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Dietary Trajectories in the Menopause Transition Among Québec Women
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Dietary Trajectories in the Menopause Transition Among Quhbec Women MARIE-CLAUDE P A Q U E T T E 'AND CAROLM . D E V I N E ~ 'Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, Alberta, Canada T6G 2P5; 2Division of Nutritional Sciences, M V R , Cornell University, Ithaca, New York 14853-4401
ABSTRACT This qualitative study explored perimenopausal women's perceptions and experiences of continuity and change in dietary behavior.This study used a naturalistic paradigm and three in-depth qualitative interviews over a 13-month period. A purposive sample of 23 perimenopausal women was recruited from community health centers and social organizations in rural and urban areas of Qu6bec.The semistructured interview guide focused on dietary and lifestyle changes, health and body changes, social roles, and the menopause experience. Grounded theory analysis was performed on the transcribed interviews. Women's narratives described three types of dietary trajectories: unsuccessful dieting, small change, and progressive change. Women with similar trajectories shared experiences with food, dieting practices, self-efficacy, and transition in the maternal role. Although most women reported continuing on the same dietary trajectory for most of their adult lives, a few described changes in their diets. Some women associated their small changes in diet with being informed of the potential development of chronic diseases, whereas others radically changed their diets following life events such as the development of an illness. Menopause per se was not perceived by women as a time for dietary change. Health and nutrition professionals could improve the impact of their efforts by recognizing the contribution of past dietary behavior to current dietary practices. Dietary advice would also benefit from being tailored to women's existing dietary trajectories.
INTRODUCTION Midlife is a time of change for many women. Although women's experiences can vary greatly, they may experience physical changes associated with menopause and aging, social changes resulting from the departure of children or the
................................................... At the time of the study, Marie-Claude Paquettt. was a Ph.D. candidate in the Divls ~ o nof Nutritional Sciences, Cornell Un~vcrslty. Address for correspondence: Marie-Claude Paquette, Ph.D., R.D., Department of Agricultural, Food and Nutritional Sc~enccs,410 Agr~cultureForestry Centre, Unlversity of Alberta, Edmonton, AU Canada,T6G 2P5; Tel: (780) 492-3989; E-mail: [email protected]. 02000 SOCIETY F O R N U T l i l T l O N EDUCATION
needs of elderly parents for care, psychological changes such as the reassessment of life goals and reflections on the past, and health From a biomedical point of view, hormonal changes experienced by perimenopausal women are associated with an increased risk of developing chronic disThis eases such as cardiovascular disease5 and osteop~rosis.~ increased risk is not only associated with changes occurring at the menopause transition but also with cumulative lifestyle practices. Diet and other lifestyle factors play key roles in the development and prevention of these chronic disease^.^,^ Women's increased attention to the physical, social, psychological, and health changes associated with midlife and menopause could make this transition period a favorable time to provide nutrition education and to introduce dietary changes.' Furthermore, women after midlife perceive that they have more time for themselves and consequently can take better care of their health.I0 Little research has examined women's dietary practices and attitudes at midlife and menopause or factors influencing them. Women's lives are marked by physiologic and role changes associated with reproductive events such as pregnancy and menopause. These occurrences bring discontinuity and a constant need for creation and creativity." Women give their lives meaning and unity through reinterpretation of past events, perception of current experiences, and anticipation of the future, which is incorporated into their narratives."." These characteristics of women's lives can best be captured by the life course perspective. The life course perspective'" proposes that the experience of a life event like menopause occurs in the context of ongoing trajectories such as cumulative maternal and family roles, dietary and lifestyle practices, and health. Thus, the experience of transitional events like menopause is interdependent with trajectories in areas such as roles, lifestyle practices, and health. The life course perspective guided this study toward a comprehensive conceptualization of women's lives over time, provided focus for the development of the interview guides, and served as a conceptual template against which emergent themes could be compared during analysis.The goal of this study was to gain an in-depth understanding of perimenopausal women's perceptions and experiences with continuity and change in dietary behavior and how these percep-
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tions are affected by midlife changes, menopause experiences, and previous life histories.
PROCEDURES This study was guided by the naturalistic paradigrn.14 A naturalistic approach strives to inductively understand human experience in specific settings and contexts.15It is useful when little research has examined the question of interest, when responses are expected to be con~plexand contextual, and when the perceptions of the research participants are central in understanding the topic of interest.I4 Dietary change in the menopause transition is such an area of research.
Sample. Perimenopausal women were purposefully recruited from four rural and urban sites in Qukbec, Canada. Study participants were approached during menopause management programs offered by community organizations and women's health centers. Posters and brochures left in these centers also advertised the study.Women were eligible for the study if they were healthy, were between 40 and 55 years of age, and perceived themselves as experiencing perimenopause. A subjective assessment of menopausal status was used because the aim of the study was to understand how women themselves experienced menopause. Women who were postn~enopausalor who had a bilateral ovarectomy were excluded from the study. Eligibility criteria for subsequent recruitment were modified after concurrent data analysis'%f 17 initial interviews revealed that very few women reported that they were currently making changes in their diets. From this point, women who were making dietary changes were purposefully recruited in order to contrast them with women who did not report changes. Thus, study participants in the final sample included healthy wornen and women with health problems or with recent and past history of a life-threatening illness. Recruiting was discontinued when concurrent data analysis of 23 interviews showed that no new themes were emerging." The final group of 23 study participants were all Caucasian and ranged in age from 45 to 56 years old.Women had between zero and four children, 16 were employed full-time, 8 were single, and 15 were married or had a live-in partner. Further description of the sample is provided in Table 1. Data collection. The principal investigator interviewed 23 women three times in French, over a 13-month period, using a semistructured open-ended interview guide to provide rich narratives of women's experiences and perceptions ll were tape recorded and in their own w ~ r d s . ' ~ Ainterviews study participants gave written informed consent according to the procedures of the University Human Subjects Committee. The interviewer had 14 weeks of formal training in qualitative research methods and theory and had previous qualitative research experience. The interview guides focused on changes in social roles, health, diet, and physical activity as well as motivations for
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Table 1. Sociodemographic description of women according to dietary trajectory. Unsuccessful
Small
Progressive
Dieting
Change
Change
Dietary Trajectory
Total
Study participants (n) Age (yr) Marital status Married Live-in partner Single (includes divorced and separated) Mean age at birth of first child (yr) Number of children (n) Employment Full time Part time Retired Homemakers Student
these changes, experience of menopause, menopause management strategies, and changes in self-perception. Questions and probes were focused on current experiences and were directed to bring women to reflect on past practices and the events that brought about these dietary practices. Interview guides had been previously pilot tested and used in a smaller similar study examining dietary and lifestyle changes in 18 pre-, peri-, and postmenopausal women. The guides were translated into French and reviewed by French-speaking women of Qukbec and by menopause managenlent program staff to ensure cultural relevance. Minor modifications of wording were suggested. In addition, questions on spiritual changes and on psychotherapy were added because these issues were discussed by the first three participants as an important part of their lives. Steps to ensure credibility of the study findings included member checks, peer debriefing, personal reflectiveness, and depth of contact. At the beginning of the second interview, each woman was presented with a summary of her first interview. These member checks gave the researcher the opportunity to check her interpretations with those of the study participants and increased her understanding of the women's experiences and meanings.According to Lincoln and Guba,"' member checks are the "most crucial technique for establishing credibility." The interviewer kept a personal reflective journal and met regularly with the second author to discuss findings and reflect on preliminary interpretations as a form of peer debriefing." In addition, the findings were presented
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to other researchers with expertise in the area. Finally, the multiple contacts with study participants in the form of three in-depth interviews over a period of 13 months added to confidence in the reliability of the findings. Dietary trajectories emerged out of women's narratives. Data were combined from the three interviews and the member check of the second interview to elaborate women's dietary trajectories by providing patterns of dietary practices and changes in practices over time.
Data analysis. Data analysis was performed by the interviewer using the verbatim transcripts of personal interviews, field notes, and member checks.The interviewer started by open coding in which initial categories of segments of information about the phenomenon under study were created through iterative reading of the interview transcripts and other data sources.20These emergent categories were then explored further by comparing them to data being concurrently collected up to the point of saturation, when the new information obtained in data collection did not further proPatterns of continuity and vide insight into the ~ategories.~',~' change, influences on and associations with the phenomena of interest, and the context of these relationships were explored.Types of dietary trajectories were compared among women. As working hypotheses and models developed to explain dietary continuity and change, they were compared to women's narratives and negative cases were sought." Inconsistencies in the model were explored and reflected upon, and revisions were made to the model. This constant confirmation of the model and subsequent modifications ensured that the final model accurately reflected women's experiences, stories, and perceptions. O f the 24 women originally interviewed, one woman's narrative did not fit in any one dietary trajectory as she shared characteristics from the three trajectories. She was excluded from this article due to a lack of space to explore her particular case.Thus, the findings reflect the data from 23 women.
Although a majority of women described continuity in dietary trajectories across adulthood, seven women reported having undergone a dietary transition characterized by radical n~odificationsin diet and lifestyle habits. These dietary transitions followed life events such as major role changes or serious health problems or threats. This discontinuity in some women's dietary trajectories resulted not only from the occurrence of life events but, more importantly, from the meaning that women gave these events and their perceptions of their current dietary and lifestyle habits. In the findings below, data from each trajectory will be presented followed by additional data from the women who made changes in their dietary pathways.
Unsuccessful dieting: "I try but I can't get myself to eat right." Narratives of the 10 women in the unsuccessful dieting group described starting on this path as a result of excess weight in childhood or adolescence or as a result of postpartum weight retention and weight gain in their forties. Dietary change for these women was always principally motivated by the goal ofweight 1oss.They had tried many weightreducing strategies such as very low-calorie diets, fasting, fad diets, and liquid protein diets.The first weight loss efforts often resulted in temporary success, invariably followed by weight gain that was greater than the weight 1oss.This led to greater weight dissatisfaction, thus perpetuating the cyc1e.A 53-yearold social worker gives an example of this: I have been on so many diets. Weight Watchers, Mince-a-vie, liquidproteins, hormones. I evenfasted. I lost the weight but it all comes back! 1 never really changed my habits.
These women's changes in dietary habits were always temporary. In addition to feeling that they had poor dietary habits, they also felt guilty about their failure at permanent dietary changes, as described by this 45-year-old nurse: BcfiforeI was really careful, Ifollowed my diet, but I couldn't keep it up, I have no will power.. .see how bad I am.
FINDINGS Continuous dietary trajectories across adulthood emerged from the narratives of 17 of the 23 study participants.Three types of dietary trajectories-Unsuccessful Dieting, Small Change, and Progressive Change-emerged from participants' narratives. Dietary trajectories were interpreted as women's cumulative experiences with food and eating, dieting, and weight management. Within each trajectory, women's accounts described similar dietary pathways that predated midlife and often found their origin in young adulthood. Women on each trajectory reported common experiences with dieting for weight control, patterns of weight gain, attitudes toward weight gain, motivations and level of self-efficacy for dietary change, and level of self-care. Menopause was not perceived per se as a motivator of change in dietary and lifestyle habits.
Many women's accounts described food as something they "had to be careful about," that required vigilance. Numerous unsuccessful attempts at dietary change and weight loss led women on the unsuccessful dieting trajectory to the belief that they were now incapable of successfully changing their diets.This 48-year-old homemaker is one of these women: I know all the right things I need to do, but will I ever do them? I don't know. Will lever be able to do them and stick with them? 1don't think so.
Interestingly, all unsuccessful dieters attributed their "failures" to lose weight and change their dietary habits to themselves and to their lack of willpower rather than doubting the efficacy of the weight-reducing strategies they had attempted.
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In addition to dealing with issues of body weight, food, and eating, unsuccessful dieters were experiencing difficulties in their maternal role. Whereas some women were worried about their adolescent children's delinquency problems or the financial difficulties of their adult children, others, like this 46-year-old mother of two, were adjusting to their children leaving home: I have raised my boys to be independent. I knew they would leave one day. But it's really hard seeing them leave; knowing it and living it is not the same thing.
Women on the unsuccessful dieting trajectory reported that they had never taken time to take care of themselves due to the many obligations related to their maternal and work roles.This 46-year-old crossing guard explains: I try to take more care ofmyselJ But it's hard; I have always been taking care ofothers.
Five of the 10 unsuccessful dieters reported experiencing a major life event such as the death of a spouse or cancer, recently or in the last 4 years, that resulted in radical changes in their dietary habits.As suggested by these women's narratives, this recent dietary change was not comparable to their past dieting attempts. They described how their attitudes toward restrictive dieting had changed and that dietary practices they were now putting in place would be permanent. This is illustrated by a 54-year-old bank manager: I don't even want to hear about dieting anymore. I am not focused on we2ht. I f I have good eating habits and eat in a reasonable quantity, then I should be healthy.
In summary, women on the unsuccessful dieting trajectory described a long-term trajectory of unsuccessful struggles to change their dietary habits. Five unsuccessful dieters experienced a dietary transition following a major life event. The remaining five women continued with restrictive dieting cycles and reported little confidence in their ability to make dietary changes, which may have developed out of numerous unsuccessful dieting attempts.Their motivation to change their diets stemmed mainly from their desire to decrease their body weight.
Small change:"I have made small changes in my diet." Eight women followed the small change trajectory. Narratives of small changers described stable dietary practices until midlife, after which they made small changes in their diets. Most women reported that the dietary habits they had for most of their lives developed after leaving home and getting married.Women in the small change group believed that they had always eaten well and had never been preoccupied with their eating habits.This is the case of a 51-year-old homemaker: Q: How would you describe your eating habits?
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R: Well, I have always eaten well ... We always ate healthy in my family, on the farm, and I continued that way with my own family.
These women's accounts described gaining 1 or 2 pounds every year since their forties. Nevertheless, none described ever having followed a weight control diet, and all still considered their body weights satisfactory. Yet, small changers discussed concerns about staying within a personally established weight range and viewed important weight gains and obesity as a negative occurrence mostly because of esthetics and social stigmatization. Small changers told of recent changes in their diets in the last few months. These changes were viewed as small ones such as drinking a glass of orange juice in the morning, drinking more milk, switching from white to whole-wheat bread, and taking only one dessert instead of two. For all small changers, dietary change occurred following either reading brochures on cardiovascular disease and osteoporosis provided by physicians or participation in a menopause management program. Menopause management programs consisted of 6 to 10 weekly 3-hour meetings, including one session on nutrition and physical activity.They also discussed menopause management strategies such as hormone replacement therapy (HRT). Information on H R T was the primary motivation that these women gave for attending the program. Small changers' narratives suggest that they did not perceive a need to change their dietary habits before they were sensitized to potentially developing chronic diseases. Being better informed seemed to bring about reflection, and small changers now perceived that they were at risk and, in response, were willing to make some small changes, as illustrated by the following woman: Q: Have there been any recent changes in your dietary habits? R: Yes, well I worry more about my eating.. .I worry more about drinking milk and osteoporosis...Since the program I think more about it. I already knew it, but it isgood to be reminded; you tell yourselt; oh yes, I need to pay attention.
When asked about their motives for making small changes in their diets, women in this group discussed either their fear of chronic diseases or their desire to take preventive measures to maintain their health. Women following the small change trajectory considered themselves successful at making these changes. They also reported maintaining their new habits for the study duration of 1 3 months. Because these women had never tried changing their diets in the past, it was not possible to elicit their expectations about the difficulty or ease of making dietary changes. Unlike the unsuccessful dieters, who reported troubled transitions in their maternal roles, small changers reported smooth transitions when their children left home. They linked this transition to an increase in time and ability to care for themselves.This is illustrated by a 50-year-old full-time worker and mother of three adult boys:
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Naturally, since the children aregone I have mnclz more time.for myreg I also spend more time with mygrandchildren.
A subgroup of small changers (four of eight) lived in a rural community and shared many common characteristics such as marrying and having children at an earlier age than women on the other two dietary trajectories. Thus, many small changers were already grandmothers. Being a grandmother was perceived as a very positive experience. In addition to making small changes in their diets, two small changers experienced radical changes following significant health events. O n e woman associated this radical change with her diabetes diagnosis, whereas the other associated it with her physician? warning that she would take medication if she was not able to decrease her blood cholesterol levels through diet and exercise. O n the whole, women following the small change trajectory were making small changes in their diets to prevent chronic diseases.They were experiencing positive transitions in their maternal roles, and many were acquiring the new role of grandmother. As a result of this transition and of decreasing their workload, they were taking more time to take care of themselves. Participating in a menopause management program and in physical activities was part of this increased self-care. For instance, they went to restaurants with friends or sisters, regularly walked after supper with a neighbor, or offered to baby-sit grandchildren.
Progressive change:"I have always eaten right." Progressive changers followed a dietary trajectory of change. Narratives of these five women described their dietary path as being a work in progress.They talked about making continuous gradual dietary in~provementsthroughout their adult years.They told how previous changes had been successfully accomplished and anticipated future changes to be as easily done. This is how a 54-year-old homemaker talked about dietary changes: We have always gradually changed our eat in^. Whew the kids came, trle ate better than we did befi~reand it continues. We are eating better and better every year. It is easy to keep the changes when you make small ones.
Progressive changers had explored many alternatives in their eating practices. This exploration occurred primarily when women left home, via personal development activities and spiritual quests. For instance, some women's dietary habits were influenced by macrobiotic diets and vegetarianism. Accordingly, these women gradually reduced their meat intake, incorporated legumes in their diets, ate more fruits and vegetables, and weaned themselves off beverages containing caffeine. Among all of the women in the study, only two expressed the importance of the connection between food, eating, pleasure, and fun. Both of these women were progressive changers. Women on the progressive change trajectory reported never having followed a weight control diet, regardless of
weight gain as adults.They perceived weight gain to be irrelevant and gave it little importance. Rather, they stressed the importance they gave to well-being and feeling good about their bodies and themselves as the motivation for their dietary changes. Progressive changers were highly conscious of the importance of staying healthy: I have made thesegradual changes in nly diet to.fiel bettcu, to have more eneyy. My body needs it and I listen to my body.
All progressive changers talked about their constant high level of self-care throughout their lives. Women described self-care as taking more time for themselves to engage in activities they enjoyed such as taking a long bath, reading a book, writing, and socializing with friends. Unlike women following the two other trajectories, women on the progressive change trajectory did not view the maternal role as a barrier to self-care.This single mother of two young boys always made time for herself to take night classes: The baby sitter came, the kids complained. 1 umuld tell them: Listen, this is the baby sitter; in afew hours you'll be in bed and I will be in class. I'll be happy, you'll be happy, what's the d!ference!
Additionally, of all three groups, these women talked the most about motherhood as a central role in their lives. Women following the progressive change trajectory spoke of the attention and time they gave their children while they were growing up. Nevertheless, they believed that as children grew older, it was healthy for the relationship between parent and child to change toward a friendship.These women also experienced a smooth transition in their maternal role. Although most progressive changers had experienced a significant life event such as an emotional burnout or cancer, they did not describe a change in their dietary habits following these events. These women did not perceive the need to change their diet or lifestyle because they believed that they already had the best habits they could have. Overall, progressive changers were on a continuous trajectory of change. Their trajectories were characterized by progressive and permanent changes in diet.This succession of positive changes contributed to these women's high self-eficacy for dietary changes. Progressive changers expressed little concern for weight gain and focused instead on well-being and health. Consistent with this focus on well-being, they also described a high level of self-care throughout their lives.
Dietary transitions. As was discussed in the preceding sections, a few women following either the unsuccessful dieting trajectory5 or the small change trajectory' described experiencing a dietary transition in response to a major life event. These women's experiences were varied. Major life events reported by participants were either social in nature, such as the death of a spouse, retirement, a job change, or serious health problems and threats, like developing diabetes (for two women), having a diagnosis of cancer, or elevated
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cholesterol. Although no woman mentioned psychological changes by themselves as prompting a dietary transition, psychological changes such as reassessment of life goals always followed these social and health changes. The women who reported making dietary transitions differed from those who reported stable trajectories, several of whom had also experienced major life events. Women who experienced dietary transitions assessed their current dietary and lifestyle habits as unhealthy or needing improvement. In addition, they interpreted the context of life events as creating a favorable environment for the maintenance of modifications toward healthy dietary habits. It was diflicult for most women to describe their new dietary trajectories following a radical transition because the changes had occurred relatively recently, but women's narratives suggested that the new trajectories promised to be stable.Women who experienced transitions did not report interest in continual improvements in their dietary habits, like the progressive changers; rather, they were working on maintaining their recently adopted habits. The three dietary trajectories, Unsuccessful Dieting, Small Change, and Progressive Change, are summarized in Figure 1.The figure illustrates how women on the unsuccessful dieting trajectory experienced a series of cycles of failed attempts at change whereas On the change trajectory only experienced small positive changes in their diets at menopause. Women on the progressive change trajectory, on the other hand, seemed to be on a continuous path of improving their dietary habits by a succession of positive changes. Finally, the women who experienced a dietary transition are also shown as deviating greatly from the unsuccessful dieting and small change trajectories.
DISCUSSION The narratives of these women provide a picture of continuous dietary trajectories across perimenopause. Study participants' narratives described one of three trajectories: repeated cycles of unsuccessful restrictive dieting for weight loss, stable dietary habits until midlife when small health-oriented changes were made, or progressive health-oriented changes throughout life. In a few cases, women who experienced serious life events reported making radical dietary transitions in response to them. Life events that led to transitions were either major role changes, serious health problems, or health threats. For the majority of study participants, menopause per se was not a factor associated with dietary change. Most women continued on their previous dietary trajectories even while experiencing the numerous changes associated with midlife and m e n ~ p a u s e . ' ~These ' ~ ~ ~ findings are consistent with reports that menopause is not perceived as a prominent event in the midlife period.',24," Continuity of dietary behaviors has been suggested in prior studies exploring the diets of adolescent women," postpartum women,'7 and menopausal women." In this last study," menopausal women perceived
Unsuccessful Dieting
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Failed attempts at dietary change
transitions /-'
Menopause
Small Change
? i
Progressive Change
Successful small
dietary changes
Successful small dietary changes
Time
+
Figure 1. Dietary trajectories of perirnenopausal study participants.
themselves as having healthy dietary habits and reported that these habits were sustained and reinforced by the physical changes experienced at menopause. Continuity of dietary habits in the menopause transition could be explained by the fact that menopause is a normative transition and may not provoke change because it is expected.28It is also possible that women do not link menopause and menopausal manifestations to the need for dietary change. Nevertheless, six women on the small change trajectory r e p o r t e d making small dietary changes d u r i n g t h e menopause transition. These women's narratives described changing their diets following sensitization to the long-tern~ consequences of menopause and thus for the prevention of chronic diseases rather than for menopause management. Even if small changers did not view dietary changes as a menopause management strategy, they described both modifying their dietary practices and taking H R T to alleviate long-term consequences of menopause.They viewed H R T as more effective in preventing chronic diseases and in controlling menopausal manifestations such as hot flashes and vaginal dryness than diet. Still, dietary practices were described as an adjuvant to HRT. For women following a small change trajectory, participation in a menopause management program could be a key factor in motivating their dietary changes. Indeed, most women on a small change trajectory shared characteristics in the timing of their lives and social context as they were from the same rural community. The timing of the birth of their first child, at an early age, could have launched them onto a
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life path that transformed the menopause management program into an opportunity for dietary behavior change.This was not the case for the other women in the sample who participated in menopause management programs. In addition, the menopause management program experience for small changers could have been different than for women following other programs. Many women in the rural group knew each other because they had encouraged their sisters and neighbors to come with them to the program. More research needs to focus on timing and context of life events to understand the creation of opportunities for diet and lifestyle changes later in life. Seven women who described experiencing a radical change in dietary habits associated it with major life events such as social or health changes that in turn prompted psychological changes.We found several such radical changes in diet mostly due to our revised sampling scheme that purposefully sought dietary change. Life events seemed to be interpreted as creating new environments and favorable conditions that were experienced as turning points4 for these women to change habits.These findings are supported by a recent study2ythat also found that unplanned factors such as role changes and development of illness were reported as opportunistic times for dietary changes. More research is needed to explore how the occurrence, type, and timing of life events influence diet and lifestyle changes. The life course approach used in this study is helpful in elucidating patterns in dietary behavior over time. It was then possible to explore the links between the different trajectories in women's lives as well as the impact of transitions on ~ ~ ~dietary ' trajectories described by these t r a j e c t ~ r i e s . ~The study participants were long-term patterns that women traced back to young adulthood or, in some cases, to childhood. For some women, dietary trajectories were linked with their weight trajectories. For instance, weight gain in adulthood was seen by some women as instrumental in initiating restrictive dieting cycles of the unsuccessful dieting trajectory. Furthermore, for some women, weight gain in adulthood was perceived to be the result of postpartum weight retention, suggesting that weight trajectories might be influenced by maternal roles. For these women, inception of the maternal role trajectory had a lasting impact on their weight and dietary trajectories. Finally, emergent data implied that the health and dietary trajectories influenced each other.Women (in small change and unsuccessful dieting) experiencing a major health transition also reported radical changes in their dietary practices. More research needs to be done to confirm the links between the dietary, weight, maternal role, and health trajectories as well as their mutual influences at times of transition. Findings from this study are consistent with Social Cognitive Theory (SCT)32and its concept of reciprocal determinism. Although not an explicit test of that model, cumulative personal, behavioral, and environmental factors emerged from these data as life course influences on women's experience of menopause. For instance, in this study, failure
to make dietary changes for women in the unsuccessful dieter group was associated with low self-efflcacy level (person),little opportunity for change (environment), perceived barriers (environment), and past experiences with unsuccessful attempts at making permanent changes (behavior). This potentially new longitudinal conception of SCT needs to be explored further in future studies. This study has many strengths and limitations associated with design, sampling, and interpretation. It used a purposeful sample that included perimenopausal, healthy, Caucasian, French-speaking women of Qukbec. The sample did not include women with diverse sexual orientations, poor women, or English-speaking women.Thus, these findings are limited to women who are similar to this population of women. The sampling strategy used women's health and community centers, which meant that at each site some women knew each other.This factor contributed to decreasing the diversity of respondents, as people who know each other are likely to have similar characteristics, such as the small changers from one rural site. These similarities could influence the study findings by reducing the number of dietary trajectories we found in women. Finally, women in this study had a particular cultural and social context that influenced their experiences. The use of conceptual frameworks to guide the study was a key element in identification of emergent themes. However, frameworks, without forcing data analysis, did guide interpretation and thus guided it in one direction rather than another. Other interpretations could have emerged when using other theoretical frameworks. Furthermore, interpretations are influenced by the researcher's biases and values. Analysis conducted by a researcher from another field or with other experiences could find other interpretations. This study's main strengths are that it took a comprehensive or holistic approach to dietary change at menopause and used the naturalistic paradigm. Many researchers have called for such an approach that explores the biologic, social, and psychological aspects of the menopause experience in the context of midlife, but too few have taken up the ~ h a l l e n g e . ~ ~ - ~ " In addition, combining a holistic approach with the naturalistic paradigm ensured a broad and contextual approach to menopause. It also made possible the emergence of life events as influential factors in dietary trajectories. In addition to ensuring data quality, prolonged engagement in the field and multiple interviews permitted the researcher to follow the midlife women of the study during a full year of their perimenopause, a period of intense changes.There is no better way to study change and process than to be there when it happens.
IMPLICATIONS F O R RESEARCH A N D PRACTICE Future researchers should be urged to conceptualize dietary behavior in terms of trajectory, taking the long view. A crosssectional view, including only current habits, is missing crucial information about the pathways leading to those habits.
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Our data suggest that women with similar dietary habits at midlife might have followed different dietary trajectories to achieve these same habits, resulting in potential differences in their nutritional health such as the density of their bones and their risk of developing chronic diseases. Research topics yet to be explored include the development of dietary self-ef'iicacy in childhood and adolescent women and its progression throughout life. Findings reported here indicated varying levels of self-efficacy in adulthood that need to be examined in more depth. Finally, more research is needed on the occurrence, timing, and meaning of life events in the context of their influence on dietary changes. Continuity of perimenopausal women's dietary behavior does not rule out menopause as an opportunistic time for health promotion efforts. However, it does underscore the complexity of dietary changes and the challenge of developing creative and innovative future health and nutrition promotion activities that build on existing patterns of behavior. Too few programs have used techniques other than knowledge acquisition or behavioral techniques. Nutrition education programs that empower women toward controlling their own health have not been widely used. Nutrition education needs to dissociate healthy eating from weight management, dieting, boredom, and insipid foods and connect them with fun, positive attitudes and self-care.This could translate into nontraditional interventions that impact dietary habits by increasing social support, self-esteem, and selfworth by programs such as volunteering groups, singing groups, and women's social support groups. In conclusion, future research and health promotion efforts need to recognize the contribution of cumulative life course experiences and pathways to current dietary practices. By conceptualizing dietary practices as trajectories and by understanding that adult life events such as roles and health can help shape these trajectories, future endeavors should be more successful in reaching their goal of facilitating adoption of dietary practices to preserve women's health and quality of life long after menopause.
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5. Meilahn EN, Becker R C , Corrao JM. Primary prevention of coronary heart disease in women. Cardiology 1995;86:286-98. 6. Dempster DW, Lindsay R . Pathogenesis of osteoporosis. Lancet 1993; 341:797-805. 7. Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years and older. N Engl J Med 1997;337:670-6. 8. National Cholesterol Education Program National Heart Lung and Blood Institute. Report of the National Cholesterol Education Program Expert Panel on detection, evaluation and treatment of high blood cholesterol in adults. Arch Intern Med 1988;148:36-9. 9. Borgatta EF, Bulcroft K, Montgomery RJ, Bulcroft R . Health promotion over the life course. Res Aging 1990;12:373-88. 10. Devine CM, Olson CM.Women's dietary prevention motives: life stage influences. J Nutr Educ 1991;23:269-74. 11. Bateson MC. Composing a life. New York: Plume/Penguin, 1990. 12. McAdams DP. Narrating the self in adulthood. In: Birren JE, Kenyon GM, Ruth J-E, Schroots JJF, Svensson T, eds. Aging and biography: explorations in adult development. NewYork: Springer, 1996:131-48. 13. Elder GH. Life course. In: Borgatta EF, Borgatta ML, eds. Encyclopedia of sociology. 3rd Ed. NewYork: Macmillan, 1992:1120-30. 14. Marshall C, Rossman GB. Designing qualitative research. 2nd Ed. Thousand Oaks, CA: Sage, 1995. 15. Patton MQ. Qualitative evaluation and research methods. 2nd Ed. Newbury Park, CA: Sage, 1990. 16. Morse JM. Designing funded qualitative research. In: Denzin NK, LincolnYS, e d ~Handbook . of qualitative research. Thousand Oaks, CA: Sage, 1994:220-35. 17. Glaser BG. Theoretical sensitivity. Advances in the methodology of grounded theory. Millvalley, CA:The Sociology Press, 1978. 18. Spradley JP.The ethnographic interview. New York: Holt, Rinehart & Winston, 1979. 19. Lincoln YS, Guba EG. Naturalistic inquiry. Beverly Hills, CA: Sage, 1985:314. 20. Creswell JW. Qualitative inquiry and research design.Thousand Oaks, CA: Sage, 1997. 21. Glaser B, Strauss A. The discovery of grounded theory. Chicago: Adeline, 1967. 22. Strauss AL, Corbin JM. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, CA: Sage, 1990.
REFERENCES
23. Jones JB. Representations of menopause and their health care implications: a qualitative study.Am J Prev Med 1997;13:58-65.
1. Neugarten BL. Middle age and aging: a reader in social psychology. Chicago: University of Chicago Press, 1968.
24. ApterT. Paths ofdevelopment in midlife women. Femin Psycho1 1996; 6:557-62.
2. Lachman ME, Lewkowicz C, Marcus A, Peng Y. Images of mid-life
25. Groupe de travail de la corporation professionnelle des midecins.
development among young, middle-aged, and older adults.J Adult Dev
Enquete sur la sante des quebkcoises de 45-54 ans. Montreal: Corpo-
1994;1:201-11.
ration professionnelle des midecins du Quebec, 1988.
3. Clausen JA. Gender, contexts and turning points in adults' lives. In:
26. Calam R,Waller G.Are eating and psychosocial characteristics in early
Moen P, Elder GJ, Luscher K, eds. Examining lives in context: perspec-
teenage years useful predictors of eating characteristics in early adult-
tives on the ecology of human development. Washington, DC: American Psychological Association, 1995:365-89. 4. Wethington E, Cooper H, Holmes CS. Turning points in midlife. In: Gotlib IH,Wheaton B, eds. Stress and adversity over the lifecourse: trajectories and turning points. Cambridge, UK: Cambridge University Press, 1997:215-31.
hood? A 7-year longitudinal study. Int J Eat Disord 1998;24:351-62. 27. Devine C, Bove C, Olson C. Continuity and change in women's weight orientations and lifestyle practices through pregnancy and the postpartum period. Soc Sci Med 2000;50:567-82. 28. Fiske M,Chiroboga DA. Change and continuity in adult life. San Francisco: Jossey-Bass, 1990.
328
Paquette and Devine/DIETARY TKAJECTORIES I N T H E MENOPAUSE T R A N S I T I O N A M O N G QUEBEC W O M E N
29. Keenan DP, AbuSabha R , SignlawGrant M, Achterberg C, Rufing J. Factors perceived to influence dietary fat reduction behaviors. J Nutr Educ 1999;31:134-44. 30. Elder GHJ. Families and lives: some development in life course studies. J Fam Hist 1987;12:179-99. 31. Mayer KU,Tuma NB. Life course research and event history analysis: an overview. In: Mayer KU, Tuma NB, eds. Event history analysis in life
33. Kaufert PA.A health and social profile of the menopausal woman. Exp Gerontol 1994;29:343-50. 34. Rossi AS. A life course perspective on the menopausal transition. Chicago: Society for Menstrual Cycle Research, 1997. 35. Brooks-Gunn J, Kirsh B. Life events and the boundaries of midlife for women. In: Baruch G, Brooks-Gunn J, eds. Women in mid-life. New York: Plenum, 1984:11-30.
course research. Madison,WI: University ofWisconsin Press, 1993:3-20.
36. Rostosky SS,Travis CC. Menopause research and the dominance of the
32. Bandura A. Social foundations of thought and action. Englewood
biomedical model 1984-1994. Psychol Women Q 1996;20:285-312.
Cliffs, NJ: Prentice-Hall, 1986.
Dietary Trajectories in the Menopause Transition Among Quhbec Women MARIE-CLAUDE P A Q U E T T E 'AND CAROLM . D E V I N E ~ 'Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, Alberta, Canada T6G 2P5; 2Division of Nutritional Sciences, M V R , Cornell University, Ithaca, New York 14853-4401
ABSTRACT This qualitative study explored perimenopausal women's perceptions and experiences of continuity and change in dietary behavior.This study used a naturalistic paradigm and three in-depth qualitative interviews over a 13-month period. A purposive sample of 23 perimenopausal women was recruited from community health centers and social organizations in rural and urban areas of Qu6bec.The semistructured interview guide focused on dietary and lifestyle changes, health and body changes, social roles, and the menopause experience. Grounded theory analysis was performed on the transcribed interviews. Women's narratives described three types of dietary trajectories: unsuccessful dieting, small change, and progressive change. Women with similar trajectories shared experiences with food, dieting practices, self-efficacy, and transition in the maternal role. Although most women reported continuing on the same dietary trajectory for most of their adult lives, a few described changes in their diets. Some women associated their small changes in diet with being informed of the potential development of chronic diseases, whereas others radically changed their diets following life events such as the development of an illness. Menopause per se was not perceived by women as a time for dietary change. Health and nutrition professionals could improve the impact of their efforts by recognizing the contribution of past dietary behavior to current dietary practices. Dietary advice would also benefit from being tailored to women's existing dietary trajectories.
INTRODUCTION Midlife is a time of change for many women. Although women's experiences can vary greatly, they may experience physical changes associated with menopause and aging, social changes resulting from the departure of children or the
................................................... At the time of the study, Marie-Claude Paquettt. was a Ph.D. candidate in the Divls ~ o nof Nutritional Sciences, Cornell Un~vcrslty. Address for correspondence: Marie-Claude Paquette, Ph.D., R.D., Department of Agricultural, Food and Nutritional Sc~enccs,410 Agr~cultureForestry Centre, Unlversity of Alberta, Edmonton, AU Canada,T6G 2P5; Tel: (780) 492-3989; E-mail: [email protected]. 02000 SOCIETY F O R N U T l i l T l O N EDUCATION
needs of elderly parents for care, psychological changes such as the reassessment of life goals and reflections on the past, and health From a biomedical point of view, hormonal changes experienced by perimenopausal women are associated with an increased risk of developing chronic disThis eases such as cardiovascular disease5 and osteop~rosis.~ increased risk is not only associated with changes occurring at the menopause transition but also with cumulative lifestyle practices. Diet and other lifestyle factors play key roles in the development and prevention of these chronic disease^.^,^ Women's increased attention to the physical, social, psychological, and health changes associated with midlife and menopause could make this transition period a favorable time to provide nutrition education and to introduce dietary changes.' Furthermore, women after midlife perceive that they have more time for themselves and consequently can take better care of their health.I0 Little research has examined women's dietary practices and attitudes at midlife and menopause or factors influencing them. Women's lives are marked by physiologic and role changes associated with reproductive events such as pregnancy and menopause. These occurrences bring discontinuity and a constant need for creation and creativity." Women give their lives meaning and unity through reinterpretation of past events, perception of current experiences, and anticipation of the future, which is incorporated into their narratives."." These characteristics of women's lives can best be captured by the life course perspective. The life course perspective'" proposes that the experience of a life event like menopause occurs in the context of ongoing trajectories such as cumulative maternal and family roles, dietary and lifestyle practices, and health. Thus, the experience of transitional events like menopause is interdependent with trajectories in areas such as roles, lifestyle practices, and health. The life course perspective guided this study toward a comprehensive conceptualization of women's lives over time, provided focus for the development of the interview guides, and served as a conceptual template against which emergent themes could be compared during analysis.The goal of this study was to gain an in-depth understanding of perimenopausal women's perceptions and experiences with continuity and change in dietary behavior and how these percep-
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tions are affected by midlife changes, menopause experiences, and previous life histories.
PROCEDURES This study was guided by the naturalistic paradigrn.14 A naturalistic approach strives to inductively understand human experience in specific settings and contexts.15It is useful when little research has examined the question of interest, when responses are expected to be con~plexand contextual, and when the perceptions of the research participants are central in understanding the topic of interest.I4 Dietary change in the menopause transition is such an area of research.
Sample. Perimenopausal women were purposefully recruited from four rural and urban sites in Qukbec, Canada. Study participants were approached during menopause management programs offered by community organizations and women's health centers. Posters and brochures left in these centers also advertised the study.Women were eligible for the study if they were healthy, were between 40 and 55 years of age, and perceived themselves as experiencing perimenopause. A subjective assessment of menopausal status was used because the aim of the study was to understand how women themselves experienced menopause. Women who were postn~enopausalor who had a bilateral ovarectomy were excluded from the study. Eligibility criteria for subsequent recruitment were modified after concurrent data analysis'%f 17 initial interviews revealed that very few women reported that they were currently making changes in their diets. From this point, women who were making dietary changes were purposefully recruited in order to contrast them with women who did not report changes. Thus, study participants in the final sample included healthy wornen and women with health problems or with recent and past history of a life-threatening illness. Recruiting was discontinued when concurrent data analysis of 23 interviews showed that no new themes were emerging." The final group of 23 study participants were all Caucasian and ranged in age from 45 to 56 years old.Women had between zero and four children, 16 were employed full-time, 8 were single, and 15 were married or had a live-in partner. Further description of the sample is provided in Table 1. Data collection. The principal investigator interviewed 23 women three times in French, over a 13-month period, using a semistructured open-ended interview guide to provide rich narratives of women's experiences and perceptions ll were tape recorded and in their own w ~ r d s . ' ~ Ainterviews study participants gave written informed consent according to the procedures of the University Human Subjects Committee. The interviewer had 14 weeks of formal training in qualitative research methods and theory and had previous qualitative research experience. The interview guides focused on changes in social roles, health, diet, and physical activity as well as motivations for
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Table 1. Sociodemographic description of women according to dietary trajectory. Unsuccessful
Small
Progressive
Dieting
Change
Change
Dietary Trajectory
Total
Study participants (n) Age (yr) Marital status Married Live-in partner Single (includes divorced and separated) Mean age at birth of first child (yr) Number of children (n) Employment Full time Part time Retired Homemakers Student
these changes, experience of menopause, menopause management strategies, and changes in self-perception. Questions and probes were focused on current experiences and were directed to bring women to reflect on past practices and the events that brought about these dietary practices. Interview guides had been previously pilot tested and used in a smaller similar study examining dietary and lifestyle changes in 18 pre-, peri-, and postmenopausal women. The guides were translated into French and reviewed by French-speaking women of Qukbec and by menopause managenlent program staff to ensure cultural relevance. Minor modifications of wording were suggested. In addition, questions on spiritual changes and on psychotherapy were added because these issues were discussed by the first three participants as an important part of their lives. Steps to ensure credibility of the study findings included member checks, peer debriefing, personal reflectiveness, and depth of contact. At the beginning of the second interview, each woman was presented with a summary of her first interview. These member checks gave the researcher the opportunity to check her interpretations with those of the study participants and increased her understanding of the women's experiences and meanings.According to Lincoln and Guba,"' member checks are the "most crucial technique for establishing credibility." The interviewer kept a personal reflective journal and met regularly with the second author to discuss findings and reflect on preliminary interpretations as a form of peer debriefing." In addition, the findings were presented
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to other researchers with expertise in the area. Finally, the multiple contacts with study participants in the form of three in-depth interviews over a period of 13 months added to confidence in the reliability of the findings. Dietary trajectories emerged out of women's narratives. Data were combined from the three interviews and the member check of the second interview to elaborate women's dietary trajectories by providing patterns of dietary practices and changes in practices over time.
Data analysis. Data analysis was performed by the interviewer using the verbatim transcripts of personal interviews, field notes, and member checks.The interviewer started by open coding in which initial categories of segments of information about the phenomenon under study were created through iterative reading of the interview transcripts and other data sources.20These emergent categories were then explored further by comparing them to data being concurrently collected up to the point of saturation, when the new information obtained in data collection did not further proPatterns of continuity and vide insight into the ~ategories.~',~' change, influences on and associations with the phenomena of interest, and the context of these relationships were explored.Types of dietary trajectories were compared among women. As working hypotheses and models developed to explain dietary continuity and change, they were compared to women's narratives and negative cases were sought." Inconsistencies in the model were explored and reflected upon, and revisions were made to the model. This constant confirmation of the model and subsequent modifications ensured that the final model accurately reflected women's experiences, stories, and perceptions. O f the 24 women originally interviewed, one woman's narrative did not fit in any one dietary trajectory as she shared characteristics from the three trajectories. She was excluded from this article due to a lack of space to explore her particular case.Thus, the findings reflect the data from 23 women.
Although a majority of women described continuity in dietary trajectories across adulthood, seven women reported having undergone a dietary transition characterized by radical n~odificationsin diet and lifestyle habits. These dietary transitions followed life events such as major role changes or serious health problems or threats. This discontinuity in some women's dietary trajectories resulted not only from the occurrence of life events but, more importantly, from the meaning that women gave these events and their perceptions of their current dietary and lifestyle habits. In the findings below, data from each trajectory will be presented followed by additional data from the women who made changes in their dietary pathways.
Unsuccessful dieting: "I try but I can't get myself to eat right." Narratives of the 10 women in the unsuccessful dieting group described starting on this path as a result of excess weight in childhood or adolescence or as a result of postpartum weight retention and weight gain in their forties. Dietary change for these women was always principally motivated by the goal ofweight 1oss.They had tried many weightreducing strategies such as very low-calorie diets, fasting, fad diets, and liquid protein diets.The first weight loss efforts often resulted in temporary success, invariably followed by weight gain that was greater than the weight 1oss.This led to greater weight dissatisfaction, thus perpetuating the cyc1e.A 53-yearold social worker gives an example of this: I have been on so many diets. Weight Watchers, Mince-a-vie, liquidproteins, hormones. I evenfasted. I lost the weight but it all comes back! 1 never really changed my habits.
These women's changes in dietary habits were always temporary. In addition to feeling that they had poor dietary habits, they also felt guilty about their failure at permanent dietary changes, as described by this 45-year-old nurse: BcfiforeI was really careful, Ifollowed my diet, but I couldn't keep it up, I have no will power.. .see how bad I am.
FINDINGS Continuous dietary trajectories across adulthood emerged from the narratives of 17 of the 23 study participants.Three types of dietary trajectories-Unsuccessful Dieting, Small Change, and Progressive Change-emerged from participants' narratives. Dietary trajectories were interpreted as women's cumulative experiences with food and eating, dieting, and weight management. Within each trajectory, women's accounts described similar dietary pathways that predated midlife and often found their origin in young adulthood. Women on each trajectory reported common experiences with dieting for weight control, patterns of weight gain, attitudes toward weight gain, motivations and level of self-efficacy for dietary change, and level of self-care. Menopause was not perceived per se as a motivator of change in dietary and lifestyle habits.
Many women's accounts described food as something they "had to be careful about," that required vigilance. Numerous unsuccessful attempts at dietary change and weight loss led women on the unsuccessful dieting trajectory to the belief that they were now incapable of successfully changing their diets.This 48-year-old homemaker is one of these women: I know all the right things I need to do, but will I ever do them? I don't know. Will lever be able to do them and stick with them? 1don't think so.
Interestingly, all unsuccessful dieters attributed their "failures" to lose weight and change their dietary habits to themselves and to their lack of willpower rather than doubting the efficacy of the weight-reducing strategies they had attempted.
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In addition to dealing with issues of body weight, food, and eating, unsuccessful dieters were experiencing difficulties in their maternal role. Whereas some women were worried about their adolescent children's delinquency problems or the financial difficulties of their adult children, others, like this 46-year-old mother of two, were adjusting to their children leaving home: I have raised my boys to be independent. I knew they would leave one day. But it's really hard seeing them leave; knowing it and living it is not the same thing.
Women on the unsuccessful dieting trajectory reported that they had never taken time to take care of themselves due to the many obligations related to their maternal and work roles.This 46-year-old crossing guard explains: I try to take more care ofmyselJ But it's hard; I have always been taking care ofothers.
Five of the 10 unsuccessful dieters reported experiencing a major life event such as the death of a spouse or cancer, recently or in the last 4 years, that resulted in radical changes in their dietary habits.As suggested by these women's narratives, this recent dietary change was not comparable to their past dieting attempts. They described how their attitudes toward restrictive dieting had changed and that dietary practices they were now putting in place would be permanent. This is illustrated by a 54-year-old bank manager: I don't even want to hear about dieting anymore. I am not focused on we2ht. I f I have good eating habits and eat in a reasonable quantity, then I should be healthy.
In summary, women on the unsuccessful dieting trajectory described a long-term trajectory of unsuccessful struggles to change their dietary habits. Five unsuccessful dieters experienced a dietary transition following a major life event. The remaining five women continued with restrictive dieting cycles and reported little confidence in their ability to make dietary changes, which may have developed out of numerous unsuccessful dieting attempts.Their motivation to change their diets stemmed mainly from their desire to decrease their body weight.
Small change:"I have made small changes in my diet." Eight women followed the small change trajectory. Narratives of small changers described stable dietary practices until midlife, after which they made small changes in their diets. Most women reported that the dietary habits they had for most of their lives developed after leaving home and getting married.Women in the small change group believed that they had always eaten well and had never been preoccupied with their eating habits.This is the case of a 51-year-old homemaker: Q: How would you describe your eating habits?
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R: Well, I have always eaten well ... We always ate healthy in my family, on the farm, and I continued that way with my own family.
These women's accounts described gaining 1 or 2 pounds every year since their forties. Nevertheless, none described ever having followed a weight control diet, and all still considered their body weights satisfactory. Yet, small changers discussed concerns about staying within a personally established weight range and viewed important weight gains and obesity as a negative occurrence mostly because of esthetics and social stigmatization. Small changers told of recent changes in their diets in the last few months. These changes were viewed as small ones such as drinking a glass of orange juice in the morning, drinking more milk, switching from white to whole-wheat bread, and taking only one dessert instead of two. For all small changers, dietary change occurred following either reading brochures on cardiovascular disease and osteoporosis provided by physicians or participation in a menopause management program. Menopause management programs consisted of 6 to 10 weekly 3-hour meetings, including one session on nutrition and physical activity.They also discussed menopause management strategies such as hormone replacement therapy (HRT). Information on H R T was the primary motivation that these women gave for attending the program. Small changers' narratives suggest that they did not perceive a need to change their dietary habits before they were sensitized to potentially developing chronic diseases. Being better informed seemed to bring about reflection, and small changers now perceived that they were at risk and, in response, were willing to make some small changes, as illustrated by the following woman: Q: Have there been any recent changes in your dietary habits? R: Yes, well I worry more about my eating.. .I worry more about drinking milk and osteoporosis...Since the program I think more about it. I already knew it, but it isgood to be reminded; you tell yourselt; oh yes, I need to pay attention.
When asked about their motives for making small changes in their diets, women in this group discussed either their fear of chronic diseases or their desire to take preventive measures to maintain their health. Women following the small change trajectory considered themselves successful at making these changes. They also reported maintaining their new habits for the study duration of 1 3 months. Because these women had never tried changing their diets in the past, it was not possible to elicit their expectations about the difficulty or ease of making dietary changes. Unlike the unsuccessful dieters, who reported troubled transitions in their maternal roles, small changers reported smooth transitions when their children left home. They linked this transition to an increase in time and ability to care for themselves.This is illustrated by a 50-year-old full-time worker and mother of three adult boys:
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Naturally, since the children aregone I have mnclz more time.for myreg I also spend more time with mygrandchildren.
A subgroup of small changers (four of eight) lived in a rural community and shared many common characteristics such as marrying and having children at an earlier age than women on the other two dietary trajectories. Thus, many small changers were already grandmothers. Being a grandmother was perceived as a very positive experience. In addition to making small changes in their diets, two small changers experienced radical changes following significant health events. O n e woman associated this radical change with her diabetes diagnosis, whereas the other associated it with her physician? warning that she would take medication if she was not able to decrease her blood cholesterol levels through diet and exercise. O n the whole, women following the small change trajectory were making small changes in their diets to prevent chronic diseases.They were experiencing positive transitions in their maternal roles, and many were acquiring the new role of grandmother. As a result of this transition and of decreasing their workload, they were taking more time to take care of themselves. Participating in a menopause management program and in physical activities was part of this increased self-care. For instance, they went to restaurants with friends or sisters, regularly walked after supper with a neighbor, or offered to baby-sit grandchildren.
Progressive change:"I have always eaten right." Progressive changers followed a dietary trajectory of change. Narratives of these five women described their dietary path as being a work in progress.They talked about making continuous gradual dietary in~provementsthroughout their adult years.They told how previous changes had been successfully accomplished and anticipated future changes to be as easily done. This is how a 54-year-old homemaker talked about dietary changes: We have always gradually changed our eat in^. Whew the kids came, trle ate better than we did befi~reand it continues. We are eating better and better every year. It is easy to keep the changes when you make small ones.
Progressive changers had explored many alternatives in their eating practices. This exploration occurred primarily when women left home, via personal development activities and spiritual quests. For instance, some women's dietary habits were influenced by macrobiotic diets and vegetarianism. Accordingly, these women gradually reduced their meat intake, incorporated legumes in their diets, ate more fruits and vegetables, and weaned themselves off beverages containing caffeine. Among all of the women in the study, only two expressed the importance of the connection between food, eating, pleasure, and fun. Both of these women were progressive changers. Women on the progressive change trajectory reported never having followed a weight control diet, regardless of
weight gain as adults.They perceived weight gain to be irrelevant and gave it little importance. Rather, they stressed the importance they gave to well-being and feeling good about their bodies and themselves as the motivation for their dietary changes. Progressive changers were highly conscious of the importance of staying healthy: I have made thesegradual changes in nly diet to.fiel bettcu, to have more eneyy. My body needs it and I listen to my body.
All progressive changers talked about their constant high level of self-care throughout their lives. Women described self-care as taking more time for themselves to engage in activities they enjoyed such as taking a long bath, reading a book, writing, and socializing with friends. Unlike women following the two other trajectories, women on the progressive change trajectory did not view the maternal role as a barrier to self-care.This single mother of two young boys always made time for herself to take night classes: The baby sitter came, the kids complained. 1 umuld tell them: Listen, this is the baby sitter; in afew hours you'll be in bed and I will be in class. I'll be happy, you'll be happy, what's the d!ference!
Additionally, of all three groups, these women talked the most about motherhood as a central role in their lives. Women following the progressive change trajectory spoke of the attention and time they gave their children while they were growing up. Nevertheless, they believed that as children grew older, it was healthy for the relationship between parent and child to change toward a friendship.These women also experienced a smooth transition in their maternal role. Although most progressive changers had experienced a significant life event such as an emotional burnout or cancer, they did not describe a change in their dietary habits following these events. These women did not perceive the need to change their diet or lifestyle because they believed that they already had the best habits they could have. Overall, progressive changers were on a continuous trajectory of change. Their trajectories were characterized by progressive and permanent changes in diet.This succession of positive changes contributed to these women's high self-eficacy for dietary changes. Progressive changers expressed little concern for weight gain and focused instead on well-being and health. Consistent with this focus on well-being, they also described a high level of self-care throughout their lives.
Dietary transitions. As was discussed in the preceding sections, a few women following either the unsuccessful dieting trajectory5 or the small change trajectory' described experiencing a dietary transition in response to a major life event. These women's experiences were varied. Major life events reported by participants were either social in nature, such as the death of a spouse, retirement, a job change, or serious health problems and threats, like developing diabetes (for two women), having a diagnosis of cancer, or elevated
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cholesterol. Although no woman mentioned psychological changes by themselves as prompting a dietary transition, psychological changes such as reassessment of life goals always followed these social and health changes. The women who reported making dietary transitions differed from those who reported stable trajectories, several of whom had also experienced major life events. Women who experienced dietary transitions assessed their current dietary and lifestyle habits as unhealthy or needing improvement. In addition, they interpreted the context of life events as creating a favorable environment for the maintenance of modifications toward healthy dietary habits. It was diflicult for most women to describe their new dietary trajectories following a radical transition because the changes had occurred relatively recently, but women's narratives suggested that the new trajectories promised to be stable.Women who experienced transitions did not report interest in continual improvements in their dietary habits, like the progressive changers; rather, they were working on maintaining their recently adopted habits. The three dietary trajectories, Unsuccessful Dieting, Small Change, and Progressive Change, are summarized in Figure 1.The figure illustrates how women on the unsuccessful dieting trajectory experienced a series of cycles of failed attempts at change whereas On the change trajectory only experienced small positive changes in their diets at menopause. Women on the progressive change trajectory, on the other hand, seemed to be on a continuous path of improving their dietary habits by a succession of positive changes. Finally, the women who experienced a dietary transition are also shown as deviating greatly from the unsuccessful dieting and small change trajectories.
DISCUSSION The narratives of these women provide a picture of continuous dietary trajectories across perimenopause. Study participants' narratives described one of three trajectories: repeated cycles of unsuccessful restrictive dieting for weight loss, stable dietary habits until midlife when small health-oriented changes were made, or progressive health-oriented changes throughout life. In a few cases, women who experienced serious life events reported making radical dietary transitions in response to them. Life events that led to transitions were either major role changes, serious health problems, or health threats. For the majority of study participants, menopause per se was not a factor associated with dietary change. Most women continued on their previous dietary trajectories even while experiencing the numerous changes associated with midlife and m e n ~ p a u s e . ' ~These ' ~ ~ ~ findings are consistent with reports that menopause is not perceived as a prominent event in the midlife period.',24," Continuity of dietary behaviors has been suggested in prior studies exploring the diets of adolescent women," postpartum women,'7 and menopausal women." In this last study," menopausal women perceived
Unsuccessful Dieting
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325
Failed attempts at dietary change
transitions /-'
Menopause
Small Change
? i
Progressive Change
Successful small
dietary changes
Successful small dietary changes
Time
+
Figure 1. Dietary trajectories of perirnenopausal study participants.
themselves as having healthy dietary habits and reported that these habits were sustained and reinforced by the physical changes experienced at menopause. Continuity of dietary habits in the menopause transition could be explained by the fact that menopause is a normative transition and may not provoke change because it is expected.28It is also possible that women do not link menopause and menopausal manifestations to the need for dietary change. Nevertheless, six women on the small change trajectory r e p o r t e d making small dietary changes d u r i n g t h e menopause transition. These women's narratives described changing their diets following sensitization to the long-tern~ consequences of menopause and thus for the prevention of chronic diseases rather than for menopause management. Even if small changers did not view dietary changes as a menopause management strategy, they described both modifying their dietary practices and taking H R T to alleviate long-term consequences of menopause.They viewed H R T as more effective in preventing chronic diseases and in controlling menopausal manifestations such as hot flashes and vaginal dryness than diet. Still, dietary practices were described as an adjuvant to HRT. For women following a small change trajectory, participation in a menopause management program could be a key factor in motivating their dietary changes. Indeed, most women on a small change trajectory shared characteristics in the timing of their lives and social context as they were from the same rural community. The timing of the birth of their first child, at an early age, could have launched them onto a
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life path that transformed the menopause management program into an opportunity for dietary behavior change.This was not the case for the other women in the sample who participated in menopause management programs. In addition, the menopause management program experience for small changers could have been different than for women following other programs. Many women in the rural group knew each other because they had encouraged their sisters and neighbors to come with them to the program. More research needs to focus on timing and context of life events to understand the creation of opportunities for diet and lifestyle changes later in life. Seven women who described experiencing a radical change in dietary habits associated it with major life events such as social or health changes that in turn prompted psychological changes.We found several such radical changes in diet mostly due to our revised sampling scheme that purposefully sought dietary change. Life events seemed to be interpreted as creating new environments and favorable conditions that were experienced as turning points4 for these women to change habits.These findings are supported by a recent study2ythat also found that unplanned factors such as role changes and development of illness were reported as opportunistic times for dietary changes. More research is needed to explore how the occurrence, type, and timing of life events influence diet and lifestyle changes. The life course approach used in this study is helpful in elucidating patterns in dietary behavior over time. It was then possible to explore the links between the different trajectories in women's lives as well as the impact of transitions on ~ ~ ~dietary ' trajectories described by these t r a j e c t ~ r i e s . ~The study participants were long-term patterns that women traced back to young adulthood or, in some cases, to childhood. For some women, dietary trajectories were linked with their weight trajectories. For instance, weight gain in adulthood was seen by some women as instrumental in initiating restrictive dieting cycles of the unsuccessful dieting trajectory. Furthermore, for some women, weight gain in adulthood was perceived to be the result of postpartum weight retention, suggesting that weight trajectories might be influenced by maternal roles. For these women, inception of the maternal role trajectory had a lasting impact on their weight and dietary trajectories. Finally, emergent data implied that the health and dietary trajectories influenced each other.Women (in small change and unsuccessful dieting) experiencing a major health transition also reported radical changes in their dietary practices. More research needs to be done to confirm the links between the dietary, weight, maternal role, and health trajectories as well as their mutual influences at times of transition. Findings from this study are consistent with Social Cognitive Theory (SCT)32and its concept of reciprocal determinism. Although not an explicit test of that model, cumulative personal, behavioral, and environmental factors emerged from these data as life course influences on women's experience of menopause. For instance, in this study, failure
to make dietary changes for women in the unsuccessful dieter group was associated with low self-efflcacy level (person),little opportunity for change (environment), perceived barriers (environment), and past experiences with unsuccessful attempts at making permanent changes (behavior). This potentially new longitudinal conception of SCT needs to be explored further in future studies. This study has many strengths and limitations associated with design, sampling, and interpretation. It used a purposeful sample that included perimenopausal, healthy, Caucasian, French-speaking women of Qukbec. The sample did not include women with diverse sexual orientations, poor women, or English-speaking women.Thus, these findings are limited to women who are similar to this population of women. The sampling strategy used women's health and community centers, which meant that at each site some women knew each other.This factor contributed to decreasing the diversity of respondents, as people who know each other are likely to have similar characteristics, such as the small changers from one rural site. These similarities could influence the study findings by reducing the number of dietary trajectories we found in women. Finally, women in this study had a particular cultural and social context that influenced their experiences. The use of conceptual frameworks to guide the study was a key element in identification of emergent themes. However, frameworks, without forcing data analysis, did guide interpretation and thus guided it in one direction rather than another. Other interpretations could have emerged when using other theoretical frameworks. Furthermore, interpretations are influenced by the researcher's biases and values. Analysis conducted by a researcher from another field or with other experiences could find other interpretations. This study's main strengths are that it took a comprehensive or holistic approach to dietary change at menopause and used the naturalistic paradigm. Many researchers have called for such an approach that explores the biologic, social, and psychological aspects of the menopause experience in the context of midlife, but too few have taken up the ~ h a l l e n g e . ~ ~ - ~ " In addition, combining a holistic approach with the naturalistic paradigm ensured a broad and contextual approach to menopause. It also made possible the emergence of life events as influential factors in dietary trajectories. In addition to ensuring data quality, prolonged engagement in the field and multiple interviews permitted the researcher to follow the midlife women of the study during a full year of their perimenopause, a period of intense changes.There is no better way to study change and process than to be there when it happens.
IMPLICATIONS F O R RESEARCH A N D PRACTICE Future researchers should be urged to conceptualize dietary behavior in terms of trajectory, taking the long view. A crosssectional view, including only current habits, is missing crucial information about the pathways leading to those habits.
Journal of Nutrition Education Volume 32 Number 6
Our data suggest that women with similar dietary habits at midlife might have followed different dietary trajectories to achieve these same habits, resulting in potential differences in their nutritional health such as the density of their bones and their risk of developing chronic diseases. Research topics yet to be explored include the development of dietary self-ef'iicacy in childhood and adolescent women and its progression throughout life. Findings reported here indicated varying levels of self-efficacy in adulthood that need to be examined in more depth. Finally, more research is needed on the occurrence, timing, and meaning of life events in the context of their influence on dietary changes. Continuity of perimenopausal women's dietary behavior does not rule out menopause as an opportunistic time for health promotion efforts. However, it does underscore the complexity of dietary changes and the challenge of developing creative and innovative future health and nutrition promotion activities that build on existing patterns of behavior. Too few programs have used techniques other than knowledge acquisition or behavioral techniques. Nutrition education programs that empower women toward controlling their own health have not been widely used. Nutrition education needs to dissociate healthy eating from weight management, dieting, boredom, and insipid foods and connect them with fun, positive attitudes and self-care.This could translate into nontraditional interventions that impact dietary habits by increasing social support, self-esteem, and selfworth by programs such as volunteering groups, singing groups, and women's social support groups. In conclusion, future research and health promotion efforts need to recognize the contribution of cumulative life course experiences and pathways to current dietary practices. By conceptualizing dietary practices as trajectories and by understanding that adult life events such as roles and health can help shape these trajectories, future endeavors should be more successful in reaching their goal of facilitating adoption of dietary practices to preserve women's health and quality of life long after menopause.
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5. Meilahn EN, Becker R C , Corrao JM. Primary prevention of coronary heart disease in women. Cardiology 1995;86:286-98. 6. Dempster DW, Lindsay R . Pathogenesis of osteoporosis. Lancet 1993; 341:797-805. 7. Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years and older. N Engl J Med 1997;337:670-6. 8. National Cholesterol Education Program National Heart Lung and Blood Institute. Report of the National Cholesterol Education Program Expert Panel on detection, evaluation and treatment of high blood cholesterol in adults. Arch Intern Med 1988;148:36-9. 9. Borgatta EF, Bulcroft K, Montgomery RJ, Bulcroft R . Health promotion over the life course. Res Aging 1990;12:373-88. 10. Devine CM, Olson CM.Women's dietary prevention motives: life stage influences. J Nutr Educ 1991;23:269-74. 11. Bateson MC. Composing a life. New York: Plume/Penguin, 1990. 12. McAdams DP. Narrating the self in adulthood. In: Birren JE, Kenyon GM, Ruth J-E, Schroots JJF, Svensson T, eds. Aging and biography: explorations in adult development. NewYork: Springer, 1996:131-48. 13. Elder GH. Life course. In: Borgatta EF, Borgatta ML, eds. Encyclopedia of sociology. 3rd Ed. NewYork: Macmillan, 1992:1120-30. 14. Marshall C, Rossman GB. Designing qualitative research. 2nd Ed. Thousand Oaks, CA: Sage, 1995. 15. Patton MQ. Qualitative evaluation and research methods. 2nd Ed. Newbury Park, CA: Sage, 1990. 16. Morse JM. Designing funded qualitative research. In: Denzin NK, LincolnYS, e d ~Handbook . of qualitative research. Thousand Oaks, CA: Sage, 1994:220-35. 17. Glaser BG. Theoretical sensitivity. Advances in the methodology of grounded theory. Millvalley, CA:The Sociology Press, 1978. 18. Spradley JP.The ethnographic interview. New York: Holt, Rinehart & Winston, 1979. 19. Lincoln YS, Guba EG. Naturalistic inquiry. Beverly Hills, CA: Sage, 1985:314. 20. Creswell JW. Qualitative inquiry and research design.Thousand Oaks, CA: Sage, 1997. 21. Glaser B, Strauss A. The discovery of grounded theory. Chicago: Adeline, 1967. 22. Strauss AL, Corbin JM. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, CA: Sage, 1990.
REFERENCES
23. Jones JB. Representations of menopause and their health care implications: a qualitative study.Am J Prev Med 1997;13:58-65.
1. Neugarten BL. Middle age and aging: a reader in social psychology. Chicago: University of Chicago Press, 1968.
24. ApterT. Paths ofdevelopment in midlife women. Femin Psycho1 1996; 6:557-62.
2. Lachman ME, Lewkowicz C, Marcus A, Peng Y. Images of mid-life
25. Groupe de travail de la corporation professionnelle des midecins.
development among young, middle-aged, and older adults.J Adult Dev
Enquete sur la sante des quebkcoises de 45-54 ans. Montreal: Corpo-
1994;1:201-11.
ration professionnelle des midecins du Quebec, 1988.
3. Clausen JA. Gender, contexts and turning points in adults' lives. In:
26. Calam R,Waller G.Are eating and psychosocial characteristics in early
Moen P, Elder GJ, Luscher K, eds. Examining lives in context: perspec-
teenage years useful predictors of eating characteristics in early adult-
tives on the ecology of human development. Washington, DC: American Psychological Association, 1995:365-89. 4. Wethington E, Cooper H, Holmes CS. Turning points in midlife. In: Gotlib IH,Wheaton B, eds. Stress and adversity over the lifecourse: trajectories and turning points. Cambridge, UK: Cambridge University Press, 1997:215-31.
hood? A 7-year longitudinal study. Int J Eat Disord 1998;24:351-62. 27. Devine C, Bove C, Olson C. Continuity and change in women's weight orientations and lifestyle practices through pregnancy and the postpartum period. Soc Sci Med 2000;50:567-82. 28. Fiske M,Chiroboga DA. Change and continuity in adult life. San Francisco: Jossey-Bass, 1990.
328
Paquette and Devine/DIETARY TKAJECTORIES I N T H E MENOPAUSE T R A N S I T I O N A M O N G QUEBEC W O M E N
29. Keenan DP, AbuSabha R , SignlawGrant M, Achterberg C, Rufing J. Factors perceived to influence dietary fat reduction behaviors. J Nutr Educ 1999;31:134-44. 30. Elder GHJ. Families and lives: some development in life course studies. J Fam Hist 1987;12:179-99. 31. Mayer KU,Tuma NB. Life course research and event history analysis: an overview. In: Mayer KU, Tuma NB, eds. Event history analysis in life
33. Kaufert PA.A health and social profile of the menopausal woman. Exp Gerontol 1994;29:343-50. 34. Rossi AS. A life course perspective on the menopausal transition. Chicago: Society for Menstrual Cycle Research, 1997. 35. Brooks-Gunn J, Kirsh B. Life events and the boundaries of midlife for women. In: Baruch G, Brooks-Gunn J, eds. Women in mid-life. New York: Plenum, 1984:11-30.
course research. Madison,WI: University ofWisconsin Press, 1993:3-20.
36. Rostosky SS,Travis CC. Menopause research and the dominance of the
32. Bandura A. Social foundations of thought and action. Englewood
biomedical model 1984-1994. Psychol Women Q 1996;20:285-312.
Cliffs, NJ: Prentice-Hall, 1986.