schools : “Introducing physical activity programs and nutritional education in schools prevents childhood obesity, laying the foundation for healthier lifestyles.”
• Global Vaccine Distribution : “Ensuring equitable global vaccine distribution addresses health disparities, protects vulnerable populations, and fosters international cooperation.”
• Healthcare Ethics : “Ethical considerations in healthcare decision-making encompass patient autonomy, informed consent, and equitable resource allocation.”
• Aging-in-Place Initiatives : “Aging-in-place programs that provide home modifications and community support enable elderly individuals to maintain independence and well-being.”
• E-Health Records Privacy : “Balancing the benefits of electronic health records with patients’ privacy concerns necessitates robust data security measures and patient consent protocols.”
• Tobacco Control : “Comprehensive tobacco control measures, including high taxation and anti-smoking campaigns, reduce tobacco consumption and related health risks.”
• Epidemiological Studies : “Conducting rigorous epidemiological studies informs public health policies, identifies risk factors, and guides disease prevention strategies.”
• Organ Transplant Policies : “Ethical organ transplant policies prioritize equitable organ allocation, ensuring fair access to life-saving treatments.”
• Workplace Wellness Programs : “Implementing workplace wellness programs promotes employee health, reduces absenteeism, and enhances productivity.”
• Emergency Medical Services : “Strengthening emergency medical services infrastructure ensures timely responses to medical crises, saving lives and reducing complications.”
• Healthcare Access for Undocumented Immigrants : “Expanding healthcare access for undocumented immigrants improves overall community health and prevents communicable disease outbreaks.”
• Primary Care Shortage Solutions : “Addressing primary care shortages through incentives for healthcare professionals and expanded training programs enhances access to basic medical services.”
• Patient-Centered Care : “Prioritizing patient-centered care emphasizes communication, shared decision-making, and respecting patients’ preferences in medical treatments.”
• Nutrition Labels Impact : “The effectiveness of clear and informative nutrition labels on packaged foods contributes to healthier dietary choices and reduced obesity rates.”
• Stress Management Strategies : “Promoting stress management techniques, such as mindfulness and relaxation, improves mental health and reduces the risk of stress-related illnesses.”
• Access to Reproductive Health Education : “Ensuring access to comprehensive reproductive health education empowers individuals to make informed decisions about their sexual and reproductive well-being.”
• Medical Waste Management : “Effective medical waste management practices protect both public health and the environment by preventing contamination and pollution.”
• Preventive Dental Care : “Prioritizing preventive dental care through community programs and education reduces oral health issues and associated healthcare costs.”
• Pharmaceutical Pricing Reform : “Addressing pharmaceutical pricing reform enhances medication affordability and ensures access to life-saving treatments for all.”
• Community Health Worker Role : “Empowering community health workers to provide education, support, and basic medical services improves healthcare access in underserved areas.”
• Healthcare Technology Adoption : “Adopting innovative healthcare technologies, such as AI-assisted diagnostics, enhances accuracy, efficiency, and patient outcomes in medical practices.”
• Elderly Falls Prevention : “Implementing falls prevention programs for the elderly population reduces injuries, hospitalizations, and healthcare costs, enhancing their overall well-being.”
• Healthcare Data Privacy Laws : “Stricter healthcare data privacy laws protect patients’ sensitive information, maintaining their trust and promoting transparent data management practices.”
• School Health Clinics : “Establishing health clinics in schools provides easy access to medical services for students, promoting early detection and timely treatment of health issues.”
• Healthcare Cultural Competence : “Cultivating cultural competence among healthcare professionals improves patient-provider communication, enhances trust, and reduces healthcare disparities.”
• Health Equity in Clinical Trials : “Ensuring health equity in clinical trials by diverse participant representation enhances the generalizability of research findings to different populations.”
• Digital Mental Health Interventions : “Utilizing digital mental health interventions, such as therapy apps, expands access to mental health services and reduces stigma surrounding seeking help.”
• Aging and Neurodegenerative Diseases : “Exploring the connection between aging and neurodegenerative diseases informs early interventions and treatment strategies to mitigate cognitive decline.”
• Healthcare Waste Reduction : “Implementing sustainable healthcare waste reduction measures decreases environmental impact and contributes to a greener healthcare industry.”
• Medical Ethics in End-of-Life Care : “Ethical considerations in end-of-life care decision-making ensure patient autonomy, quality of life, and respectful treatment choices.”
• Healthcare Interoperability : “Enhancing healthcare data interoperability between different medical systems and providers improves patient care coordination and information sharing.”
• Healthcare Disparities in Indigenous Communities : “Addressing healthcare disparities in Indigenous communities through culturally sensitive care and community engagement improves health outcomes.”
• Music Therapy in Healthcare : “Exploring the role of music therapy in healthcare settings reveals its positive effects on reducing pain, anxiety, and enhancing emotional well-being.”
• Healthcare Waste Management Policies : “Effective healthcare waste management policies regulate the disposal of medical waste, protecting both public health and the environment.”
• Agricultural Practices and Public Health : “Analyzing the impact of agricultural practices on public health highlights the connections between food production, environmental health, and nutrition.”
• Online Health Information Reliability : “Promoting the reliability of online health information through credible sources and fact-checking guides empowers individuals to make informed health decisions.”
• Neonatal Intensive Care : “Advancements in neonatal intensive care technology enhance premature infants’ chances of survival and long-term health.”
• Fitness Technology : “The integration of fitness technology in daily routines motivates individuals to engage in physical activity, promoting better cardiovascular health.”
• Climate Change and Health : “Examining the health effects of climate change emphasizes the need for mitigation strategies to protect communities from heat-related illnesses, vector-borne diseases, and other climate-related health risks.”
• Healthcare Cybersecurity : “Robust cybersecurity measures in healthcare systems safeguard patient data and protect against cyberattacks that can compromise medical records.”
• Healthcare Quality Metrics : “Evaluating healthcare quality through metrics such as patient satisfaction, outcomes, and safety indicators informs continuous improvement efforts in medical facilities.”
• Maternal Health Disparities : “Addressing maternal health disparities among different racial and socioeconomic groups through accessible prenatal care and support reduces maternal mortality rates.”
• Disaster Preparedness : “Effective disaster preparedness plans in healthcare facilities ensure timely responses during emergencies, minimizing casualties and maintaining patient care.”
• Sleep Health : “Promoting sleep health education emphasizes the importance of quality sleep in overall well-being, preventing sleep-related disorders and associated health issues.”
• Healthcare AI Ethics : “Navigating the ethical implications of using artificial intelligence in healthcare, such as diagnosis algorithms, safeguards patient privacy and accuracy.”
• Pediatric Nutrition : “Prioritizing pediatric nutrition education encourages healthy eating habits from a young age, reducing the risk of childhood obesity and related health concerns.”
• Mental Health in First Responders : “Providing mental health support for first responders acknowledges the psychological toll of their work, preventing burnout and trauma-related issues.”
• Healthcare Workforce Burnout : “Addressing healthcare workforce burnout through organizational support, manageable workloads, and mental health resources improves patient care quality.”
• Vaccine Hesitancy : “Effective strategies to address vaccine hesitancy involve transparent communication, education, and addressing concerns to maintain vaccination rates and community immunity.”
• Climate-Resilient Healthcare Facilities : “Designing climate-resilient healthcare facilities prepares medical centers to withstand extreme weather events and ensure continuous patient care.”
• Nutrition in Aging : “Emphasizing balanced nutrition among the elderly population supports healthy aging, preventing malnutrition-related health complications.”
• Medication Adherence Strategies : “Implementing medication adherence strategies, such as reminder systems and simplified regimens, improves treatment outcomes and reduces hospitalizations.”
• Crisis Intervention : “Effective crisis intervention strategies in mental health care prevent escalations, promote de-escalation techniques, and improve patient safety.”
• Healthcare Waste Recycling : “Promoting healthcare waste recycling initiatives reduces landfill waste, conserves resources, and minimizes the environmental impact of medical facilities.”
• Healthcare Financial Accessibility : “Strategies to enhance healthcare financial accessibility, such as sliding scale fees and insurance coverage expansion, ensure equitable care for all.”
• Palliative Care : “Prioritizing palliative care services improves patients’ quality of life by addressing pain management, symptom relief, and emotional support.”
• Healthcare and Artificial Intelligence : “Exploring the integration of artificial intelligence in diagnostics and treatment planning enhances medical accuracy and reduces human error.”
• Personalized Medicine : “Advancements in personalized medicine tailor treatments based on individual genetics and characteristics, leading to more precise and effective healthcare.”
• Patient Advocacy : “Empowering patients through education and advocacy training enables them to navigate the healthcare system and actively participate in their treatment decisions.”
• Healthcare Waste Reduction : “Promoting the reduction of healthcare waste through sustainable practices and responsible disposal methods minimizes environmental and health risks.”
• Complementary and Alternative Medicine : “Examining the efficacy and safety of complementary and alternative medicine approaches provides insights into their potential role in enhancing overall health and well-being.”

Thesis Statement Examples for Physical Health

Discover 10 unique good thesis statement examples that delve into physical health, from the impact of fitness technology on exercise motivation to the importance of nutrition education in preventing chronic illnesses. Explore these examples shedding light on the pivotal role of physical well-being in disease prevention and overall quality of life.

• Fitness Technology’s Influence : “The integration of fitness technology like wearable devices enhances physical health by fostering exercise adherence, tracking progress, and promoting active lifestyles.”
• Nutrition Education’s Role : “Incorporating comprehensive nutrition education in schools equips students with essential dietary knowledge, reducing the risk of nutrition-related health issues.”
• Active Lifestyle Promotion : “Public spaces and urban planning strategies that encourage physical activity contribute to community health and well-being, reducing sedentary behavior.”
• Sports Injuries Prevention : “Strategic implementation of sports injury prevention programs and adequate athlete conditioning minimizes the incidence of sports-related injuries, preserving physical well-being.”
• Physical Health in Workplace : “Prioritizing ergonomic design and promoting workplace physical activity positively impact employees’ physical health, reducing musculoskeletal issues and stress-related ailments.”
• Childhood Obesity Mitigation : “School-based interventions, including physical education and health education, play a pivotal role in mitigating childhood obesity and promoting lifelong physical health.”
• Outdoor Activity and Wellness : “Unstructured outdoor play, especially in natural settings, fosters children’s physical health, cognitive development, and emotional well-being.”
• Senior Nutrition and Mobility : “Tailored nutrition plans and physical activity interventions for seniors support physical health, mobility, and independence during the aging process.”
• Health Benefits of Active Commuting : “Promotion of active commuting modes such as walking and cycling improves cardiovascular health, reduces pollution, and enhances overall well-being.”
• Physical Health’s Longevity Impact : “Sustaining physical health through regular exercise, balanced nutrition, and preventive measures positively influences longevity, ensuring a higher quality of life.”

Thesis Statement Examples for Health Protocols

Explore 10 thesis statement examples that highlight the significance of health protocols, encompassing infection control in medical settings to the ethical guidelines for telemedicine practices. These examples underscore the pivotal role of health protocols in ensuring patient safety, maintaining effective healthcare practices, and preventing the spread of illnesses across various contexts.  You should also take a look at our  thesis statement for report .

• Infection Control and Patient Safety : “Rigorous infection control protocols in healthcare settings are paramount to patient safety, curbing healthcare-associated infections and maintaining quality care standards.”
• Evidence-Based Treatment Guidelines : “Adhering to evidence-based treatment guidelines enhances medical decision-making, improves patient outcomes, and promotes standardized, effective healthcare practices.”
• Ethics in Telemedicine : “Establishing ethical guidelines for telemedicine practices is crucial to ensure patient confidentiality, quality of care, and responsible remote medical consultations.”
• Emergency Response Preparedness : “Effective emergency response protocols in healthcare facilities ensure timely and coordinated actions, optimizing patient care, and minimizing potential harm.”
• Clinical Trial Integrity : “Stringent adherence to health protocols in clinical trials preserves data integrity, ensures participant safety, and upholds ethical principles in medical research.”
• Safety in Daycare Settings : “Implementing robust infection prevention protocols in daycare settings is vital to curb disease transmission, safeguarding the health of children and staff.”
• Privacy and E-Health : “Upholding stringent patient privacy protocols in electronic health records is paramount for data security, fostering trust, and maintaining confidentiality.”
• Hand Hygiene and Infection Prevention : “Promoting proper hand hygiene protocols among healthcare providers significantly reduces infection transmission risks, protecting both patients and medical personnel.”
• Food Safety in Restaurants : “Strict adherence to comprehensive food safety protocols within the restaurant industry is essential to prevent foodborne illnesses and ensure public health.”
• Pandemic Preparedness and Response : “Developing robust pandemic preparedness protocols, encompassing risk assessment and response strategies, is essential to effectively manage disease outbreaks and protect public health.”

Thesis Statement Examples on Health Benefits

Uncover 10 illuminating thesis statement examples exploring the diverse spectrum of health benefits, from the positive impact of green spaces on mental well-being to the advantages of mindfulness practices in stress reduction. Delve into these examples that underscore the profound influence of health-promoting activities on overall physical, mental, and emotional well-being.

• Nature’s Impact on Mental Health : “The presence of green spaces in urban environments positively influences mental health by reducing stress, enhancing mood, and fostering relaxation.”
• Mindfulness for Stress Reduction : “Incorporating mindfulness practices into daily routines promotes mental clarity, reduces stress, and improves overall emotional well-being.”
• Social Interaction’s Role : “Engaging in regular social interactions and fostering strong social connections contributes to mental well-being, combating feelings of loneliness and isolation.”
• Physical Activity’s Cognitive Benefits : “Participation in regular physical activity enhances cognitive function, memory retention, and overall brain health, promoting lifelong mental well-being.”
• Positive Effects of Laughter : “Laughter’s physiological and psychological benefits, including stress reduction and improved mood, have a direct impact on overall mental well-being.”
• Nutrition’s Impact on Mood : “Balanced nutrition and consumption of mood-enhancing nutrients play a pivotal role in regulating mood and promoting positive mental health.”
• Creative Expression and Emotional Well-Being : “Engaging in creative activities, such as art and music, provides an outlet for emotional expression and fosters psychological well-being.”
• Cultural Engagement’s Influence : “Participating in cultural and artistic activities enriches emotional well-being, promoting a sense of identity, belonging, and purpose.”
• Volunteering and Mental Health : “Volunteering contributes to improved mental well-being by fostering a sense of purpose, social connection, and positive self-esteem.”
• Emotional Benefits of Pet Ownership : “The companionship of pets provides emotional support, reduces stress, and positively impacts overall mental well-being.”

Thesis Statement Examples on Mental Health

Explore 10 thought-provoking thesis statement examples delving into various facets of mental health, from addressing stigma surrounding mental illnesses to advocating for increased mental health support in schools. These examples shed light on the importance of understanding, promoting, and prioritizing mental health to achieve holistic well-being.

• Stigma Reduction for Mental Health : “Challenging societal stigma surrounding mental health encourages open dialogue, fostering acceptance, and creating a supportive environment for individuals seeking help.”
• Mental Health Education in Schools : “Incorporating comprehensive mental health education in school curricula equips students with emotional coping skills, destigmatizes mental health discussions, and supports overall well-being.”
• Mental Health Awareness Campaigns : “Strategically designed mental health awareness campaigns raise public consciousness, reduce stigma, and promote early intervention and access to support.”
• Workplace Mental Health Initiatives : “Implementing workplace mental health programs, including stress management and emotional support, enhances employee well-being and job satisfaction.”
• Digital Mental Health Interventions : “Leveraging digital platforms for mental health interventions, such as therapy apps and online support groups, increases accessibility and reduces barriers to seeking help.”
• Impact of Social Media on Mental Health : “Examining the influence of social media on mental health highlights both positive and negative effects, guiding responsible usage and promoting well-being.”
• Mental Health Disparities : “Addressing mental health disparities among different demographics through culturally sensitive care and accessible services is crucial for equitable well-being.”
• Trauma-Informed Care : “Adopting trauma-informed care approaches in mental health settings acknowledges the impact of past trauma, ensuring respectful and effective treatment.”
• Positive Psychology Interventions : “Incorporating positive psychology interventions, such as gratitude practices and resilience training, enhances mental well-being and emotional resilience.”
• Mental Health Support for First Responders : “Recognizing the unique mental health challenges faced by first responders and providing tailored support services is essential for maintaining their well-being.”

Thesis Statement Examples on Covid-19

Explore 10 illuminating thesis statement examples focusing on various aspects of the Covid-19 pandemic, from the impact on mental health to the role of public health measures. Delve into these examples that highlight the interdisciplinary nature of addressing the pandemic’s challenges and implications on global health.

• Mental Health Crisis Amid Covid-19 : “The Covid-19 pandemic’s psychological toll underscores the urgency of implementing mental health support services and destigmatizing seeking help.”
• Role of Public Health Measures : “Analyzing the effectiveness of public health measures, including lockdowns and vaccination campaigns, in curbing the spread of Covid-19 highlights their pivotal role in pandemic control.”
• Equitable Access to Vaccines : “Ensuring equitable access to Covid-19 vaccines globally is vital to achieving widespread immunity, preventing new variants, and ending the pandemic.”
• Online Education’s Impact : “Exploring the challenges and opportunities of online education during the Covid-19 pandemic provides insights into its effects on students’ academic progress and mental well-being.”
• Economic Implications and Mental Health : “Investigating the economic consequences of the Covid-19 pandemic on mental health highlights the need for comprehensive social support systems and mental health resources.”
• Crisis Communication Strategies : “Evaluating effective crisis communication strategies during the Covid-19 pandemic underscores the importance of transparent information dissemination, fostering public trust.”
• Long-Term Health Effects : “Understanding the potential long-term health effects of Covid-19 on recovered individuals guides healthcare planning and underscores the importance of ongoing monitoring.”
• Digital Health Solutions : “Leveraging digital health solutions, such as telemedicine and contact tracing apps, plays a pivotal role in tracking and managing Covid-19 transmission.”
• Resilience Amid Adversity : “Exploring individual and community resilience strategies during the Covid-19 pandemic sheds light on coping mechanisms and adaptive behaviors in times of crisis.”
• Global Cooperation in Pandemic Response : “Assessing global cooperation and collaboration in pandemic response highlights the significance of international solidarity and coordination in managing global health crises.”

Nursing Thesis Statement Examples

Explore 10 insightful thesis statement examples that delve into the dynamic realm of nursing, from advocating for improved nurse-patient communication to addressing challenges in healthcare staffing. These examples emphasize the critical role of nursing professionals in patient care, healthcare systems, and the continuous pursuit of excellence in the field.

• Nurse-Patient Communication Enhancement : “Elevating nurse-patient communication through effective communication training programs improves patient satisfaction, treatment adherence, and overall healthcare outcomes.”
• Nursing Leadership Impact : “Empowering nursing leadership in healthcare institutions fosters improved patient care, interdisciplinary collaboration, and the cultivation of a positive work environment.”
• Challenges in Nursing Shortages : “Addressing nursing shortages through recruitment strategies, retention programs, and educational support enhances patient safety and healthcare system stability.”
• Evidence-Based Nursing Practices : “Promoting evidence-based nursing practices enhances patient care quality, ensuring that interventions are rooted in current research and best practices.”
• Nursing Role in Preventive Care : “Harnessing the nursing profession’s expertise in preventive care and patient education reduces disease burden and healthcare costs, emphasizing a proactive approach.”
• Nursing Advocacy and Patient Rights : “Nurse advocacy for patients’ rights and informed decision-making ensures ethical treatment, patient autonomy, and respectful healthcare experiences.”
• Nursing Ethics and Dilemmas : “Navigating ethical dilemmas in nursing, such as end-of-life care decisions, highlights the importance of ethical frameworks and interdisciplinary collaboration.”
• Telehealth Nursing Adaptation : “Adapting nursing practices to telehealth platforms requires specialized training and protocols to ensure safe, effective, and patient-centered remote care.”
• Nurse Educators’ Impact : “Nurse educators play a pivotal role in shaping the future of nursing by providing comprehensive education, fostering critical thinking, and promoting continuous learning.”
• Mental Health Nursing Expertise : “The specialized skills of mental health nurses in assessment, intervention, and patient support contribute significantly to addressing the growing mental health crisis.”

Thesis Statement Examples for Health and Wellness

Delve into 10 thesis statement examples that explore the interconnectedness of health and wellness, ranging from the integration of holistic well-being practices in healthcare to the significance of self-care in preventing burnout. These examples highlight the importance of fostering balance and proactive health measures for individuals and communities.

• Holistic Health Integration : “Incorporating holistic health practices, such as mindfulness and nutrition, within conventional healthcare models supports comprehensive well-being and disease prevention.”
• Self-Care’s Impact on Burnout : “Prioritizing self-care among healthcare professionals reduces burnout, enhances job satisfaction, and ensures high-quality patient care delivery.”
• Community Wellness Initiatives : “Community wellness programs that address physical, mental, and social well-being contribute to healthier populations and reduced healthcare burdens.”
• Wellness in Aging Populations : “Tailored wellness programs for the elderly population encompass physical activity, cognitive stimulation, and social engagement, promoting healthier aging.”
• Corporate Wellness Benefits : “Implementing corporate wellness programs enhances employee health, morale, and productivity, translating into lower healthcare costs and higher job satisfaction.”
• Nutrition’s Role in Wellness : “Prioritizing balanced nutrition through education and accessible food options plays a pivotal role in overall wellness and chronic disease prevention.”
• Mental and Emotional Well-Being : “Fostering mental and emotional well-being through therapy, support networks, and stress management positively impacts overall health and life satisfaction.”
• Wellness Tourism’s Rise : “Exploring the growth of wellness tourism underscores the demand for travel experiences that prioritize rejuvenation, relaxation, and holistic well-being.”
• Digital Health for Wellness : “Leveraging digital health platforms for wellness, such as wellness apps and wearable devices, empowers individuals to monitor and enhance their well-being.”
• Equitable Access to Wellness : “Promoting equitable access to wellness resources and facilities ensures that all individuals, regardless of socioeconomic status, can prioritize their health and well-being.”

What is a good thesis statement about mental health?

A thesis statement about mental health is a concise and clear declaration that encapsulates the main point or argument you’re making in your essay or research paper related to mental health. It serves as a roadmap for your readers, guiding them through the content and focus of your work. Crafting a strong thesis statement about mental health involves careful consideration of the topic and a clear understanding of the points you’ll discuss. Here’s how you can create a good thesis statement about mental health:

• Choose a Specific Focus : Mental health is a broad topic. Determine the specific aspect of mental health you want to explore, whether it’s the impact of stigma, the importance of access to treatment, the role of mental health in overall well-being, or another angle.
• Make a Debatable Assertion : A thesis statement should present an argument or perspective that can be debated or discussed. Avoid statements that are overly broad or universally accepted.
• Be Clear and Concise : Keep your thesis statement concise while conveying your main idea. It’s usually a single sentence that provides insight into the content of your paper.
• Provide Direction : Your thesis statement should indicate the direction your paper will take. It’s like a roadmap that tells your readers what to expect.
• Make it Strong : Strong thesis statements are specific, assertive, and supported by evidence. Don’t shy away from taking a clear stance on the topic.
• Revise and Refine : As you draft your paper, your understanding of the topic might evolve. Your thesis statement may need revision to accurately reflect your arguments.

How do you write a Health Thesis Statement? – Step by Step Guide

Crafting a strong health thesis statement requires a systematic approach. Follow these steps to create an effective health thesis statement:

• Choose a Health Topic : Select a specific health-related topic that interests you and aligns with your assignment or research objective.
• Narrow Down the Focus : Refine the topic to a specific aspect. Avoid overly broad statements; instead, zoom in on a particular issue.
• Identify Your Stance : Determine your perspective on the topic. Are you advocating for a particular solution, analyzing causes and effects, or comparing different viewpoints?
• Formulate a Debatable Assertion : Develop a clear and arguable statement that captures the essence of your position on the topic.
• Consider Counterarguments : Anticipate counterarguments and incorporate them into your thesis statement. This adds depth and acknowledges opposing views.
• Be Concise and Specific : Keep your thesis statement succinct while conveying the main point. Avoid vague language or generalities.
• Test for Clarity : Share your thesis statement with someone else to ensure it’s clear and understandable to an audience unfamiliar with the topic.
• Refine and Revise : Your thesis statement is not set in stone. As you research and write, you might find it necessary to revise and refine it to accurately reflect your evolving arguments.

Tips for Writing a Thesis Statement on Health Topics

Writing a thesis statement on health topics requires precision and careful consideration. Here are some tips to help you craft an effective thesis statement:

• Be Specific : Address a specific aspect of health rather than a broad topic. This allows for a more focused and insightful thesis statement.
• Take a Stance : Your thesis statement should present a clear perspective or argument. Avoid vague statements that don’t express a stance.
• Avoid Absolute Statements : Be cautious of using words like “always” or “never.” Instead, use language that acknowledges complexity and nuance.
• Incorporate Keywords : Include keywords that indicate the subject of your research, such as “nutrition,” “mental health,” “public health,” or other relevant terms.
• Preview Supporting Points : Your thesis statement can preview the main points or arguments you’ll discuss in your paper, providing readers with a roadmap.
• Revise as Necessary : Your thesis statement may evolve as you research and write. Don’t hesitate to revise it to accurately reflect your findings.
• Stay Focused : Ensure that your thesis statement remains directly relevant to your topic throughout your writing.

Remember that your thesis statement is the foundation of your paper. It guides your research and writing process, helping you stay on track and deliver a coherent argument.

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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

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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.

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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

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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.

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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

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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.

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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.

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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

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Published : 05 May 2024

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

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Watch CBS News

RFK Jr. says he suffered from a parasitic brain worm and mercury poisoning

By Allison Novelo

Updated on: May 9, 2024 / 9:24 AM EDT / CBS News

The campaign of Robert F. Kennedy Jr. , the independent running for president, confirmed Wednesday that he contracted a parasite in his brain over a decade ago. 

His campaign's comment came after The New York Times reported he said in a 2012 deposition that a parasitic worm "ate a portion" of his brain and may have caused cognitive issues. 

Kennedy campaign spokesperson Stefanie Spear said in a statement to CBS News that he contracted a parasite after traveling "extensively in Africa, South America and Asia as his work as an environmental advocate."

"The issue was resolved more than 10 years ago, and he is in robust physical and mental health. Questioning Mr. Kennedy's health is a hilarious suggestion, given his competition," Spear said. 

Kennedy quipped in a post on X Wednesday, "I offer to eat 5 more brain worms and still beat President Trump and President Biden in a debate."

During a deposition given by Kennedy in 2012 amid his divorce from his second wife, Mary Richardson Kennedy, The Times reports he stated that he faced "cognitive problems" and experienced memory loss and brain fog, leading one doctor to say he had a dead parasite in his brain in 2010. 

The Times reported that Kennedy said in the deposition that a friend pushed him to seek out medical care after noticing his cognitive issues, initially thinking Kennedy might be suffering from a brain tumor. 

It is possible that Kennedy could have contracted a parasitic worm in his brain, according to a medical expert, although it wouldn't have been "eating his brain." However, parasites such as tapeworms do not consume brain tissue, as Kennedy suggested during his deposition.

Tapeworm infections, or neurocysticercosis, can be contracted from consuming undercooked pork or drinking contaminated water, particularly in regions with poor sanitation such as parts of Latin America, sub-Saharan Africa and Asia. When individuals ingest tapeworm eggs, these can travel through the bloodstream and infest various organs including the brain, muscles, liver and other tissues.

Symptoms can include nausea, headaches and seizures, said CBS News medical contributor Dr. Celine Gounder on "CBS Mornings,"  although many people who suffer from this type of infection may not see symptoms. 

Treatment for tapeworm infection typically involves medications such as anti-parasitic drugs to kill the worms.

In some cases, if the worm dies, the body's immune system may clear the dead worm from the brain tissue without requiring surgery, unless complications arise. It's unclear whether Kennedy underwent surgery for this diagnosis, though he informed the Times in a recent interview that he has fully recovered from the memory loss and brain fogginess and has experienced no other lingering effects. He also mentioned that no treatment was necessary for the parasitic condition.

According to The Times, during Kennedy's 2012 deposition, he also reported having been diagnosed with mercury poisoning, which he said was the result of a diet heavy on tuna and other fish. He reportedly said, "I have cognitive problems, clearly. I have short-term memory loss, and I have longer-term memory loss that affects me."

Memory loss is more commonly associated with mercury poisoning than with a parasitic worm, experts say.

Kennedy told the paper that he attributed his mercury poisoning diagnosis to his diet. He said medical tests showed his mercury levels were 10 times what the Environmental Protection Agency considers safe.

" I loved tuna fish sandwiches. I ate them all the time," Kennedy said to The Times.

Kennedy has long been an outspoken activist against vaccines containing thimerosal, a mercury-based preservative that was phased out of childhood vaccines two decades ago, falsely linking vaccinations in children to a rise in autism and other medical conditions. There is no evidence to suggest that low doses of thimerosal causes harm to people, but an excess consumption of mercury, found in fish, can be toxic to humans.

And while both parasitic infections and mercury poisoning can lead to long-term brain damage, it is also possible to make a full recovery, experts say.

Allison Novelo is a 2024 campaign reporter for CBS News.

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