Management of healthy eating in everyday life among senior Europeans

Appetite 55 (2010) 616–622

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Research report

Management of healthy eating in everyday life among senior Europeans§ Pernilla Lundkvist a,*, Christina Fjellstro¨m a, Birgitta Sidenvall b, Margaret Lumbers c, Monique Raats c Food in Later life Team1 a

Department of Food, Nutrition and Dietetics, Uppsala University, BMC/Husargatan 3, Box 560, SE-751 22 Uppsala, Sweden Department of Nursing Science, School of Health Sciences, Jo¨nko¨ping University, Barnarpsgatan 39, P.O. Box 1026, SE-551 11 Jo¨nko¨ping, Sweden c Food, Consumer Behaviour and Health Research Centre, University of Surrey, Guildford, Surrey GU2 7XH, UK b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 10 May 2009 Received in revised form 23 August 2010 Accepted 18 September 2010

The aim of the present study is to explore how older people reflect on, make sense of and express their views about healthy eating messages and how they narrate these responses in relation to managing their diets along with strategies adopted in terms of existing food and meal patterns. This qualitative study draws on data from 564 in depth interviews collected as part of the European Union (EU)-funded project Food in Later life – Choosing foods, eating meals: sustaining independency and quality of life in old age. The two major areas studied related to the connection between food and health and management of a healthy everyday life. Eating healthy was regarded as an investment to ensure independence was kept as the transition of old age approached, but old age could also be a reason for not bothering about it. Participants described different ways that they simplified and organized in order to manage ‘‘healthy eating’’. When trying to support senior Europeans, those working in health and community services should take into account the situational context of the older person and be aware of the variation in their conceptualization of ‘‘healthy eating’’. ß 2010 Elsevier Ltd. All rights reserved.

Keywords: Food Nutrition Health Qualitative Europe Senior Moral

Introduction Messages about healthy eating and individuals’ attempts to maintain a healthy diet have become an integral part of our daily lives (Arcury, Quandt, & Bell, 2001; Giddens, 1991; Lupton, 1996). In society today, the relationship between diet, nutrition and health is the subject of significant public interest and constant scientific debate. The World Health Organization (WHO) reports that food-related diseases are one of the main threats to well-being in the Western world. In the European health report for 2005 (WHO, 2005), it is stated that interventions are needed to empower

§ This study has been carried out with financial support from the Commission of the European Communities, specific RTD program ‘‘Quality of Life and Management of Living Resources’’, QLK1-2002-02447, ‘‘Choosing foods, eating meals: sustaining independence and quality of life in old age’’. It does not necessarily reflect its views and in no way anticipates the Commission’s future policy in this area. The whole Food in Later Life Project Team comprises research scientists, interviewers, technicians, administrative staff and managers who continue to make the study possible. We are extremely grateful to all the representatives from day-care centers, local authorities, industry and professional bodies who took part. * Corresponding author. E-mail address: [email protected] (P. Lundkvist). 1 The whole Food in Later Life Project Team comprises research scientists, interviewers, technicians, administrative staff and managers who made the study possible.

0195-6663/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2010.09.015

and encourage individuals as well as populations to make healthenhancing decisions about diet. During the past years, there has been increased interest in explaining and describing the factors that influence food choice (Furst, Connors, Bisogni, Sobal, & Falk, 1996; Rozin, 1990). Food choice and its underlying motives constitute a complex phenomenon, and several approaches have been used to develop models to describe or measure it (Sobal, Bisogni, Devine, & Jastran, 2006; Steptoe, Pollard, & Wardle, 1995). Overall, there has been a great deal of research on influences affecting food choice other than people’s actual ‘‘beliefs’’ about food and health and on ways to manage healthy eating even though this perspective is known to be important. Earlier research exploring the meaning of health maintenance behaviors suggests that older adults and health professionals often speak different languages when discussing activities such as diet (Arcury et al., 2001). This research highlights the importance of critically examining beliefs about food and health and how these impact on the health behavior of older people. Several studies have reported that trying to maintain a healthy diet is one of the most important factors affecting food choice among Europeans (Kearney, Kearney, & Gibney, 1997) and older consumers (Divine & Lepisto, 2005; Lennerna¨s et al., 1997). Food is viewed by many as being one of the primary means to achieve a healthy life and a better understanding of how senior Europeans make sense of healthy eating messages and incorporate these

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beliefs into their everyday life is needed (Ristovski-Slijepcevic, Chapman, & Beagan, 2008). Previous research has tended to be based on predefined healthy eating behaviors and definitions of health (De Almedia, Graca, Afonso, Kearney, & Gibney, 2001; Povey, Conner, Sparks, James, & Sheperd, 1998). However, people define and rationalize healthy eating in many different ways (Chapman & Beagan, 2003; Falk, Sobal, Bisogni, Connors, & Devine, 2001). Interpretations may change over the life course or be specific to older generations (Blane, Abraham, Gunenell, & Ness, 2003; Kearney et al., 1997). Some qualitative studies have focused on the older people’s definitions of healthy eating. For example, in one study healthy eating was conceptualized as ‘‘proper meals’’ that tended to be traditional in composition and preparation (McKie, 1999). Proper food meant having fresh ‘‘natural’’ ingredients, and having an eating routine where eating in moderation was also stressed. McKie (1999) also found that food was considered to be of great importance in maintaining independence. More recent research by Ristovski-Slijepcevic et al. (2008) explored different ways in which people make sense of healthy eating. The research revealed three broad healthy eating discourses: cultural/traditional, mainstream and complementary/ethical. Engagement in different discourses is found to lead to different food-related practices. Today, eating healthy food may serve as a basis for identity, social categorization and moral valuation, much as religion has done in the past (Lindeman & Stark, 1999). Giddens (1990, 1991) discusses how Western societies have been influenced by the modern movement during the past centuries, with an emphasis on natural science and logical reasoning and a view of the world as analyzed, planned and controlled. Many specific life course influences are unique to a given generation or cohort (Blane et al., 2003; Warde, 1997). The current food choices, beliefs and behaviors of older people have been shaped by their experiences during their entire lives (Lupton, 1996). Food acts as constructs of historical, social and cultural forces through which individuals act out their place in the cultural and social milieu (Mattsson-Sydner, Sidenvall, Fjellstro¨m, Raats, & Lumbers, 2007; Quandt, 1999). Throughout history, societies have developed complex ways of explaining health and illness, drawing on different ways to conceptualize health (Coveney, 2000). The present population of seniors has experienced enormous changes in the food system during their life course (Mattsson-Sydner et al., 2007) and finds itself at historic crossroads between the democratization of what was once considered high-status food (i.e., red meat, butter, eggs, cheese and whole milk) and how nutritional science now promotes the consumption of fruits and vegetables, fish and skimmed milk, to give some examples (Blane et al., 2003; Fjellstro¨m, 1990). Today’s senior Europeans’ ideas about what is regarded as healthy or not and the ways in which they report on putting these ideas into practice in everyday life should therefore be viewed as grounded in their social, cultural and historical world. The aim of the present study is to explore how older people reflect on, make sense of and express their views about healthy eating messages and how they narrate these responses in relation to managing their diets along with strategies adopted in terms of existing food and meal patterns. Method This qualitative study is part of the EU-funded project Food in Later life – Choosing foods, eating meals: sustaining independency and quality of life in old age, which was carried out in 2003–2005. Eight countries participated in the project: Sweden, the United Kingdom, Denmark, Germany, Italy, Poland, Portugal and Spain. The present study reports on data from one of the work packages in

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the project developed by the Swedish team and carried out in all participating countries. Participants Participants were recruited from all countries with the exception of Portugal. A total of 564 older people aged 65–98 years were interviewed for the purpose of the study. Eighty participants were recruited from each country and stratified according to gender, living circumstances (living alone or as cohabitants) and age (65–74 years and 75 years and over). This distribution according to gender, living circumstances and age produced eight groups from each country. The inclusion criteria were: men and women aged 65 years and older, who speak the native language of the country and who do not live in supported accommodations or have extreme visual or hearing impairments. Variables of socio-economic or demographic characteristics were collected as part of a specially designed questionnaire administered in advance of the interviews across all countries, yet these data were not analyzed in relation to each of the 546 participant’s narratives on health. Thus the socio-economic and demographic data were collected to provide the ‘context’ of the research and thereby improve the ‘rigor’ of work and not to make comparisons between groups given the nature of the approach used. Recruitment procedures varied across the participating countries and included direct recruitment at meetings for a range of different senior associations or at daycare centers and the like, random sampling from a database and advertising in newspapers or circulars for welfare organizations. Each country also recruited participants using snowball sampling. Participation was voluntary and all data were treated confidentially. Interviews Semi-structured interviews were chosen to ensure consistency in topics covered during the interviews by each country sample. A constructivist approach was used – where the topic of ‘‘healthy eating’’ was viewed from the perspective of the participant. The semi-structured interviews were based on a conceptual framework in which the following topics areas were used; the concept of the meal, favorite or ideal meals and food habits during life. The first topic emphasized the participants to elaborate on what constituted a ‘‘meal’’ and what they associated with this specific concept. The second topic aimed at exploring what could be an ideal meal as well as the opposite of this. The last topic included questions on how food habits, including food choices, had changed during the participant’s life span. Although the interviews did not explicitly focus on health-related issues, it became apparent from the outset that ‘‘health’’ formed an important area in relation to food. This led researchers to specifically probe about health even for those participants who did not spontaneously raise the issue during the course of the interview. Interviews were undertaken based on an interview guide developed by the Swedish team in order to ensure that key areas were covered whilst allowing flexibility to probe participants further if certain themes emerged. Both the design and analysis of the present study were based on Patton’s work relating to interview guides and inductive qualitative analysis (Patton, 2002). This entails developing an interview guide with openended questions and being able to condense extensive so called raw data into an understandable brief summary and to show links between the research objectives and the brief summary findings derived from the data. The Swedish team gave detailed advice and instructions to the other research teams and recommended appropriate research literature to help them gain a deeper understanding of the specific methodological issues. The interview guide was pilot tested in each participating country, and the

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Table 1 The process of method development and analyses of qualitative interviews for the theme ‘food-related health perspectives’. Sweden Step Step Step Step Step

1 2 3 4 5

Construction of interview guide Piloting qualitative interviews and preliminary analyses Reconstruction of interview guide Qualitative interviews and verbatim transcripts Construction of code-tree from further preliminary analyses

Step 6

Step 7 Step 8

All countries

Data analyses in MAXqda and preparation of country-specific reports with quotes. Eight style reports, one for each group (age, sex, and living circumstances) were produced from each country Reading of all country-specific reports – seven countries chosen for further analyses Further data analyses in MAXqda of country-specific reports and selection of verifying quotes

resulting interview transcripts were analyzed and interpreted at two different project team meetings in order to reach a consensus and understanding of the entire process. Interviews were conducted face-to-face in each local language and most often performed in the home of the participant. They were tape recorded and transcribed verbatim. For an overview of the process of method development and analyses (see Table 1). Analysis The interview transcripts were coded using a code tree developed by the Swedish team based on pilot interviews from all countries. The code tree came to focus on food-related health perspective after this initial analysis. Each country was there after responsible for analyzing and reporting in so called Style reports their country-specific material, translated into English and presented according to gender; living circumstance and age (older versus younger). These Style reports included condensed extensive raw data into an understandable brief summary illustrated by numerous quotes. A second coding schedule was developed based on all reports. Data were entered into MAXqda software (2001), a computer package designed to facilitate qualitative analysis. The second data analysis, however, was performed using the Style reports for development of a new code-tree focused particularly on examining the different ways in which the consumers narrated about food to make sense of their ideas and beliefs about food in relation to health in everyday life. Detailed information of each participant was collected prior to the interviews, including socioeconomic and demographic and health data but the main focus of the present study was to determine the consensus of views as well as identifying variation in these commonalities from the perspectives of this senior European cohort. Thus the data were not analyzed in relation to each of the 546 participant’s narratives on health, but more from a group perspective and a cultural generational perspective. Still, the citations were chosen to verify and reflect participants’ views and experiences, as well as to ensure that they included the different countries and were distributed across sex, age and living situation. Abbreviations for living alone (LA) and living together (LT) are used. Findings The findings will be presented in relation to the two main objectives; reflections on how to make sense of health information and management of healthy everyday life. Making sense of health information For oneself, by oneself The heightened focus on health and nutrition in contemporary society was well recognized by most of these senior Europeans.

Participants recognized their own responsibility in trying to make sense of all the messages they encountered, either by adapting to advice or stating that they were not bothered. Eating healthy was however regarded as an investment to ensure independence was kept as the transition of old age approached. The notion of ‘‘looking after oneself’’ drove this motivation. Benefits of eating a healthy diet were expressed as a means to avoid becoming ill or to control existing disease. Eating a healthy diet was seen as a way to prevent or slow down this process. I think a lot about healthiness, because I want to live longer and avoid all kind of diseases, like cancer. . . I am careful not to eat fat. I don’t eat butter or margarine, and I haven’t done that the last 25 years, and if I did then I would not be alive today, and I don’t smoke either. (Denmark, man, 79 years, LA) Despite the recognition of eating healthy, information on food and health could be viewed as contradictory, and it was sometimes hard to know who to listen to and to orient themselves in the current flood of information. Controversial information on the benefits and harms of certain products and foods was difficult to weigh and put in perspective. Even though participants expressed a concern about maintaining a healthy diet and described how they avoid unhealthy food, they were sometimes in doubt about the benefits of their behavior. Advice on what you should or should not eat from a health perspective could change from one day to another. Some participants thus stated that they did not depend on any experts to guide them. They strongly emphasized that they trusted their own ideas instead, which could mean that they chose to listen to their own bodies for guidance on what to eat. To be bothered or not, an age issue Old age was referred to both as a reason for paying more attention to healthy eating and as a reason for not bothering about it. Participants thought that as older people they needed to be more concerned about their diet and therefore take special precautions to ensure healthy eating. This woman describes how the media influenced her to change her diet because of health considerations. We have been influenced by mass media talking about what could be harmful and what not to eat at our age. . . We have been using less salt, fiber is healthy so we consume fiber. . . vegetables. (Italy, woman, 75 years, LA) The opposite view was also narrated. Participants thought it was too late to change their habits and did not perceive such a change as meaningful at their age, or argued that if they had managed to live this long on their diet, it would probably be fine for a while longer. This was not guided by whether or not they were diagnosed with an illness. They considered themselves to be too old to be bothered, as described by this man:

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And then they were saying about Kellogg’s breakfast is healthy and all that. At 76 years of age I wonder do I really want to know about this. I am getting to the end of the line. I have switched off the fast lane now. I am in the slow one. (United Kingdom, man, 76 years, LA) Reflections on old age were evident with participants appearing to be rather ambivalent about their own actions towards food and health with advancing years and yet still worrying about food and health. For example, this woman describes how she has relaxed her health precautions in some areas because of age, but at the same time acknowledges that it is her own responsibility to eat healthily in order to stay well. I do think that it changes with age, I have to say that I am not so afraid anymore of being poisoned by BSE, because I say, I’m old anyway. But then I say, if I take too much fat or live too unhealthy, like eat too much, it could lead to complications like a stroke or something like that, then I’d have a bad conscience. (Germany, woman, 73 years, LA) In her final statement, this woman declares that she has been thinking about her role in causing illness and its relation to her food habits, something that was also evident in the narratives. Thus, making sense of healthy eating messages were seen as complicated, and sometimes not important, yet something the individual was responsible for, resulting in turning to the self, rather than the expert, to be able to manage the everyday task of eating healthy. That could however have been managed in as many ways as there were individuals participating in this study, and depending on age, living conditions, gender, individual experiences, life course, culture, etc., making it impossible to relate for example specific food practices to a specific variable. Management of a healthy everyday life These senior Europeans narrated about adaptations already made or about how they tried to make some changes in their daily food habits. Trying to maintain a healthy diet affected how food products were judged. Categorizing food, however, was not enough; you also had to consider different food practices, that is, food preparation and eating routines. The way in which foods and food preparation methods were judged by participants Choosing food and meals on a daily basis involves many decisions and reflections. When these senior Europeans talked about food in relation to health, they described foods they tried to avoid and food that should be added to their daily eating. Food was often categorized and stereotyped as good or bad from a health perspective. When they talked about healthy and unhealthy food, they often did so in terms of what they should eat ideally and what they should try to avoid. Healthy food represented an ideal category into which food one wished to consume more of was placed. Food was sometimes classified on multiple dimensions that conflicted with each other. Some foods were viewed as both good and bad from a health perspective, depending on which aspect is considered. One example of this was vegetables, though mostly promoted as good from a health perspective; they could also be regarded as unhealthy because of pesticides or gene modification. Sweeteners/sugar replacements contained fewer calories, but on the other hand no one knows the effects they may have in the future. Participants expressed their concern about food safety in relation to different food products. Meat could be harmful because of BSE. Liver and fish were bad because they were polluted, and vegetables were unhealthy because of pesticides and gene

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modification. Organic food that was ‘‘too perfect’’ was also evidence of being unhealthy, because of unnatural contamination rather than natural decay. Food preparation was also found to play an important role in whether or not the food or meal was perceived as healthy. Boiling was the healthy way to prepare food and frying was the opposite, and there was evident skepticism regarding the healthiness of processed food, like take-away foods, pre-packed and readycooked meals. Home cooked meals and natural foods (i.e., those with the least processing before they reach the kitchen) were perceived as healthier. Distrust in convenience products was evident, as it was hard to know what these products contained and because they had added preservatives. Food practices adopted Many different efforts to eat healthy and different ways of doing so were described. Participants narrated about different food practices and described how they managed healthy eating in everyday life. In addition to trying to avoid certain foods or to consume more of others, they also described more elaborative behaviors. Some described specific strategies in detail, while others used more general terms like variation, balance, regularity and moderation. Some used these terms more like a statement as to how important it was to ‘‘eat a balanced diet’’ but without any further explanation, while others offered more detailed explanations as to how this affected their eating on a daily basis, as shown below. These food practices highlighted the importance of variety, the idea of maintenance and regularity of dietary habits, the importance of moderation and use of compensatory behaviors as well as compliance with diets prescribed for health. Eating a varied diet and using small amounts of everything were mentioned as a way to ensure that one’s diet was complete and therefore healthy. This could mean that you did not need to restrict your eating as much and that nothing was perceived as bad to eat. One reason was that if one did not know what nutrients were in a given food, this was the best way to go about it. It is quite so that my meals are varied, because I like that, and my common sense makes me act reasonably, and since I don’t know what nutrients are in what foods I try to eat everything in small amounts. (Poland, man, 67 years, LA) For some, healthy eating meant trying to maintain a balanced diet and meals. Some talked about balancing their meals by following models for healthy eating, while others, like this man, plainly stated that balance was important when considering food and health. I think food and health are very important, yes. I think, to labor the expression, eating a balanced diet is a very important part of one’s health regime – there’s so much written about it these days, but I certainly think food is a very important part of your life from the health point of view. (United Kingdom, man, 75 years, LA) Regularity in eating was also discussed, such as the importance of eating foods considered healthy every day, eating several times a day and having your meals at fixed times. The participants narrated about the importance of consuming fruits and vegetables as well as cooked meals on a regular basis. I have 5 meals a day, but my main meal is lunch. I try to eat on a regular basis, always at the same time, more or less. (Poland, woman, 79 years, LA) Moderation was described as the limitation and restriction of specific foods and portion size. Hunger was talked about, as you

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should only eat when you are hungry and stop eating when you still feel a little hungry. In relation to this strategy, participants were greatly concerned about hunger and taking care not to overeat, as over indulgence in food was to be avoided. In Germany, the following expression was commonly used by the participants. Always according to the principle: Breakfast like a king, lunch like a normal person, dinner like a beggar. A nutritious breakfast, a normal lunch with mainly salad and a yoghurt and occasionally meat. And in the afternoon, sometimes a piece of cake. And in the evening only a cheese sandwich. (Germany, woman, 71 years, LT) Participants also described a more specific strategy that demonstrates a compensatory behavior. If they felt they had eaten too much at one meal or on one day, they restricted their eating on the following day or occasion by eating less or nothing at all, or by having something they considered healthy on the next day or eating occasion to compensate for any overindulgence. This could mean having only a salad as the next meal or only eating fruit for one day, as described by this woman. We do that together, today e.g. a fruit day. Because yesterday we lived too extravagantly. We gained over one kilogram and that’s why today it is fruit day and that’s how we keep our weight. (Germany, woman, 78 years, LT) Others used this strategy of compensation on a more regular basis. This could mean restricting their eating on weekdays to allow for more on weekends. It could also mean allowing yourself one product considered unhealthy if you at the same time avoided another. Another example is when participants ate one unhealthy item and added something healthy to that product to make it more acceptable, e.g., eating cake, but choosing the one with fruit in it. Participants talked about allowing or treating themselves to something considered ‘‘sinful’’ and trying to ease their guilty conscience by compensating with another healthier behavior. Participants also narrated about healthy eating in terms of following a diet, either one prescribed by a health care professional or one that is self-imposed. Those using this strategy did not seem to modify the diet or only use it partially. They seemed to have accepted the whole concept without questioning it. A meal was conceptualized as what they were allowed to eat according to their diet. My doctor made a list for me of what I should not eat and by now I have got used to that. Vegetables at my pleasure, but meat, fish and cheese. . .carefully weighted. (Italy, woman, 70 years, LT) Some participants followed a ‘‘key-item diet’’, i.e., they described products they consumed because they were perceived as having a specific, almost magical effect. Food mentioned in this manner included, for example, apple cider vinegar or juice taken to reduce one’s appetite and body weight or having yogurt every day to stay in good shape. . . . and for appetite eh vinegar, apple-cider vinegar. . .Yes it is for, what should I say. . . it’s because I shouldn’t get so fat, that’s it! (Sweden, man, 77 years, LA)

Discussion Conceptualizing healthy eating The present participants, as members of contemporary society, were faced with a vast array of different messages and advice on

how to live a healthy life. The senior Europeans often seemed motivated to work toward healthy eating, which has also been reported in earlier studies (Arcury et al., 2001; Divine & Lepisto, 2005; Lennerna¨s et al., 1997). On the other hand, it could be difficult to sort among the flood of information and to understand the underlying reasons for various recommendations. The contradictory messages frequently caused confusion regarding which characteristics of food were healthful and which were harmful, a phenomenon earlier described by Rozin, Ashmore, and Markwith (1996). Findings reporting on connections between health and food (based on single experimental or epidemiological studies) have not been accompanied with education of the public on how to interpret and judge this information, and as a result research findings are often taken to be facts (Rozin, 1998). Most of the participants acknowledged their responsibility, which is evident in today’s ‘‘risk analysis society’’. Warde (1997) discusses how the assumption of personal responsibility for the state of one’s body is a central component of the trend toward individualization. In society today, health is frequently described as something that consumers have to take individual responsibility ¨ stberg, 2003; Turner, 1996). The modern view of people’s for (O responsibility for looking after themselves, and doing so by engaging in risk calculation, was clearly evident in the narratives. Having said this, it might also be in order to say that one should not over-emphasize the focus on health and the ‘‘risk society’’, although as one of the features of modern society, it is interesting to take this point of view in examining the senior Europeans’ beliefs. Norms about being healthy are represented through discourses of risk, focused on health promotion and illness prevention by monitoring and modifying risk factors (Castel, 1991). Food risks can be said to typify contemporary risks for several reasons, and management of these food risks involves the person in an complex assessment in which different messages have to be balanced against each other, because we have to eat and cannot simply choose to avoid everything that is potentially dangerous (Beck, 1992). The present focus on food and health might not have aroused a high degree of anxiety, but there was evidence in the present senior Europeans’ narratives that they had been influenced by our modern risk society. The present narratives revealed different ways of managing decision-making in relation to food and health. Participants could choose either to ignore or accept the connection between food and health. Age considerations were found to be a strong motive both for engaging in healthy eating and for not bothering about it. Engagement might have been motivated by the feeling of being ‘‘closer to harms and benefits’’. Some of these senior Europeans demonstrated a lack of concern about healthy eating, but in an overt way rather than displaying a passive lack of interest. They seemed to be demonstrating their resistance to modern health discourses by contributing to their rhetorical construction of themselves as survivors, who were to some extent invulnerable to risk, a phenomenon earlier described by Green, Draper, and Dowler (2003). Dealing with healthy eating on a daily basis involves many decisions, and participants described how they simplified and organized their daily choices in order to manage this. Many different efforts to maintain a healthy diet were described in the interviews, and they all had in common that they required some effort and self-monitoring. One way to manage was to simplify and adopt some ‘‘nutritional truths’’ and to put effort into following them. In practice, of course, decisions about food are made fairly routine (Green et al., 2003). Participants reported a range of strategies to describe their food choices, revealing that most decision-making was routine and unremarkable. These strategies were useful when making and especially when justifying decisions

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about food choice, in that they summarized categories of food and practices that were either bad or good from a health perspective. To some extent, these descriptions are, as earlier stated by Green et al. (2003), rhetorical devices used to describe decision-making in an ideal or hypothetical world. The participants’ narratives illustrate this in that they often described how and what they should ideally eat. Even though many recommendations appear to have been universal among these senior Europeans their ways of handling and interpreting the information varied as they made their personal interpretation and adapted the messages to make them fit into their daily life. Influenced by the modern risk-society/ health discourses, participants were adept at creating strategies to feel comfortable about their food habits – strategies that imparted confidence about the healthiness of the food they consume. It was particularly interesting to study the perspective of this group of senior Europeans, given that they have experienced a shift in focus toward a ‘‘medicalized’’ way of eating. Falk (1996) discusses the change in meaning structure given to food in terms of four dimensions, fuel, poison, medicine and pleasurable, and argues that there has been a shift toward the duality of medicine and poison. Earlier research on older people has presented the view that healthy food is proper food. To some extent this perspective was present among the present senior Europeans as well when they talked about preferring home cooked and natural food and when they referred to the old ways and nostalgia around food. Earlier research on food and health (Ristovski-Slijepcevic et al., 2008) describes three discourses regarding healthy eating that are found in society today – cultural/traditional, mainstream and complementary/ethical. Although much of the content in these senior Europeans’ narratives supported the dichotomy focused on the medical, risk assessment perspective discussed by Falk (1996), other ways of thinking about healthy eating more connected to the discourse focused on the cultural and traditional perspective, as described by Ristovski-Slijepcevic et al. (2008) were also evident, like when participants perceived home cooked meal as a healthier alternative. The seniors in this study also described how they adapted these home cooked traditional meals to incorporate healthy eating advice. It is thus important to consider the influence from earlier generations and the historical and social context if we are to avoid stereotyping the meaning of health and healthy food habits. Meanings and practices are socially and historically situated and therefore may change within time and context (Coveney, 2000). As stated by Bourdieu (1984), food choice is also dependent on the ideas that each class has of the body and what effects certain food has on it. The narratives were not analyzed according to the participants’ class or social background. Had this been done, there might have been differences in the way healthy eating was conceptualized related to habitus or for example cultural capital (Bourdieu, 1984). A large part of the narratives focused on different food that was judged and stereotyped as healthy or unhealthy. In studies by Oakes and Slotterback (2005) and Rozin et al. (1996), it has been shown that people tend to categorize food as solely good or solely bad, without any consideration for how much or how often one consumes the food item or the amount of ‘‘bad ingredients’’, or whether it has any positive values as well. Food items were categorized as good or bad based on what they contained and in comparison with other products from the same food group that were marketed as healthier alternatives. As stated by Rozin et al. (1996), this categorical thinking presents problems specifically in relation to nutrients like salt, sugar and fat, as people tend to believe that they are harmful and immoral in any amount. Rozin (1990) argues that the common principle ‘‘you are what you eat’’ is a form of contagion or sympathetic magic. Eating transfers the qualities of the food without regard to dose. The value of this contact, negative or positive, forms a dichotomy with moral

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connotations that are reflected in these senior Europeans’ narratives. To situate this research in a greater context, health can be viewed as one of the personal values that people might consider when making food choices. Others, like for example taste, cost or convenience, can also play an important part. Since this research only focused on the health perspective, this has not been further examined in this study. Food choice constitutes a complex phenomenon and includes behavioral, psychological, biological, economic, cultural, social, political, historical, environmental, geographical and other influences that affect food choice in both conscious and subconscious ways (Sobal et al., 2006). This study reported on the views of the participants and how they chose to present and describe their experience of ‘‘healthy eating’’. To use this information one must situate it in a greater perspective and also acknowledge that people are not aware of all their decisions. Wansink and Sobal (2007) describes this as ‘‘mindless eating’’. As they conclude, people are only aware of a fraction of the food decisions they make and unaware or unwilling to acknowledge the influence our environment play in food related decisions. Conclusion An understanding of how these senior Europeans acted to manage healthy eating by organizing and simplifying in order to feel comfortable with their food choices is important when communicating food and health messages. On a practical level, dieticians and other health care professionals could focus more on asking how healthy eating is managed in everyday life, since it was evident that the participants had developed their own very different and specific strategies. It was also clear that participants used terms and messages similar to those found in nutritional recommendations. However, the ‘‘meanings’’ sometimes deviated from those intended by health promoters and information providers. Information may therefore be interpreted and acted on in ways not intended by the experts. When trying to support senior Europeans, those working in health and community services should take into account the situational context of the older person and be aware of the variation in their conceptualization of ‘‘healthy eating’’.

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