Food stories: Unraveling the mechanisms underlying healthful eating

Appetite 120 (2018) 456e463

Contents lists available at ScienceDirect

Appetite journal homepage: www.elsevier.com/locate/appet

Food stories: Unraveling the mechanisms underlying healthful eating Emily Swan a, *, Laura Bouwman a, Noelle Aarts c, Leah Rosen a, Gerrit Jan Hiddink b, Maria Koelen a a

Health and Society Chair Group, Wageningen University, PO Box 8130, 6700EW Wageningen, The Netherlands Strategic Communication Chair Group, Wageningen University, PO Box 8130, 6700EW Wageningen, The Netherlands c Institute for Science in Society (ISiS) Radboud University, P.O. Box 9010, 6500 GL Nijmegen, The Netherlands b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 17 April 2017 Received in revised form 19 September 2017 Accepted 3 October 2017 Available online 4 October 2017

The biomedical model of health (BMH) studies the causes and origins of disease. When applied to nutrition research, eating is studied as a behavior that supports physical health. However, the lack of attention the BMH pays to social and historical circumstances in which health behaviors are constructed has been widely addressed in literature. When people are studied without considering contextual influences, the relevance to everyday life is limited. As a result, how individuals actively deal with their context to manage healthful eating is poorly understood. This research applies a complementary model, salutogenic model of health (SMH), and uses life course research methodology to study a group of healthy eaters. The purpose of this research is to unravel how healthful eating develops in everyday life. Healthy eaters (n ¼ 17) were identified and recruited from the NQplus research panel at Wageningen University, the Netherlands. Life course experiences were examined through narrative inquiry. Participants recalled and visually explored life experiences with food and health using timelines. Results indicate that healthful eating results from exposure to individual- and context-bounded factors during childhood and adulthood and involves specific mental and social capacities relevant to coping including amongst others, critical self-awareness; flexibility, craftiness, and fortitude. Through life-course learning moments, participants were able to develop proactive coping strategies which strengthened their sense of agency and helped them in overcoming stressors and challenges. Findings show that nutrition strategies should not only focus on strengthening food-specific factors like cooking skills and nutrition knowledge, but other factors like stress management, empowerment, and participation. Such factors support the development of adaptive skills and behaviors, enable individuals to deal with the demands of everyday life, and are building blocks for health promotion. © 2017 Elsevier Ltd. All rights reserved.

1. Introduction The biomedical model of health (BMH) orients towards pathogenesis, the study of disease origins and causes. The starting point is to understand determinants of ill-health, and that health is generated through the elimination of risks for diseases (Eriksson & €m, 2008). When applied to nutrition research, the underLindstro lying assumption is that eating is a physiological act, and that eating supports physical health. This risk-oriented, pathogenic view underlies the search within nutritional research and promotion for

* Corresponding author. E-mail addresses: [email protected] (E. Swan), laura.bouwman@ wur.nl (L. Bouwman), [email protected] (N. Aarts), [email protected] (L. Rosen), [email protected] (G.J. Hiddink), [email protected] (M. Koelen). https://doi.org/10.1016/j.appet.2017.10.005 0195-6663/© 2017 Elsevier Ltd. All rights reserved.

nutrients, foods, and meals that prevent, treat, or manage dietrelated conditions. Yet this view tends to ignore the fact that eating is much more than just a basic health behavior (Biltekoff, 2010). Food choices are highly complex and have shown to be multifaceted, situational, and dynamic (Sobal, Bisogni, & Jastran, 2014). Research has shown that eating involves other factors besides physical health, such as taste, convenience, costs, moral concerns, and the maintenance of relationships (Sobal, Bisogni, Devine, & Jastran, 2006). Also, a systematic review of qualitative studies confirms that people assign diverse personal, social, and cultural meanings to healthful eating (Bisogni, Jastran, Seligson, & Thompson, 2012). The lack of attention the BMH pays to social and historical circumstances in which health behaviors are constructed has been widely addressed in literature (Fischer, 2006; Furst, Connors, Bisogni, Sobal, & Falk, 1996; Green, 2006;

E. Swan et al. / Appetite 120 (2018) 456e463

Johnson, Sharkey, & Dean, 2010)). The emphasis on physical health is also apparent in current nutritional guidelines (Delormier, Frohlich, & Potvin, 2009) that are oriented towards the physical side of health, overlooking the social embeddedness of food and health behavior. When people are studied without considering contextual influences, the relevance to everyday life is limited (Green, 2006, Scrinis (2008) As a result, the way in which individuals actively deal with their context to manage healthful eating is poorly understood (Bouwman, te Molder, Koelen, & van Woerkum, 2009). This knowledge gap that results from the dominant role of the BMH in nutrition research can be addressed by applying a complementary model, Antonovsky's salutogenic model of health (SMH) (Antonovsky, 1979). SMH takes a life course perspective to search for answers to the question “what creates health?” rather than only “what causes disease?” Within SMH, health is defined as a process and it is shaped through the interaction between people and their everyday context. This approach aligns with people's striving for quality and “goodness” in life. The underlying assumption is that healthful eating, together with other biological, material, and psychosocial resources, makes it easier for people to perceive their lives as consistent, structured, and understandable (Antonovsky, 1996). A key difference between the SMH and the BMH is the notion that health-related practices e such as eating for physical health e are a resource for living rather than a central goal in life (Antonovsky, 1987). Instead of having a focus on physiological factors involved in illness and the prevention of disease, SMH has an emphasis on the positive aspects of health and well-being (Mittelmark & Bull, 2013), taking into account the diverse physical, mental, and social factors that promote health (Eriksson & € m, 2008). In SMH, health is placed on the so-called “ease Lindstro e disease continuum”. Throughout life, people are constantly being bombarded by stressors. These stressors range from psychosocial stressors (e.g. unexpected loss of a job, relationship problems) to physical and biochemical stressors (e.g. water pollution, disease outbreaks). It is impossible to avoid these stressors since they are an inherent part of everyday life. Stressors have the potential to cause internal tension and can impact health in a negative way. Coping successfully with the tension leads to a movement towards the ease end of the continuum (healthy). If not successful, then people experience stress and breakdown (either physically or emotionally) and there is movement towards the dis-ease end of the continuum (Buch, 2006). Table 1 provides an overview of the major differences between the BMH and the SMH. A major construct within SMH is the Sense of Coherence (SOC). SOC is a coping capacity that supports people in dealing with challenging situations and in maintaining a healthy life orientation (Antonovsky, 1987). Evidence shows that a strong SOC is associated with dietary patterns more in line with dietary recommendations €, & Saraheimo, 2012; Ray, Suominen, & Roos, 2009; (Ahola, Mikkila Swan, Bouwman, Hiddink, Aarts, & Koelen, 2015) and higher intake of fruit and vegetables (Packard et al., 2012; Wainwright et al., 2007). To date, the SMH has only been applied in nutrition research to study the relationship between SOC and food choices. As a result, the mechanisms underlying this relationship remain unclear. Evidence continues to be limited and we lack a comprehensive picture of how people deal with challenges throughout the life-course and result in a (un)healthful orientation to eating. Such understanding can contribute to the design of strategies that support people in accomplishing healthful eating in the context of everyday life. This research applies the SMH using life course research methodology to study a group of healthy eaters. The overall aim is to unravel how a healthful eating orientation develops in everyday life. Life course research methodology observes lives in time

457

according to different social, contextual and cultural factors but also the internal responses resulting from those fluctuating external stimuli (Wethington, 2005). Life course research contributes to understanding how food choice develops and provides insights into the development of personal agency, provides a means for selfreflection and is embedded within the lifespans of social, cultural and historical contexts (Hinchman & Hinchman, 1997; Sobal et al., 2014). In doing so, it discerns patterns of change or consistency across the life span and is of particular interest to health behaviors (Szwajcer, Hiddink, Koelen, & van Woerkum, 2007). 2. Materials and methods 2.1. Participants Healthy eaters were identified and recruited using purposive sampling from the NQplus research panel at Wageningen University (Van Lee et al., 2012). Research panel participants all live in the province of Gelderland in the Netherlands. They receive a physical health check (e.g. height, weight, blood pressure) and complete a food frequency questionnaire (FFQ) that measures consumption of the major food groups as well as salt, fat, sugar and convenience foods. From the FFQ, a diet quality index (DQI) score is computed that measures diet quality in relation to the Dutch dietary guidelines. The DQI has been shown to be a valid measurement instrument in ranking participants according to their adherence to the Dutch guidelines for a healthy diet and a good measure of nutrient density of diets (Van Lee et al., 2012). Participants for this study were recruited from the NQplus research panel that met the following inclusion criteria:    

highest quartile of DQI scores female cohabitating aged 35e55 years

Females living with a partner were chosen for this study since our previous quantitative study found that cohabitating women had healthier dietary patterns in a cross-sectional Dutch population (Swan et al., 2015). Those aged 35e55 were specifically targeted to ensure that participants had a sufficient range of life experiences to discuss with researchers. Women meeting the inclusion criteria (n ¼ 33) were sent a study recruitment invitation by email. From these emails, 17 women agreed to take part in this study and provided informed consent. The participants' ages ranged from 36 to 52 years old (mean age 47), they all had tertiary education and all but one were employed. 2.2. Methods Life course events were examined through narrative inquiry, which is defined as systematic listening to people's life stories (Keats, 2009). Stories were elicited through timelines, an established research tool involving drawing and visually exploring life experiences (Sheridan, Chamberlain, & Dupuis, 2011). The timelines helped guide the interviews through what participants marked as significant and meaningful life experiences. The timeline was used as a tool to encourage participants to remember and reflect upon past experiences and to make it easier to tell stories about their lives during the in-depth interviews. Participants were also asked to construct a “Food and Me” box, which represented aspects that were important to them in terms of eating. Participants could include any objects that were meaningful to them, such as specific food items, photographs, utensils, pictures of meal settings, recipes, and so forth. The box was used as a tool to help participants

458

E. Swan et al. / Appetite 120 (2018) 456e463

Table 1 Major differences between the biomedical model of health (BMH) and the salutogenic model of health (SMH).

Definition of health Starting point

BMH

SMH

Absence of disease

Dynamic process, shaped through the interaction between people and context.

Pathogenesis - identifying determinants of ill-health Underlying Eating is important for physical health and assumption the prevention of disease Notions Eating for physical health is a central goal in life

Salutogenesis, understanding factors that create, enhance, and improve physical, mental, social health. Healthful eating, together with other biological, material and psychosocial resources, make it easier for people to perceive their lives as consistent, structured, and understandable Eating for physical health is a resource for living

reflect on their current eating practices and to enhance narrative depth and storytelling during the interview. An introductory meeting of 30 min took place in participants' homes. Interviewers (the first and third author) explained the research focus and instructions, and provided materials for the timeline and food box. Participants signed an informed consent form and were given 1e2 weeks to construct their timelines and prepare the food box. Interviewers then returned to participants' homes for an in-depth interview of duration 60e80 min. Women were first asked to discuss and explain their timelines, going through their life stories chronologically from birth to present day. Subsequently, participants were asked to describe key life-events and turning points in relation to food practices and health. Then, women discussed the contents of the “Food and Me” box. The interviewers probed with questions when they wanted participants to describe further ideas or past events. The key topics discussed in the interviews are shown in Table 2. All interviews were recorded on a hand held digital recorder, and were later transcribed verbatim by the research team.

2.3. Analysis of interviews Transcripts were analyzed using interpretative phenomenological analysis (IPA). IPA was chosen since it takes into account the world of participants and analyzing articulation of events, processes and relationships (Larkin, Watts, & Clifton, 2006). Coding of transcripts followed the protocol described by Smith and Osborn (Smith & Osborn, 1997) to unravel how healthful eating practices develop in everyday life. First, transcripts were read and re-read to become familiar with the data. Then, researchers noted any salient points in the left side margin in an open coding procedure. The notes were literal and paraphrased the participant's narrative. Then, more elaborate sentences were formed on the right hand margin. These sentences were drawn directly from the left hand side comments and echoed a slightly higher level of interpretation. For instance, an open comment in the left hand margin of “enjoys cooking with her husband” was interpreted at a higher level as “cooking as a social practice.” In line with the salutogenic framework, particular attention was given to: (a) stressors, (b) heuristics, and (c) social and historical life path. Stressors were defined using Antonovsky's description as psychosocial, physical or biochemical stressors confronted in daily life (Antonovsky, 1979). Heuristics are strategies people employ to make judgments in moments of uncertainty (Peters, McCaul, Stefanek, & Nelson, 2006). In particular, there was a focus on examining ways of doing and key learning moments in terms of triggers and turning points. This was done in order to examine ways that participants organize their eating practices in response to potential stressors. The social and historical life path referred to significant people and events that were important in the life course of participants. This was chosen since the social and historical context greatly influences the development of health in salutogenesis (Antonovsky, 1987), as well as individual

food choices (Furst et al., 1996). Findings were discussed by the research team and compared at length until a consensus was achieved on emerging themes. Then the team members attempted to make sense of the connections between emerging factors and similar factors, which were then clustered together. Researchers then compared these and produced a table of major factors, along with supporting text, which reflect food-life experiences and coping strategies across the interview transcripts. 3. Results Factors operating along the life course played a key role in developing healthful eating. Specifically, participants described specific food-related as well as more general life experiences (Fig. 1). Experiences had a cumulative learning effect through the life course and these enabled coping strategies for healthful eating. 3.1. Life experiences Major life experiences during childhood included: accustomed to non-processed foods and positive child-parent interactions and during adulthood; regained stability and structure in stressful life events and forged positive experiences with food. 3.1.1. Accustomed to non-processed foods All participants grew up in the 1960s and 1970s, and during this time, the availability of commercially processed foods was limited in the Netherlands. This aspect is central in that their exposure to these foods was automatically restricted, thus limiting habitual consumption of these foods. As one woman explained, “You could buy pre-peeled potatoes but that, I think, that was almost it”. Some participants used a language of dislike towards processed foods such as ready-made meals and convenience foods. One woman gave her opinion of pre-cut bagged vegetables in supermarkets, “So I don't like for example when I'm, I go to the supermarket I see the people, they buy everything already prepared, also the vegetables are cut and washed and e I think it's nice to do it, to do your touch, to prepare yourself and to cut things”. This dislike of prepared and convenience foods was a major unifying element in the participant's narratives. 3.1.2. Positive child-parent interactions If the food was appetizing diverse and even more so, if participants recalled good family interaction, then this had a strong effect later on in the lives of the participants. In fact, when both of these elements were present, participants would re-create this positive social eating context they recalled in their youth in their current eating practices. For example, one participant described why she regularly invites her daughter's friends for dinner, “She likes it because she knows if someone comes and eats with us again, everyone is happy. Not that we weren't happy when we are with three but well,

E. Swan et al. / Appetite 120 (2018) 456e463

459

Table 2 Key topics discussed in the interviews.             

What sort of food did you eat as a child? Did your family eat meals together? Did you get taught to cook by your parents? When did you start liking that sort of food? When did you start cooking for yourself? How old were you when you met your partner? Can you tell me what made you eat like that? What foods do you like to eat at the moment? Who does the cooking in your household? Do you eat alone or with others? Have you faced any challenges in relation to your health? Have you had any difficult periods in terms of eating? How did you overcome challenges you faced during that difficult period?

it's a little, it's like a little party because she gets a lot of attention.(laughter) When we were younger my brother and I always brought friends home and my mom let them eat also with us and all weekend we used to stay at our parents' house with like 10 friends, and all having dinner with my parents and well, it was always, you were always welcome like that”. In cases where food was not recalled being that tasty or diverse, the pleasurable memories around the dinner table and preparing food in the kitchen, seemed to have moderated the effect. One woman explained, “You could have a lousy mother, who is not cooking a lot, but the environment, socially, and the place where you are living, makes the difference.” Another participant described how although her mother was not very good at making vegetarian dishes for her, she tried her best. The participant recalled how her mother prepared special dishes for her since she was the only one who was vegetarian in the family: “She did that every day especially for me and that was not so easy at that time because there weren't many things that she could choose”. In this sense, while the taste of the food is significant, the memories and emotions surrounding it are demonstrated to be just as crucial. 3.1.3. Regained stability and structure in stressful life events All of the participants went through stressful life events during some point in their lives. Events ranged from serious health problems, sexual abuse, death of loved ones, and challenging transitions such as emigrating to a new country or work-related stress. For some participants, these events had a negative impact on their food habits. One women described what happened after the unexpected death of her husband, “I had an extremely difficult time then, had totally abnormal eating, and I was drinking a lot. Back then I was drinking a lot, I wouldn't say a bottle of wine a day, but definitely a lot in the first year. I lost a lot of weight, at a certain point I weighed 55 kg and that really is too little for me”. One common element that helped participants rebound from difficult moments was regaining stability and overall structure in their lives. This was outwardly

recognized as being a contributor of good health habits for many participants. For example, one participant described a difficult period with her weight, linking it to pressure in a competitive sport she was involved in and family problems. However, later on in her narrative, she discussed how gaining a more stable life situation and having no external pressure helped her stabilize her relationship with food. “I think that was a more stable period in my life. I had a normal job, a very nice group of colleagues to work with … it was relaxing in that sense, that it was no emotional pressure, no prestige. And so I joined a running club there and had some friends and so […] I stabilized towards the food and the issue of weight”. 3.1.4. Forged positive experiences with food later in life For the participants who did not have pleasurable food experiences from childhood, building them later on in life held a crucial role. This occurred through encountering situations where they were able to associate food with positive and pleasurable experiences. Constructing positive experiences occurred at different points during adulthood and in different contexts. For some participants, this occurred when they were “leaving the nest.” At this time, they became more interested in food through communal living with roommates, doing their own grocery shopping, becoming empowered to make their own personal choices and freeing themselves of parental structural dependence. For example, one participant mentioned that her mother followed a very traditional cooking pattern and when she left home, she began eating more exotic types of food that she learned about from college roommates or through cookbooks. These experiences made a huge impact on her cooking practices. She explained: “I saw a lot of different styles in the cooking and a lot of it I thought that's more to my needs than other styles”. For other participants, experiences were forged when they met a supportive partner that was either a hobby cook or professional chef. Partners were described as pro-active and hands-on in the kitchen and some talked about how they plan meals, do food

Fig. 1. Overview of study participants’ significant experiences through the life course.

460

E. Swan et al. / Appetite 120 (2018) 456e463

shopping or cook together with their partners. One woman explained about her partner, “He has taken cooking classes and he really likes it. We designed our kitchen around it actually, so we can be together and cook with each other”. Many also discussed how their partners had “a positive influence” in helping them learn new things related to cooking, as well as different international cuisines. This seems to have been an important supportive factor when it came to continuing on a healthful eating path. One woman said, “Because he is in the catering business, he's used to eating different foods, and as a result he's brought different foods into my life that I never ate before I met him. For example, oysters e I had never eaten those. And mussels e I had not had those for a very long time. When you're together, you're going to be more open to try things.” For participants that were able to travel outside the Netherlands, the effects were positive in that it helped them discover new cuisines, inspired new cooking styles and eating practices, and helped to develop an appreciation of different flavors. For one participant, her travels through Mexico not only had an influence on what she ate, but how she ate. In the following text excerpt, she describes how when she was a fast eater as a child but her travels to Mexico taught her to enjoy her food more. “My brother and I were fast eaters and would finish a meal in about 2 min. But there I learned to eat slower and enjoy the food. It's not fun going out to restaurants with someone who finishes eating in 2 min” 3.2. Coping strategies Life experiences gave rise to coping strategies that helped direct eating practices towards health. Strategies included 1) organizing eating in an uncomplicated manner; 2) applying creativity in the kitchen; 3) valuing good food with good company; 4) approaching eating with critical self-awareness; and 5) applying craftiness and fortitude during difficult moments. 3.2.1. Organizing eating in an uncomplicated manner Participants described healthful eating as a way of life and never in an obsessive, all or nothing, or extreme way. One participant described her strategy for allowing her children occasional treats, “I work in the weekends, so in the weekend they can have white bread and chocolate spread. In the week, they eat brown bread with cheese or peanut butter, and no chocolate”. The word diet rarely came up in conversations, and some even mentioned that they disliked the word. In this sense, healthful foods just seemed to be part of their lifestyle and did not require a lot of extra effort. This approach to eating also was applied to cooking practices. One woman explained, “You don't necessarily need a recipe to make things, but you can combine things and most of the time it goes good. But even one time it turns out wrong and not the way it should taste, you know that the next time, you will just make it the right way”. Another participant described how she cooks meals from scratch every day despite the fact that she is a busy working mother with two children. “I got a couple of simple books with well, I knew how to do it but I didn't have the routine everyday so I selected a number of simple recipes to cook in half an hour. You can make a nice pasta for example, this kind of thing”. Many had the perception that cooking fresh meals was an uncomplicated matter. One woman described how for many years, cooking tasks have been divided between herself and her husband, “He likes to cook, also in the week. My job is further away so he cooked in the week and I cooked in the weekend. And that's still happening. So I have to eat what he makes (laughter)”. 3.2.2. Applying creativity in the kitchen Many of the participants discussed how they were experimental in the kitchen, prepared colorful and diverse dishes, and were not

afraid of tasting new foods or to cook foreign dishes. They either learned this through trial and error with cooking, by finding inspiration in cook books, or being exposed to exotic foods through their travels. One woman explained, “I like to travel, and every time we travel we try new things. Some of these things we bring back home, if it's good. Actually, from all our trips, we have something we cook, still, at home”. It is also important to note that the participants had developed a good amount of cooking skills after the years or had a partner with an interest in cooking, so this helped them in approaching new recipes in a confident manner. In the following interview excerpt, one woman describes how she enjoys experimenting with new dishes and foods, “I think I just continued the example that I learned at home, so I continued what I learned as a child, but as a student I studied various kitchens e Greek, Italian, etcetera e because I was cooking for myself alone but wanted to experience new foods”. 3.2.3. Valuing good food, with good company Food played a larger role than just to support and nourish physical health. The participants associated food with pleasurable tastes and enjoyable social contexts. For them, food means enjoyment and fun, and for many it was also a hobby. One woman explained, “Eating is a pleasure, to share it with other people and especially people you love, the family or friends, yeah, I hope I will never, there will never come a time that I have to eat alone”. For most of the participants, food had a high priority in their lives and it was integrated into a larger scheme of social interaction and quality family times. One woman described how cooking meals was a family event when she was a child, “We were always preparing it together e and food is not only eating, but for me, is very related to the preparation of everything. This is my memory from childhood”. Another participant described, “And it's nice now, when my children have birthdays, my husband is always cooking. And all the people still have dinner with us; it doesn't matter how many, my husband is cooking, and then, they're always like e ‘ah, that's nice’that's nice and for me, it's so normal already”. By doing so, food was associated with fun and pleasurable moments with loved ones. While some kept it more intimate by simply eating sit down meals with their families on a regular basis, others enjoyed making it a bigger social event, for example, with cooking clubs and dinner parties. As one participant explained, “I like to invite people over for dinner and I like to be invited also and discover new things. With some friends, maybe once a year, everyone makes and brings something. And then you discover many different things. Everyone wants to show off their own cooking e the best recipes are picked and exchanged e I like that”. 3.2.4. Approaching eating with critical self-awareness and flexibility Many participants exhibited a high degree of foresight and mindfulness towards their eating practices. For some, this was the result of going through a period in which their eating practices were affected due to a poor state of mind or stress. One woman described how experiencing burnout influenced her approach to eating, “Some people say you get stronger from it and in a way you can because you learn a lot about how you tap into energy, but it also made me quite aware and careful about my energy and you need to rest and get good night's sleep - and eat good food! It started an awareness in me on how to handle my own health.” One woman described her rationale for not buying food from the fast food restaurants she passes by while commuting to work, “I just don't like it, I don't like walking and eating at the same time. If I eat, I sit. If I see people walking around and eating and running errands at the same time, I think to myself, no. You're not tasting that”. Another participant was able to reflect on a difficult time in her past

E. Swan et al. / Appetite 120 (2018) 456e463

and why she had gained a lot of weight. Emerging from that experience, she became more conscious and aware of her current eating practices, helping her see that being happy and accepting who she is inside supports her in eating better. Her reflection is in the following text excerpt: “Eating has a lot to do with how you feel. I see that during this point of my life. If you are not happy in your own skin, then your eating is going to be bad. At this point in my life now, I am happy. And thus I am more aware of it all”. Participants did not talk about following strict diets, nor did they have many self-prescribed rules about what and how much they ate. If they did have some rules for themselves, these rules were not set in stone and they were modified depending on the context, situation or their state of mind. One woman explained how she deals with fast food and her children, “We say the whole time that fast food is bad food e that you will become fat when you eat it e but we don't say to them that you cannot eat it, but even with a glass of wine, it has to stay as one or two, and then cannot eat any more. We say sometimes you can eat it, that it’s not ‘not at all’, but it has to be sometimes e the rest of the time it has to be good food”. This approach allowed them a certain level of flexibility since they typically did not deny themselves or restrict foods. 3.2.5. Applying craftiness and fortitude during difficult moments Time was often evoked as a limitation as the participants were busy juggling work, social obligations and in some cases, children. However, in many situations, strategies were crafted in order to work around these inevitable time limitations and sustain healthful eating. For one participant, juggling a part time job with a long commute, raising two children, and staying on track with her eating was a challenge. She describes in the following excerpt how she dealt with this, “So I got up at 5 and made my salads and went to Zwolle, by train, came home at 7, it was quite pretty hard to keep, to stick to that kind of thing, but I managed’'. Although some participants had faced a diagnosis or health condition, they did not act helplessly. They had a rational and accepting language towards the matter and attempted to overcome it with a high level of determination. For example, one participant had a stroke in her 20s that required major rehab and therapy to relearn how to perform daily activities of living, including cooking and feeding herself. She described how she was able to overcome it, “Well, I hear stories and I know people who really have had major problems and feel sorry for themselves e well, I don't feel sorry for myself e I was just unlucky. And it has made me a better person. Because I was able to quit my job and then go to the next level e maybe without this experience I wouldn't have been able to.” In this sense, their determination to cope and handle things that came their way, was at the core of these participant's strength and power. 4. Discussion We conclude that healthful eating results from exposure to individual- and context-bounded factors during childhood and adulthood, and involves specific mental and social capacities relevant to coping with everyday life situations and challenges. Firstly, healthful eating is learned through both food-related life experiences (e.g. cooking together with a partner, cooking clubs) and nonfood related life experiences (e.g. positive child-parent interactions, work-related stress). These life experiences have a cumulative learning effect and even in the face of hardships and adverse experiences, set-backs could be overcome later in life. This is relevant as it suggests that it is never too late to promote healthful eating. Secondly, one's ability to effectively cope with stressors challenging healthful eating is supported through an interplay between coping strategies (e.g. self-efficacy, cooking skills, flexibility) and the learning effect of life experiences in both childhood and adulthood.

461

This interplay underlies the mechanism driving healthful eating practices. Through life-course learning moments, participants were able to develop proactive coping strategies which strengthened their sense of agency and helped them in overcoming stressors and challenges. Thirdly, the findings show that a number of mental and social capacities enable healthy eating, including amongst others, critical self-awareness, applying creativity in the kitchen, and valuing good food with good company. This research has brought forth a number of important contributions for nutrition research. Firstly, the findings show that the role of healthful eating went beyond only physical health and played multiple roles in participants' lives; through an expression of affection, pleasure, and self-identity. It is also striking that many participants had partners that were chefs or hobby cooks and they helped inspire new cooking techniques and in approaching recipes in a confident manner. This shows that healthful eating practices are learned and embedded within the social context. Along with being a social activity, other research has found that eating behaviors are also influenced by broader contextual factors such as social capital (Johnson et al., 2010) and the historical context (Furst et al., 1996). What our research adds to this is that healthful eating goes beyond the physical act of eating and involves other dimensions. Specifically, it is about keeping the balance between the mental, social and physical dimensions of eating in everyday life. The research findings have also advanced the state of the art of the SMH. Previous nutrition research applying SMH has focused on understanding the linear relationship between SOC and healthful eating. Consequently, there was limited understanding of building blocks that underlie the development of SOC and healthful eating and it was unknown what is needed in health promotion activities to strengthen SOC (Super, Wagemakers, Picavet, Verkooijen, & Koelen, 2015). The research findings have brought forth new understanding of factors and mechanisms that drive forward the relationship between SOC and healthful eating. Specifically, one's ability to effectively cope with stressors challenging healthful eating, is enabled through an interplay between coping strategies (e.g. self-efficacy, cooking skills, flexibility) and the cumulative learning effect of life experiences in both childhood and adulthood. Although participants in our study not only talked extensively about nutrition knowledge, most of the women also portrayed themselves to be skilled and competent in preparing nutritious meals. This competence originates in procedural knowledge, which relates to knowledge on how to do things and use certain skills. This is different from declarative knowledge, which has to do with knowing the facts, such as knowing nutrient and vitamin content of foods (Hiebert, 2013). These findings also relate very much to a new concept in health promotion called food literacy. Food literacy is defined as both the ability to understand the nature of food and how it is important to you, as well as the ability to gain information about food, analyze it, and act upon it (Vidgen & Gallegos, 2010). Therefore, although knowledge is important, the skills and competencies to actively deal with food and eating in everyday life is just as crucial for enabling healthful eating. Another important finding is that participants were not overly strict about what they ate (many disliked the word diet) and they took a flexible approach to eating. Previous research has found that psychological flexibility is positively associated with intuitive eating factors including eating for physical reasons and reliance on hunger/satiety cues (Sairanen et al., 2015). Our previous study also found that having a flexible approach to eating, as opposed to a dichotomous approach, was associated with healthier eating practices (Swan et al., 2015). These findings underpin the importance of communication strategies that incorporate more flexibility into nutrition advice, rather than employing a prescriptive approach. This can help people to build changes into their everyday

462

E. Swan et al. / Appetite 120 (2018) 456e463

lives and make healthful eating manageable in the long term. For many participants, a warm and supportive social context was in the backdrop of their narratives. Therefore, positive interactions went beyond food itself and towards making an opportunity for togetherness and sharing. This is in line with a previous study that found that food upbringing, particularly enjoyable family activities and rituals that included fruits and vegetables, positively influenced fruit and vegetable consumption later in life (Devine, Connors, Bisogni, & Sobal, 1998). This supports the fact that there should be more of an emphasis on encouraging a positive social atmosphere and interactions with food within nutrition promotion. Part of these positive interactions can involve activities including cooking clubs or community gardens, which have also been shown to promote healthier eating (Gatenby, Donnelly, & Connell, 2011). We specifically focused at the micro-level of participants' social context to examine how the development of healthful eating is influenced by everyday social interactions (e.g. with parents, children, domestic partners, friends, and colleagues). Given time limitations of the study, it was not possible to also take into account broader meso- and macro-levels to analyze the influence of social structures, social systems, and institutions in which people are immersed. It will be important that future research examines the role of these broader socio-contextual factors in the development of healthful eating practices. Study strengths include its rigorous recruitment process of healthy eaters, which was based on DQI scores derived from an extensive FFQ. Another strength was the novel use of the research tool of time-lining to study life course experiences in relation to eating and health. Since time-lining facilitated participant storytelling and self-reflection, interviews were not led by the researchers own agendas but by what participants felt to be meaningful and relevant. Furthermore, it is important to discuss both strengths and limitations relating to the study's research methodology. Life course research is an excellent vehicle for looking back across an individual's or a cohort's life experiences for clues to current patterns of health and disease (WHO, 2000). However, the process of collecting time-lines and life stories from participants was incredibly time consuming, and took many months to undertake. The subsequent analysis of the data using IPA was also a labor-intensive process for the research team. Therefore, future research should take these factors into consideration in the budgeting and planning of similar studies. Lastly, due to the purposive selection criteria, participants were all cohabitating, welleducated women living in eastern Netherlands with ages between 36 and 52 years. Therefore, we do not know if findings can transfer to other groups. However, our findings can be considered a grounded indication of a research phenomenon that deserves further attention. Future research should explore these questions further to understand what generates healthful eating in other socio-demographic groups and cultural contexts. Nutrition research and practice should consider applying the timeline methodology as it can be a useful tool to get deeper insights into the “whys and hows” of eating behavior, and the social and historical context that influences healthful eating. The findings brought forth in this study are relevant for nutrition promotion in a number of ways. Firstly, besides focusing only on childhood, nutrition promotion should also take into account other key turning points and stages of life, such as leaving the nest, change in employment, or marriage, as these can also provide significant opportunities to shape healthful eating practices. Secondly, nutrition education should not only be centered on the physical act of eating and the impact of eating on physical health. Advice should be more balanced in promoting flexibility and balance in eating and life. This can be accomplished by not only focusing on strengthening food- and eating-specific factors like

cooking skills, but also on more general health promotion factors like mindfulness, critical thinking, adaptiveness, and stress management. Therefore, health professionals should not only talk about nutrition promotion, but also about promoting a healthful life orientation. By doing this, we can enable individuals to deal effectively with the demands of everyday life, which are the fundamental building blocks for both healthful eating and overall health promotion (Nutbeam, 1998). Thirdly, strategies should facilitate health-directed learning processes. These learning process require reflecting on what will create health, what the avail€m & able resources are, and how to improve quality of life (Lindstro Eriksson, 2010). For example, strategies that support healthdirected learning processes must focus on strengthening procedural knowledge such as food literacy and healthful cooking practices. They should also include socially-embedded experiences involving the selection, purchase, and preparation of healthful food such as taste lessons in schools, community gardens and cookery clubs. Future nutrition promotion research should consider the application of SMH to further complement the current evidence base derived from biomedically-oriented nutrition research. Whereas the biomedical model of health informs factors that prevent disease and ill-health, the SMH informs factors that create health and well-being through learning processes, empowerment, and participation (Gregg & O'Hara, 2007). However, we do not suggest a complete change to using only the SMH, nor do we suggest that this model is superior. We plea for a shift from the current emphasis on disease, disability and poor functioning, to a more balanced approach in which positive aspects of well-being also receive attention (Mittelmark & Bull, 2013). Through this additional salutogenic lens, we can gain a more complete understanding of the origins of healthful eating in the everyday context. Acknowledgements We express our gratitude to the participants that took part in the interviews and for the kind cooperation from Prof. Feskens and her team at Wageningen Univeristy for helping recruit participants from the NQplus research panel. This study was made possible by funding from Wageningen UR and the Dutch Dairy Organization. References Ahola, A. J., Mikkil€ a, V., & Saraheimo, M. (2012). Sense of coherence, food selection and leisure time physical activity in type 1 diabetes. Scandinavian Journal of Public Health, 40(7), 621e628. Antonovsky. (1979). Health, stress and coping. San Francisco: Jossey-Bass. Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well (1st ed.). San Francisco: Jossey-Bass. Antonovsky, A. (1996). The salutogenic model as a theory to guide health promotion. Health Promotion International, 11(1), 11e18. Biltekoff, C. (2010). Consumer response: The paradoxes of food and health. Annals of New York Academy of Sciences, 1190(March), 174e178. Bisogni, C. A., Jastran, M., Seligson, M., & Thompson, A. (2012). How people interpret healthy Eating: Contributions of qualitative research. Journal of Nutrition Education and Behavior, 44(4), 282e301. Bouwman, L. I., te Molder, H., Koelen, M. M., & van Woerkum, C. M. J. (2009). I eat healthfully but I am not a freak. Consumers' everyday life perspective on healthful eating. Appetite, 53(3), 390e398. Buch, B. (2006). Salutogenesis and shamanism. Department of Health Psychology and Health Education University of Flensburg. Master’s Thesis. Delormier, T., Frohlich, K. L., & Potvin, L. (2009). Food and eating as social practiceeunderstanding eating patterns as social phenomena and implications for public health. Sociology of Health & Illness, 31(2), 215e228. Devine, C. M., Connors, M., Bisogni, C. A., & Sobal, J. (1998). Life-course influences on fruit and vegetable Trajectories: Qualitative analysis of food choices. Journal of Nutrition Education, 30(6), 361e370. € m, B. (2008). A salutogenic interpretation of the Ottawa Eriksson, M., & Lindstro charter. Health Promotion International, 23(2), 190e199. Fischer, A. (2006). Social context inside and outside the social psychology lab. In P. Van Lange (Ed.), Bridging social psychology; benefits from transdisciplinary

E. Swan et al. / Appetite 120 (2018) 456e463 approaches (pp. 371e376). Mahwah: Psychology Press. Furst, T., Connors, M., Bisogni, C. A., Sobal, J., & Falk, L. W. (1996). Food choice: A conceptual model of the process. Appetite, 26(3), 247e266. Gatenby, L. A., Donnelly, J., & Connell, R. (2011). Cooking communities: Using multicultural after-school cooking clubs to enhance community cohesion. Nutrition Bulletin, 36(1), 108e112. Green, L. W. (2006). Public health asks of systems Science: To advance our evidence-based practice, can you help us get more practice-based evidence? American Journal of Public Health, 96(3), 406e409. Gregg, J., & O'Hara, L. (2007). Values and principles evident in current health promotion practice. Health Promotion Journal of Australia, 18(1), 7e11. Hiebert, J. (2013). Conceptual and procedural knowledge: The case of mathematics. Routledge. Hinchman, L. P., & Hinchman, S. K. (1997). Memory, identity, community: The idea of narrative in the human sciences. Albany: SUNY Press. Johnson, C. M., Sharkey, J. R., & Dean, W. R. (2010). Eating behaviors and social capital are associated with fruit and vegetable intake among rural adults. Journal of Hunger & Environmental Nutrition, 5(3), 302e315. Keats, P. A. (2009). Multiple text analysis in narrative research: Visual, written, and spoken stories of experience. Qualitative Research, 9(2), 181e195. Larkin, M., Watts, S., & Clifton, E. (2006). Giving voice and making sense in interpretative phenomenological analysis. Qualitative Research in Psychology, 3(2), 102e120. € m, B., & Eriksson, J. (2010). The hitchhiker's guide to salutogenesis: SalutoLindstro genic pathways to health promotion. Helsinki: Folkhalsan Research Centre. Health Promotion Research and the UIHPE Global Working Group on Salutogenesis. Mittelmark, M. B., & Bull, T. (2013). The salutogenic model of health in health promotion research. Global Health Promotion, 20(2), 30e38. Nutbeam, D. (1998). Health promotion glossary. Health Promotion International, 13(4), 349e364. Packard, C. J., Cavanagh, J., McLean, J. S., McConnachie, A., Messow, C.-M., Batty, G. D., et al. (2012). Interaction of personality traits with social deprivation in determining mental wellbeing and health behaviours. Journal of Public Health, 34(4), 615e624, 2012. Peters, E., McCaul, K. D., Stefanek, M., & Nelson, W. (2006). A heuristics approach to understanding cancer risk perception: Contributions from judgment and decision-making research. Annals of Behavioral Medicine, 31(1), 45e52. Ray, C., Suominen, S., & Roos, E. (2009). The role of parents' sense of coherence in irregular meal pattern and food intake pattern of children aged 10e11 in Finland. Journal of Epidemiology and Community Health, 63(12), 1005e1009.

463

€rvela €, E., Rantala, S., et al. Sairanen, E., Tolvanen, A., Karhunen, L., Kolehmainen, M., Ja (2015 Mar 25). Psychological flexibility and mindfulness explain intuitive eating in overweight adults. Behavior Modification, 0145445515576402. Scrinis, G. (2008). On the ideology of nutritionism. Gastronomica: The Journal of Food and Culture, 8(1), 39e48. Sheridan, J., Chamberlain, K., & Dupuis, A. (2011). Timelining: Visualizing experience. Qualitative Research, 11(5), 552e569. Smith, J. A., & Osborn, M. (1997). Interpretative phenomenological analysis and the psychology of health and illness. Material Discourses of Health and Illness, 68e91. Sobal, J., Bisogni, C. A., Devine, C. M., & Jastran, M. (2006). A conceptual model of the food choice process of the life course. In R. Shepherd, & M. Raats (Eds.), The psychology of food choice. Wallingford: CABI. Sobal, J., Bisogni, C. A., & Jastran, M. (2014). Food choice is multifaceted, contextual, dynamic, multilevel, integrated, and diverse. Mind, Brain, and Education, 8, 6e12. Super, S., Wagemakers, M. A. E., Picavet, H. S. J., Verkooijen, K. T., & Koelen, M. A. (2015). Strengthening sense of coherence: Opportunities for theory building in health promotion. Health Promotion International, 1e10. Swan, E., Bouwman, L., Hiddink, G. J., Aarts, N., & Koelen, M. (2015). Profiling healthy eaters: Determining factors which predict healthy eating practices amongst Dutch adults. Appetite, 89, 122e130. Szwajcer, E. M., Hiddink, G. J., Koelen, M. A., & van Woerkum, C. M. J. (2007). Nutrition awareness and pregnancy: Implications for the life course perspective. European Journal of Obstetrics & Gynecology and Reproductive Biology, 135(1), 58e64, 2007. Van Lee, L., Geelen, A., van Huysduynen, E. J., de Vries, J. H., van't Veer, P., & Feskens, E. (2012). The Dutch healthy diet index (DHD-index): An instrument to measure adherence to the Dutch guidelines for a healthy diet. Nutrition Journal, 11(49). Vidgen, H. A., & Gallegos, D. (2010). Food literacy: Time for a new term or just another buzzword? Journal of the Home Economics Institute of Australia, 17(2), 2e8. Wainwright, N. W. J., Surtees, P. G., Welch, A. A., Luben, R. N., Khaw, K.-T., & Bingham, S. A. (2007). Healthy lifestyle choices: Could sense of coherence aid health promotion? Journal of Epidemiology and Community Health, 61(10), 871e876. Wethington, E. (2005). An overview of the life course Perspective: Implications for health and nutrition. Journal of Nutrition Education and Behavior, 37(3), 115e120. World Health Organization. (2000). The implications for training and embracing a life course approach to health (electronic version) from. http://www.who.int/ageing/ publications/lifecourse/alc_lifecourse_training_en.pdf.