Understanding healthful eating from a salutogenic perspective

The biomedical model of health orients towards pathogenesis, the study of disease origins and causes. The starting point is to understand determinants of ill-health, and health is defined in this model as the absence of disease. When applied to nutrition research, the underlying assumption is that eating is a physiological act, and that eating supports physical health. This risk-oriented, pathogenic view also underlies the search for determinants of unhealthful eating. However, there is such an emphasis on finding risk factors, that the biomedical model overlooks the fact that individuals also possess, or have access to, factors that support healthful eating. As a result, very little is known on factors that enable healthful eating and how these factors can be used to complement current health promotion strategies. The overall aim of this research was to contribute to a better understanding of healthful eating in the context of everyday life. We applied a complementary research framework, the salutogenic model of health, to 1) map factors underlying the development of sense of coherence (SOC); 2) study which of these factors are predictors for healthy eating; 3) unravel how people develop healthful eating practices in everyday life; and 4) integrate this understanding and provide building blocks for nutrition promotion. This research employed a mixed research design, using cross-sectional survey research and in-depth interviews.

Chapter 2 explored the possibilities of applying the salutogenic framework as a complementary approach to biomedical-oriented nutrition research and practice. Nutrition research takes a mostly biomedical-oriented approach to better understand risk factors that determine unhealthful eating. Though relevant for curative medicine, such an approach limits the evidence base for health promotion, which is guided by the principles that personal and social resources are preconditions for health and well-being. Moreover, biomedical-oriented nutrition promotion takes a reductionist approach and studies and enacts upon individual or the external environment separately. Disjointedly studying and enacting upon people and context may be easier, yet it does not do justice to reality and limits the relevance and applicability in everyday eating situations. The salutogenic model of health can provide complementary knowledge on what is already known through biomedical approaches. It guides the study of the dynamics between people and their environment and how health develops from this interaction. Since salutogenesis guides the study of health as an interplay between physical, mental, and social factors, it is more in line with how people experience eating in their everyday lives. In the study described in chapter 3, we examined individual, social, and physical-environmental factors that underlie SOC. Dutch adults (n=781) participated in a cross-sectional study examining the relationship between SOC and a set of individual, social- and physical-environmental factors. The main findings indicate that high SOC was significantly (p<.05) associated with a diverse set of factors including lower doctor oriented multidimensional health locus of control (MHLC); higher satisfaction with weight; higher situational self-efficacy for healthy eating; lower perceived social discouragement for healthy eating; higher perceived levels of neighborhood collective efficacy; and higher perceived neighborhood affordability, accessibility and availability of healthy foods. Non-significant factors (p≥.05) included gender; employment status; education level; cohabitation; BMI; nutrition knowledge; internally oriented MHLC; chance oriented MHLC; and perceived social support for healthy eating. These findings are relevant since they can inform the design of nutrition interventions that target factors that strengthen SOC and provide building blocks for a healthier life orientation. Next, the study in chapter 4 aimed to determine a set of individual, social and physical-environmental factors that predict healthy eating practices in a cross-sectional study of Dutch adults. Data were analyzed from participants (n=703) that completed the study’s survey and logistic regression analysis was performed to test the association of survey factors on the outcome variable high dietary score. In the multivariate logistic regression model, five factors contributed significantly (p<.05) to the predictive ability of the overall model: being female; cohabitation; a strong sense of coherence; flexible restraint of eating; and self-efficacy for healthy eating. Non-significant factors (p≥.05) in the multivariate logistic regression model included age; employment status; net monthly household income; education level; nutrition knowledge; internally oriented MHLC; perceived social support and discouragement for healthy eating; perceived neighborhood collective efficacy and perceived neighborhood affordability, availability and accessibility of healthy foods. Findings complement what is already known of the factors that relate to poor eating practices. This can provide nutrition promotion with a more comprehensive understanding of the factors that both support and hinder healthy eating practices.

Lastly, the qualitative study described in chapter 5 examined a group of healthy eaters and explored life experiences and coping strategies that foster healthful eating through narrative inquiry. The study was undertaken with seventeen Dutch women (aged 36- 54 years) in the highest quartile of dietary quality index scores. The main findings showed that life experiences gave rise to coping strategies that enabled healthful eating. Childhood experiences included: accustomed to non-processed foods and positive child-parent interactions. Adulthood experiences included: regained stability and structure in stressful life events and forged positive experiences with food. Coping strategies included: organizing eating in an uncomplicated manner; creativity in the kitchen; valuing good food with good company; approaching eating with critical self-awareness; and applying craftiness and fortitude during difficult moments. The findings suggest that there is an interplay between life experiences and coping strategies, and this mechanism underpins healthful eating. Findings offer potential entry points for nutrition promotion to foster healthful eating.

When integrating the research findings in chapter 6, we found that healthful eating results from three composite factors: balance and stability, sense of agency, and sensitivity to the dynamics of everyday life. Firstly, healthful eating results from balance and stability in life, represented by a strong SOC, which characterizes a balanced mixture of giving meaning to eating as an integral part of life, comprehending its importance to oneself, and having competencies to manage its organization in the everyday social context. In the life course, healthful eating also results from the ability to regain stability and structure in stressful life events and craftiness and fortitude during difficult moments. Healthful eating is also rooted in a sense of agency (the feeling of being in control of one’s own actions), with regards to the ability to take action related to eating and life in general. This sense of agency is enabled through flexibility, lower doctor oriented MHLC, applying creativity in the kitchen, and approaching eating with critical self-awareness. Thirdly, healthful eating results from a sensitivity to the dynamics of everyday life, with regards to the how people deal with and navigate through everyday challenging situations by applying individual- and context-bound factors including situational self-efficacy, organizing eating in an uncomplicated manner, valuing good food with good company, and perceiving less social discouragement for healthy eating from family and friends.

Few of the factors associated with SOC and healthful eating converged with risk factors for unhealthful eating found in previous studies, including coping, self-efficacy, restraint of eating, and living situation. Our findings show that the set of factors related to the origins of health substantially diverged from the set of factors related to the origins of disease. From this, we conclude that the “origins of health” differ from the “origins of disease”. Hence, factors that foster and support healthful eating are not simply the reversed version of the factors known to increase the risk of unhealthful food choices. This implies that a different set of factors should inform health promoting strategies, in addition to the factors informing strategies targeting the prevention of diet-related illnesses.

The new insights brought forth in this research provide building blocks for salutogenic-oriented nutrition promotion. 1) Strategies should take a more holistic orientation to food and eating, emphasizing a balance between physical, social, and mental health. Similarly, dietary guidelines should emphasis more than what and how much to eat for physical health and also consider the social and mental dimensions.

2) Nutrition promotion should develop strategies to support a healthful orientation to life. Through strengthening SOC, people can become more capable of coping with any situation or challenge, independent of whatever is happening in life. Nutrition promotion should also strengthen more general health promotion factors including mindfulness, critical thinking, and stress management because these skills support adaptive behavior when life circumstances change. 3) Strategies should facilitate health-directed learning processes through positive interactions and experiences with food. For instance, strategies that support health-directed learning processes should improve food-related procedural knowledge such as food literacy and cooking skills. They should also include socially-embedded learning experiences involving the selection, purchase, and preparation of healthful food; encourage positive parent-child interactions at the dinner table; and recommend that people cook regularly with partners, family or friends.