What are the perceived barriers to healthy eating in
the UK and what strategies to encourage healthy
eating are most effective?
Bsc (Hons) Health and Social Care
Cardiff School of Health Sciences
Cardiff Metropolitan University
SCH6006
Dissertation
May 2017
Word Count 13,096
Acknowledgements
Cardiff Metropolitan’s Health and Social Care course has been one of the most
important and formative experiences in my life, it has been a period of intense
learning both on an academic and personal level. This research project would not
have been possible without the support of many people and I would like to reflect on
the people who have supported and helped me through this challenging period.
Foremost, I would like to express my sincere gratitude to my dissertation advisor and
personal tutor David Miller for his encouragement, patience and insightful comments
that have guided me through the research process. I would also like to express my
gratitude to Daniel Burrows, his support, encouragement and guidance during a
challenging time in my personal life allowed me to continue my studies, without his
support this study would not have been possible. Thanks are also due to Huw Evans
who has always spared the time to answer my research questions.
Starting a family during my studies has been a whirlwind of mixed emotions and the
love for my children has kept me motivated to show them that anything is possible.
Special thanks are also due to the friends and family who have shown me love and
support by providing a listening ear and encouragement throughout my learning
experience.
i
Abstract
This small scale research study used qualitative research methods with the aim to
explore the question ‘what are the perceived barriers to healthy eating in the UK and
what strategies to encourage healthy eating are most effective?’ A systematic review
of peer reviewed literature available within the public domain was undertaken; the
literature search conducted led to the selection of five research papers which were
critically appraised in order to provide reliability and validity to the study, the papers
were then critically analysed to produce findings to the research question. The
papers selected used a combination of qualitative and quantitative methodologies in
order to provide a holistic approach to the research question. Findings highlighted
the association of cost and socio economic status as barriers to healthy eating and
suggest that individuals from low economic status were more likely to choose
unhealthier foods than those of high economic status. Additionally the role of cost for
both consumers of food and food manufacturers is a key contributor to barriers of
healthy eating. Further findings identified that the two government strategies
analysed showed little impact on improving heathy eating behaviours. This study
reviews different factors that can influence an individual’s food choices and
encourages the importance of health interventions in addressing the barriers
individuals are facing. The research identifies a relationship between the barriers
identified as strongly influenced by culture and recognises that there is a gap in the
literature in recognising the role of culture in healthy eating initiatives. Limitations of
the study recognises the small scale of the study in conjunction with lack of
researcher experience at an undergraduate level. Further research is needed to
consider alternative interventions that can overcome the barriers that are reduce
effectiveness at level of implementation.
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Contents
Acknowledgements …………………………………………………………………….. i
Abstract ………………………………………………………………………………….. ii
Declaration …………………………………………………………………………...…. iii
Chapter 1. Introduction ………………………………………………………………… 1
Chapter 2. Methodology ……………………………………………………………….. 5
2.1 Contrasting qualitative and quantitative data …………………………………... 6
2.2 Epistemology ……………………………………………………………………….. 7
2.3 Ethics Design ……………………………………………………………………….. 8
2.4 Study Selection Process ………………………………………………………...… 9
2.5 Studies Selected …………………………………………………………………….11
Chapter 3. Literature Review ……………………………………………………………13
Section One ……………………………………………………………………..……… 13
3.1 Socio Economic Status (SES) …………………………………………………….. 13
3.2 Taste …………………………………………………………………………………. 15
3.3 Urbanisation …………………………………………………………..…………….. 18
3.4 Employment ……………………………………………..………………………….. 19
3.5 Knowledge of Nutrition …………………………………………….……………….. 20
3.6 Media ………………………………………………………………………………… 21
Section Two …………………………………………………………………………….. 22
3.7 Packaging/ labelling.…………….………………………………………………….. 22
iii
3.8 Education/schools …………..…………………………………………………….. 24
3.9 Eligibility based schemes …………………………………………………………. 26
3.10 Sugar tax ……………………………………………………………….…………. 27
Chapter 4. Findings …………………………………………………………………….. 28
Themes identified ………………………………………………………………...….... 32
4.1 Cost …………………..………………………………………………………………. 32
4.2 Socio Economic Status (SES) …………………………………………………….. 34
4.3 Taste ………………………………………………………………………………......35
Chapter 5. Discussion …………………………………………………………………... 37
Chapter 6. Conclusion …………………………………………………………………... 38
Chapter 7. Recommendations ……………………………………………………….… 39
References ……………………………………………………………………………….. 43
Appendices ……………………………………………………………………………….. 50
Appendix A Ethical Approval Form …………………………………………………..… 52
Appendix B Front of Packet Traffic Light Nutrition Label ……………………………. 53
List of Tables
Table 2.4 Study selection process
Table 2.5 Literature selected for further analysis
iv
Chapter 1. Introduction
What are the perceived barriers to healthy eating in the UK and what strategies to
encourage healthy eating are most effective?
The aim of this study is to explore the perceived barriers to healthy eating in the UK
and draw upon existing research on healthy eating to evaluate what strategies are
most effective. It will begin by broadly identifying the range of relevant material
including policy and research studies, before going on to select a sample of quality
assured research papers that will be analysed to identify the perceived barriers. This
research will draw upon themes and seek to identify gaps within the research used
that may potentially enable the more successful interventions to be highlighted.
The qualitative research topic emerged, where an interest for the topic began whilst
conducting research for a nutrition module on the Health and Social Care degree
course at Cardiff Metropolitan University. As a researcher, looking at health
promotion in relation to food choice is interesting as it is an aspect of everyone’s
everyday social world that is influenced through many different factors. The
researcher found the different dynamics of health promotion and the role it plays
within the social world intriguing, therefore wished to explore these further.
The concept of healthy eating is underpinned by the understandings of health and
health promotion, therefore it would be relevant to discuss the definitions and
meanings of these terms. The World Health Organization suggests that health is
“a state of physical, mental and social well-being and not merely the absence of
disease and infirmity (The World Health Organisation, 1948). This definition of
health provides a holistic explanation taking into account of the many different
factors that can influence health, it allows us to consider how health can be an
internal feeling as well as something that can be assessed externally. However,
the definition is limited as it suggests that in order to be considered healthy all
three aspects must be reached, therefore it is difficult to outline health within one
definition as it is an individual perspective that is influenced and built from
knowledge, resistance, standards and values. Recognising the role of individual
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perspectives of health and what is understood by the term healthy is essential, as
fundamentally an individual’s health has the potential to either positively or
negatively impact upon an individual’s life and can additionally impact on society
in numerous ways.
Health promotion however is a term that focuses on improvement, prevention and
reduction of health inequalities. The term is used to empower individuals to
become aware of their health and has become the basis for many international
and national health promotion strategies and interventions (Ewles and Simnett,
1985). From these perspectives considering why health promotion is significant
and the understanding of health and the impact it has on quality of life is critical
when evaluating effectiveness of interventions.
The phrase ‘healthy eating’ is a term that has been used for many years and aims to
define the publics and health professional’s understandings, views and attitudes
about healthy eating (Devine, 2008). However it is a complex term which is
constantly evolving, dietary guidelines and healthy eating messages are constantly
progressing which often leaves consumers, policy makers and health professionals
confused over nutritional guidelines and effective intervention (Paquette, 2005).
The World Health Organisation (2015) suggest that the concept of healthy eating
is generally found to be the consumption of a balanced and varied diet based
around consuming fresh fruit and vegetables and meat in moderation, cutting
down on processed foods or foods high in saturated fat, salt and sugar. These
guidelines are often criticised to be sending out mixed messages to consumers,
as having processed foods specifically highlighted as something to be reduced,
suggests that these foods which are considered to be poor nutritional choices,
are satisfactory provided they are consumed in moderation. Yet despite the
available knowledge and widely known basic principles of what constitutes a
healthy diet, due to rapid urbanization and a change in lifestyles, dietary patterns
have changed resulting in higher consumption of processed foods (Devine,
2008).
As aforementioned, dietary advice itself has evolved immensely over the years
and is influenced by many different factors such as an individual’s cultural beliefs,
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taste preferences, age, gender, food prices, geographical locations, socio
economic status, as well as social environment (Pechey and Monsivais, 2016).
All factors need to be considered when looking at how individuals make food
choices and how these factors can become barriers or facilitators to healthy
eating.
The consumption of healthy foods plays a large role in individuals maintaining a
healthy weight and is a preventative measure for chronic diseases and premature
mortality (National Health Service, 2013). The increased consumption of
processed foods containing high levels of fats, sugars and salts can have a
negative impact on a individual’s overall quality of life. Poor nutrition has been
associated with negative mental health effects, in addition to being the leading
contributor in developing many chronic diseases such as cardiovascular disease,
type- 2- diabetes, obesity, osteoporosis and some cancers (WHO, 2015).
However the impact of obesity is a relatively new concept as past governments
were previously concerned with inadequate nutrition and underweight children
(Glasser, 1998). Politicians now launch initiatives against childhood obesity and
encourage heathier diets. This potential perspective of defining obesity as
something which should be eradicated could be argued as potentially
manipulative in influencing and pushing negative perspectives and stereotypes
on obesity onto society.
Yet there is a need to address the impact of obesity as it has risen dramatically
within the UK and is estimated to continue rising. The term obesity/overweight is
used to refer to an individual who has an excess of body fat. High levels of obesity
are causing pressure on health and social care services and the Foresight Report
(2007) estimated NHS costs related to obesity were £6.3 billion in 2015 and forecast
to be £8.3 billion in 2025 and £9.7 billion in 2050 (House Of Commons, 2017),
highlighting the need for public health intervention in healthier food choices. However
the problem of obesity is not so cut and dry as obesity prevalence is twice as high for
adults and children living in more deprived areas signifying the complex social
problems related to obesity.
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This research aims to consider the wider social processes that can influence
individual’s food choices. It is considered important that on-going research is
undertaken to explore potential causes to the obesity epidemic, as in order to
combat obesity, research firstly needs to explore the potential barriers to healthy
eating that society may be experiencing so that these can be thought about when
considering strategies to reduce obesity levels. Furthermore, with the government
focus on aiming to tackle the amount of obesity related diseases there has now been
a shift from defining food as either healthy or unhealthy (Lobstein and Davies, 2008),
to providing consumers with tools to aid them in making healthier food choices.
These tools will be evaluated within the research in order to consider their
effectiveness in health promotion whilst considering the potential barriers
interventions would need to overcome.
This research is being undertaken with the aim to breakdown the different dynamics
that influence eating behaviour. The consumption of food is essential for survival,
however the reasons behind why we choose different foods is far more complex.
Research has shown that individual’s eating behaviours go far beyond choosing a
food based on taste and have recognised that dietary choices are influenced through
physiological factors, food accessibility, food characteristics, environmental
influences, and psychological influences (Lonstein and Davies, 2008; Winston et al,
2008; Pechey and Pablo, 2016). This research will consider these factors and how
they play a role within an individual’s diet, as a greater understanding of how both
the public and health professionals view healthy eating is needed (Paquette, 2005) in
order to develop successful health promotion strategies.
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Chapter 2. Methodology
Methodology refers to the ‘principles and ideas that researchers will follow and base
their strategies of research upon’ (Flick, 2014). There are many different definitions
of research that incorporate the view of a search for knowledge through systematic
review, however for the purpose of this study the definition used is suggested by
Moule and Hek (2011, pp.11) who propose that research can be defined as “a
systematic approach to gathering information, for the purposes of answering
questions and solving problems in the pursuit of creating new knowledge about
health and social care”, this definition offers recognition on the nature of research
and the different methods that can practiced within health and social care.
The first stage of the research process undertaken was the identification of a
problem within health and social care perspective. The research question chosen
was identified as an international problem, as the consequences of an unhealthy diet
are detrimental to an individual’s health and quality of life (WHO, 2017). The
researcher chose to study the UK as part of the question due to the small size scale
of the study and in order to specifically consider policies, strategies and barriers that
relate to the course of study. The research question allows the researcher to adapt
the basic scholarly principles of social science research, that investigate human
activity and interactivity whilst considering policy problems, social values and
contexts in order to provide meaningful answers to the issue of unhealthy eating.
This exploration provides an opportunity to recognise research gaps that could build
on the already existing body of literature within this field (Silverman, 2013). The
research question was identified as researchable through the use of government
studies and access to academic literature through Cardiff Metropolitan MetSearch,
the availability of information within the public domain around the specific research
question assisted the researcher in the decision of an appropriate methodology of a
qualitative approach.
The next stage of the process was the conduction of a literature search that involved
the retrieval of relevant and up to date literature, specific to the research subject. The
literature search undertaken was structured around themes understood to be
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relevant from the researcher’s previous experience in order to give focus to the study
and avoid diversions to irrelevant literature. Resources involved accessing: Journals
and Ebooks on the Universities electronic database, reading books from the
University library and accessing government documents online. Electronic access to
literature was favoured by the researcher due to the accessibility of in depth
literature that was both recent and relevant (Moule and Goodman, 2009). The
MetSearch Eshelf was used to create a folder that saved any relevant literature
sources and furthermore a reference database grid was used to record the research
data obtained to be continuously reviewed throughout the study process.
Contrasting qualitative and quantitative data
Both qualitative and quantitative methods play an important role in the collection of
data and research. Quantitative data primarily relies on statistical measures of data
and uses more structured data tools within the research methods (Moule and
Goodman, 2009), larger samples are often used within this method, resulting in data
that can be descriptive and representative of certain demographic areas. Although
this methodology can present statistics, such as obesity levels within the UK, it is
difficult to interpret understanding of the data from numeric data alone. Alternatively
qualitative data may use small degrees of statistical analysis, however the approach
is most focused on naturalistic enquiry that ‘builds on understanding of what is
already known’ (Booth, 2004), this methodology adopts a more flexible approach to
data collection however still requires a systematic method and a evaluative
procedure.
A qualitative approach to the research question was adopted as it was considered
the most appropriate method of data collection for this small scale undergraduate
study. The purpose of the research is to identify themes and draw upon literature
that provides insight into individual’s food choices and behaviour. The researcher
took consideration in that there is a need for quantitative data within this study,
particularly when considering statistics on nutrition and weight, however the
researcher’s primary focus is to consider the complex social functions that can
influence an individual’s diet and the effectiveness of strategies currently available.
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Therefore a quantitative approach would not provide an in depth understanding. The
studies selected are a mix of both qualitative and quantitative studies, following a
mixed method approach allows the researcher to address the research question with
a broader and more in depth understanding (Silverman, 2013).
The use of qualitative methods has grown greatly over the years due to the vast
amount of research that is easily accessible and researchers have highlighted the
importance of building understanding on existing knowledge (Booth, 2004), however
the qualitative methods are still widely criticised (Golafshani, 2003). One of the
limitations of qualitative data is that the findings are often complex, combined with
the lack of numerical data the findings often cannot be generalised to the wider
population (Johnstone, 2014). Secondly when conducting secondary analysis a
limitation is that the researcher was not present within the original study, therefore
will not have full awareness of data collection and ethical procedures followed
(Abumere, 2012). However despite these limitations qualitative methods have many
strengths, as the data is already collected the researcher firstly does not have to
invest financially into the study, secondly the data is easily accessible to collect,
thirdly this methodology can produce findings that can complement and refine
quantitative data by providing more detailed and in depth understandings of complex
issues (Moule and Hek, 2011).
Epistemology
Qualitative research is an umbrella term that is used to encompass a number of
different frameworks and approaches (Abumere, 2012). The basis of qualitative
research lies in an interpretive approach to social reality and in the description of
how ‘human beings experience it in the context of their whole life’ (Flick, 2009).
Furthermore, epistemology is a term used to describe the theory of knowledge, it
studies the method of acquiring knowledge with the objective that by following a
system of principles and method of evaluation we can understand how we know
something and if the knowledge of the world around known us is valid or invalid
(Golafshani, 2003). The researcher has undertaken an interpretivist model through
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the research process, under this approach research focuses on how ‘human beings
experience their subjective reality and make sense of it’ (Flick, 2009). The
researcher has taken this stance of methodology to centre the research question
with the objective to develop deeper understanding and analyse existing data rather
than generate new knowledge, with the aim to identify themes related to individuals
food choices in the context of their whole social world rather than individual entities
to provide a subjective view to social reality (Bryman, 2001).
Ethics Design
Having identified the research question ethical approval from the research ethics
committee in Cardiff Metropolitan University was needed before conducting the
proposed research. Ethical challenges can be presented in any research design and
ethical approval is an essential process needed when conducting research within the
field of health and social care (Moule and Hek, 2011). The researcher took great
thoughtfulness in considering the ethical issues that may arise through both primary
and secondary data collection when choosing the most appropriate research design
for the study.
This research will be conducted through a desktop study, primary data could have
been used however the research identified potential ethical issues that would arise
within this research design that will now be stated. Firstly a large sample would be
needed in order to address and be representative of the research question, due to
the researchers lack of experience in undertaking and handling large data concern
arose. Secondly the research question is not aimed at one particular age group
therefore ethical consent would have been required from some participants which
may have been difficult to gain from an undergraduate level, lastly food choice and
barriers to healthy eating habits is an emotive topic that could have potentially
caused distress to participants (Abumere, 2012).
Nonetheless ethical considerations still needed to be made within secondary data
analysis, the researcher will adhere to ethical principles at all stages of the research
design by ensuring all research accessed is within the public domain and all data
chosen will be correctly referenced (Hek and Moule, 2006). Particular consideration
8
will be taken to ensure the analysis of data will not misinterpret the data used
throughout the study as outlined by Moule and Hek (2011). Due to the qualitative
approach being undertaken, the proposal to the ethical committee included the
proposed research question and details of the research approach that was to be
undertaken (See Appendix A), once ethical approval had been obtained the
researcher then progressed to the next stage of the research process.
Study Selection
This section will outline the step by step process the researcher undertook in order to
obtain the primary papers used within this study.
Stage 1
Search of database for relevant studies
N= 148, 788
Stage 2
Sift papers for relevance to topic and study design
N= 354
Stage 3
Further apply inclusion and exclusion criteria
N= 188
Stage 4
Obtain and critically appraise primary papers
N= 20
(Attree, 2004)
Step 1: Within this stage the Cardiff Metropolitan University MetSearch was used to
commence the research process; using an electronic database enabled the
researcher to instantly access a large range of research easily. Within the first
search research was identified using the following broad terms; healthy, food choices
and United Kingdom. These terms were chosen as the original starting point for the
search, however from this broad search 148, 788 results were presented. Having
such a large amount of data meant that the researcher had to carefully consider the
9
inclusion and exclusion criteria that would need to be implemented in order to ensure
relevance of research results and resourcefulness of time (Moule and Hek, 2011).
Following this initial scoping of literature the researcher was able to further specify
the search by setting inclusion criteria for peer reviewed journals of English
language, dated from 2009. By including these criteria the researcher was ensuring
quality control of the literature as well as being mindful of resource issues that would
arise from trying to translate articles that were published in different languages. The
date was selected to present studies within the past 8 years, as health messages are
constantly evolving therefore the researcher wanted to keep data within recent
years, however as many healthy eating interventions are relatively new within the UK
the researcher wanted to ensure that the literature was up to date and not restricted
by the publishing date.
Step 2: The second iteration used an advanced search where further key words
were applied. The key words used included a variation of terms such as diet, eating
habits, barriers, facilitators, influences, effectiveness, intervention, prevention and
awareness. By adding in alternative phrases for the original broad search the
researcher began filtering the search to become more refined to the research
question. Following the advanced search results, 354 pieces of literature were
presented. The researcher then sifted through titles and abstracts of the search
results presented to consider the relevance of the literature following the further
criteria applied.
Step 3: After applying a variation of terms the researcher was still presented with a
large search result, further refinements were required in order to narrow down the
literature to ensure relevance to the study. At this stage the researcher carefully
considered the inclusion of subjects within the search which included; Public Health,
Consumers, Nutrition, Diet, Sociology, Health Promotion, Marketing, Health
Behaviour and United Kingdom. These subjects were chosen as they are
representative subjects of the research question. Inclusion of these criteria resulted
in 188 results. Refinements on the publishers were further made to include articles
published by; Journal of Health Psychology, Journal of Nutrition, Education and
Behaviour and Food Policy. Adding in further criteria resulted in 20 results.
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Step 4: From the 20 results the researcher had to critically examine the studies for
quality. However within the results, six studies presented were systematic review
and two thesis/ dissertation studies, therefore they were eliminated. Out of the 12
remaining results the researcher selected six studies that were most relevant to the
research question and most appropriate for the research design. Within these results
the researcher identified only two papers that considered the effectiveness of UK
strategies to healthy eating that would be helpful to consider the research question,
highlighting a need for the evaluation of healthy eating interventions. The studies
selected were a mix of both qualitative and quantitative methods to provide a holistic
approach to the question. In order to critically appraise studies researchers often rely
on models to evaluate the quality of the literature, however there is often a lack of
consensus on how to examine qualitative research methods (Attree, 2004). For the
purpose of this research question the research has been critically examined for
quality using review criteria highlighted in Silvermans (2013) framework for
appraising qualitative research methods and was then further critiqued using CASP
Tool (2013). Following the critical appraisal one study was eliminated from the
primary papers as several flaws were recognised within the sampling technique and
ethical considerations around the sample were not highlighted.
Table 2.2. Literature selected
The five primary papers selected and critically appraised include:
Author(s)
Pechey, R.
Date Title
2016 Socioeconomic inequalities in the
and
healthiness of food choices:
Monsivais,
exploring the contributions of food
P.
expenditures.
Article
Research
Type
Method
Journal Quantitative
11
Robinson, E. 2013 Food choices in the presence of
and Higgs,
healthy and unhealthy eating
S.
partners
Pridgeon, A.
2013 A qualitative study to investigate the
and
drivers and barriers to healthy eating
Whitehead,
in two public sector workplaces.
Journal Quantitative
Journal Qualitative
K.
Sacks, G.,
2009 The impact of front of pack traffic
Ragner, M.
light nutrition labelling on consumer
and
food purchases in the UK.
Journal Quantitative
Swinburn, R.
Moore, S.,
2010 From policy to practice: Barriers to
Murphy, S.,
implementing healthy eating policies
Tapper, K.
in primary schools in Wales
Journal Qualitative
and Moore,
L.
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Chapter 3. Literature review
The many different factors that are considered to be perceived barriers to healthy
eating within the UK will now be identified and discussed in relation to theories within
health and social care practice. This will be done to allow for current understanding
of the question to be drawn upon from up to date literature that is relevant and
available within this field of research. The research drawn upon has been broken
down into sections in order to consider relevant aspects of the question: What are
the perceived barriers to healthy eating in the UK and what strategies to encourage
healthy eating are most effective? Section one will outline and discuss research
regarding the potential barriers to healthy eating and Section Two will draw upon
research that identifies facilitators and strategies to healthy eating.
Section One
Socio Economic Status (SES)
There is a substantial body of literature that recognises the many factors that can
influence an individual’s diet, often lower SES is a barrier that is portrayed to have
the main influences on an individual’s eating habits (Giskes et al, 2005), however
more research is needed in relation to how class differences and wider societal
issues create these barriers to begin with. The impact that SES can have on an
individual’s diet will now be discussed.
Socio economically disadvantaged areas are shown to have higher rates of
inequalities between education, health and occupation and it is a topic that is
extensively researched due the major health inequalities these socio economic
groups can experience (Giskes et al, 2005). This is often explained through an
individual’s behaviour and lifestyle choices, research has shown that lower
socioeconomic groups are more likely to participate in unhealthy behaviours, such as
making unhealthy food choices than individuals from high economic groups (Abel,
2008). Furthermore it has been identified that in the UK these lifestyle choices lead
to higher levels of obesity within lower social income groups and consequently a
higher prevalence of many chronic and communicable diseases (WHO, 2017). Socio
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Economic Status contributes efforts to explain the gap in socio economic differences
in health, however the participation within these unhealthy choices may not be
voluntary. Therefore considering the wider social factors underlying between these
inequalities is essential when exploring the barriers to food choices in the UK.
The structures that can influence an individual’s food choices in a daily context will
now be discussed in order to consider these wider social factors in depth, as the
environment in which an individual operates can offer wider or constrained
possibilities for food choice (Conner, and Armitage, 2002). Firstly material
deprivation has shown to be a major contributor to individuals participating in
unhealthy behaviours such as a poor diet. Individual’s living within deprived living
conditions often do not have the financial resources or housing conditions needed to
maintain a healthy balanced diet (Fraser et al, 2010). Individuals with financial
difficulties may see the consumption of fruit or vegetables everyday low on their list
of priorities when dealing with major life stresses and may not have the resources
needed to prepare fresh produce meals and may therefore be more likely to
purchase and consume food of convenience and affordability, rather than taking
nutritional value into consideration (Sheperd et al, 2006).
Material resources however are not the only explanation when considering SES,
geographical location as well as the characteristics of the area in which individual’s
live also plays a large role in influencing individual’s dietary choices (Sheperd et al,
2006). Living in a disadvantaged area may contribute to poorer dietary intakes due to
the limited availability of food shops and/or healthy foods within these shops, as well
as having difficulty in accessing shops. Research has identified that living in a
deprived area is associated with ‘lower fruit and vegetable consumption and higher
junk food choices resulting in higher fat and sugar intakes’ (Public Health England,
2016). Often within lower income areas they do not have the local amenities such as
a large grocery store or access to transport to the nearest store, which consequently
limits food choices immensely, as often the smaller supermarkets available stock
small amounts of fresh fruits and vegetables or healthy alternatives but at a higher
price (Macguire and Monsiais, 2015). In conjunction with the lack of availability of
fresh local food within more deprived areas are the high presence of fast food chains
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(Public Health England, 2016), furthermore with having the option of cheaper and
quicker food alternatives we can recognise how SES can become a barrier to
healthy eating.
Taste
Taste will now be discussed as a potential barrier to healthy eating. As humans we
have a physiological need to consume food in order to survive, however our food
choices are not purely based on necessity alone. A review of the literature
demonstrates that preference for taste differ in individuals as we all have our food
likes and dislikes, hence why we all have different diets, however it is the preference
and availability of different tastes that can become a barrier to healthy eating
(Kamphuis, 2015). After discussing the environmental factors that can become a
barrier to healthy food choices it is now essential to draw upon the biological and
genetic factors that influence our food choices through exploring how the experience
and taste of food can be a barrier to healthy eating. The four classical primary taste
senses in humans are found to be sour, salty, bitter and sweet. An individual’s taste
buds will respond to these different senses and overtime people will then learn
through experience what foods they like and dislike, suggesting that our eating
habits and food preferences are a result of learned behaviour of food experiences
and not purely taste alone’ (Kamphuis et al, 2015). Research conducted with babies
has identified that as humans we are pre-disposed to favour sweet foods (NHS,
2016) and when considering the natural sugars found in fruits and vegetables this
pre-disposed desire for sweet foods would not be considered a barrier to healthy
eating. However in a country where sugary food is vastly available and advertised
universally this desire for sweet foods becomes a difficulty. Due to the availability
and preference of such foods within society, it has become a cultural norm to snack
on sweet cakes, biscuits or chocolate bars. These high sugared foods can become
addictive and due to the normalisation of these sugary snacks (Aveena et al, 2009) it
is easy to be tempted to favour these choices over healthier alternatives, as a result
through our food choices we can consider how our socio cultural context can
influence and become a barrier to our food choices.
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Through the concept of taste, individual’s choices of food now goes beyond the
physiological need and culture and personal style is introduced. This concept could
be argued as a potential barrier to healthy eating as it can create ‘stereotypes for
people in different societal contexts and cultures as to the foods they should be
purchasing and consuming in conjunction with their life styles’ (Tiffin and Solois,
2012). Subsequently taste could be a difficult barrier to overcome when
implementing strategies to promote healthy food choices, as an individual’s cultural
background is a strong determinant to influencing their diets. Our adopted diets
within the cultural environment we are in varies alongside the range of foods
available, as well as how they should be consumed and taste, therefore it is
imperative to consider how individuals culture and taste plays a role in food choice
(Conner and Armitage, 2002).
Theorist Bourdeiu further expands on this notion through the concept of taste and
food choices in his theory of habitus, his theory argued that all ‘aspects of
socialisation must be considered when thinking about diet as food choices and class
can be reproduced through socialisation’ (Kamphuis et al 2015). The term habitus is
defined as “the way society becomes deposited in persons in the form of lasting
dispositions, or trained capacities and structured propensities to think, feel and act in
determinant ways, which then guide them” (Wacquant 2005, p315).
Suggesting that individual’s within shared social groups and social classes will have
tastes reflected of that social class to distinguish their behaviours from other social
groups. Bourdeiu argued that food choice was a classical way to reproduce habitus
within social classes, his theory suggests that ‘stereotypically working class
individuals would have a higher fat diet than the middle and upper classes’ (Turell
and Kavanagh, 2006) .This theory draws upon previous research highlighted that
lower income groups are shown to have higher levels of obesity and unhealthy
behaviours, using the theory of habitus and social capital it could be argued that
lower income groups are choosing these lifestyle behaviours to distinguish
themselves and differentiate their conventions from other social groups (Kamphuis
et al 2015). Likewise, although taste is linked to economic capital as individual’s can
only afford a lifestyle of what they can maintain, it is also highly related to cultural
capital as an individual’s tastes remain relatively established, regardless of an
16
increase in income and status (Turell and Kavanagh, 2006). For example, it has
been recognised that cultural norms and values around the way in which families eat
differs within different social groups; working class families were more likely to
prioritise food in a functional manner of the family getting to eat in the easiest and
cheapest way possible, whereas middle class families would consider mealtimes to
be an enjoyable experience with a variety of food available that were nutritious and
healthy (Williams, 1995). These findings suggest that how individuals and family eat
and perceive the experience of taste and eating has a distinct relationship to their
social relationships, signifying that culture and social structure can play a huge role
in influencings an individual’s perception of diet and food choices (Abel, 2008).
There is a vast amount of research that has identified how economic capital and
SES can be a barrier to healthy food choice behaviour, however there is little
research that draws upon the relationship between cultural capital and food choice.
Bourdeiu’s theory could potentially offer an explanation as to why strategies aimed at
overcoming SES and poor food choice are making little impact (Williams, 1995).
However despite the recognition of cultural capital and its influence on healthy
lifestyles the lack of research within this area leads to lack of evidence that cultural
capital can be applied to explanations of eating habits. Furthermore the theory
focuses on status and social classes within society and how society is influenced
within these structured, although there is relevance of social class theories within our
modern day society as it draws upon how social processes can influence our food
choices and behaviours, our society now enables more flexibility with habitus (Abel,
2008), due to more fluent movement between social structures within society
therefore it is more complex when considering movement between social processes.
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Urbanisation
Industrialisation, globalisation and urbanisation have all led to rapid changes in our
lifestyles and our diets leading to a significant negative impact on people’s health
(WHO, 2003). The availability of food due to market globalisation has expanded and
we now have more diversity in the choices of food that is available for us to
consume, however this has led to negative consequences in health (WHO, 2003).
The availability of food which could be considered poor nutritional choices has had a
profound impact on the food we consume, high availability of convenient ready to eat
food increases the likelihood of someone buying and consuming that food (Booth,
1989). Poor dietary patterns has led to an increased consumption of energy dense
foods that are high in fat, salt and sugar, the consumption of these foods combined
with decreased physical activity due to the availability of transport services,
technology in the home has all contributed to individuals leading more unhealthy
lifestyles (WHO, 2016).
Consequently the levels of diet related chronic diseases (Non communicable
diseases- NCD’s) has increased and is continuing to escalate particularly within
disadvantaged areas (Macquire and Monsivais, 2016), therefore considering the
effect of a modern day society and how it influences our food choices is essential
when considering barriers to healthy eating. Urbanisation itself has led to a more fast
paced lifestyle where food availability and preparation needs to be quick and
available on the go as well as affordable, despite the availability of fast food
restaurants offerings on lower incomes the opportunity to eat out and individual’s
leading fast paced lifestyles to consume foods on the go, they are impacting on the
nation’s health negatively (Fraser et al, 2010). There has been a dramatic increase
in non-communicable diseases such as type two diabetes, cardiovascular disease,
hypertension, stroke, and some types of cancer, these conditions are leading factors
in premature death and can significantly impact an individual’s quality of life (WHO,
2003). With an already pressured National Health Service recognising the impact
urbanisation has had upon food choices is significant as it is a barrier that is
expected to continue to negatively impact on people’s health.
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Employment
Research has identified that there are patterns in relation to food choice and food
habits within certain professional occupations (Lowden, 2010). The type of hours an
individual works, work stress, commute routine and work environment and conditions
can all play a huge role in limiting or influencing individual’s food choices. Evidence
has suggested that factors such as being a low income professional and participating
in manual labour, shift work and experiencing work stress due to poor working
environments and conditions, all of these factors within low income professionals
have all been associated with unhealthy eating habits resulting in increased levels of
obesity and increased levels of diet related diseases (Antlunes et al, 2010). Lowden
et al (2010) expanded on this theory and conducted research in relation to shift
workers diets and found that there were several factors within this working condition
that were barriers to making healthy food choices. Firstly shift work disrupts the
circadian rhythm which can affect metabolism and energy released after a meal, shift
workers were found to have difficulty in maintaining regular eating habits due to lack
of facilities in the work place, having to eat alone, as well as the disruption of not
eating at regular meal times in the day. Shift workers are also less likely to eat
breakfast as this is to them the end of their working day and when they are most
likely to sleep. Vast amount of research has identified the importance of eating a
healthy breakfast to maintain a healthy metabolism, therefore by not having
breakfast in addition to disrupted sleep patterns they are more likely to have a low
metabolism rate and gain weight easily (Atlunes, 2010).
Urbanisation has led to many people living fast paced lives particularly for those in
employment status and in an occupation where short and infrequent breaks are
available, choosing fast food or ready meals can be understood as they are quick
and convenient (Turell and Kavangh, 2006). The type of employment an individual is
in can therefore be a huge barrier in food choice and thus needs to be considered.
From this perspective it would be insightful to consider how employment status,
occupation and work stress can influence biological factors and become a barrier to
healthy eating, for that reason we can understand and see the relationship between
19
poor dietary choices and how particular occupational statuses can influence these
choices (Anlunes et al 2010).
Knowledge of Nutrition
The knowledge of how diet and nutrition can play a positive and negative role in an
individual’s life is continuously growing (WHO, 2017). However despite the
developing understanding of how food choice is a major detriment of NCD’s within
policy and practice, little has changed in addressing the prevention of these diseases
through diet (WHO,2003). Societies nutritional knowledge and awareness of what is
considered to be a healthy diet has increased (Food Standards Agency, 2007),
educational programmes on nutrition are now taught from an early age in school and
changes in product labelling and marketing campaigns has played a huge role in
developing our understanding of food (NHS, 2013). Yet nutritional knowledge alone
is not enough to overcome the barrier of poor food choices if within our educational
and cultural environment, fast food chains and junk food are still readily available
and accessible.
Nutritional knowledge is ever changing, up until recently the guidelines on a
individual’s diet were based on the Eatwell plate which contained a segment that
contained foods high in fat/or sugar, this information has been revised in the Eatwell
Guide and the fat and sugar food group has been removed in order to highlight to
consumers the role of these foods in a individual’s diet (NHS, 2017). Although this
change in information is positive as it recognises that these foods do not have to be
part of an individual’s daily intake, it also strikes up confusion and mixed
understandings for individuals trying to follow guidelines when the nutritional
guidelines are constantly evolving (Bisogni et al, 2012).
However when considering the nutritional information that is provided can be
irrelevant if individuals do not have the capacity to understand the information they
are provided with. The term health literacy is used to demonstrate how people
understand health messages, within the many health promotion programmes often
20
leaflets, posters will be used to portray these important messages, ‘health literacy is
one’s ability to understand and engage in the dialogue within these messages’
(Nutbeam, 2000) . Many individuals from lower socioeconomic groups have poor
reading abilities thus health messages aimed at targeting the general public may be
too complex. Therefore health literacy may be a major factor in sustaining health
inequalities and individual’s general understanding of what are considered to be
healthy food choices needs to be gained when working on overcoming these barriers
as it should never be assumed that they already have knowledge of food nutrition or
the impacts of nutrition on health (Abel, 2008). Likewise many individuals will low
literacy skills would not feel empowered or competent to ask questions regarding
nutritional information in discussion with professionals. Therefore a good relationship
needs to be built through communication between health professionals and
individuals in order to overcome this barrier to healthy eating (Nutbeam, 2000).
Media
The media plays an important role in how society views certain foods, as well as
changing awareness of food knowledge, therefore it can play both a positive and
negative role in how healthily an individual eats. Within social media there has been
increased preoccupation with cooking and with this focus on food we see the
introduction of many celebrities portrayed eating habits playing a huge role in
people’s food choices (Harris et al, 2009). Health related food knowledge in relation
to celebrity’s promoting their lifestyles can lead to people making heathier food
choices. However it can also be a major issue in reporting conflicting health
messages with certain foods and a misunderstanding of what is considered to be a
healthy balanced diet, as the nutrient content advertised within these foods and diets
often goes against the national guidelines for healthy eating (Booth, 2004). Social
modelling theory further suggests that the influence of media plays a huge role in
influencing society’s dietary choices and suggests that we mimic the behaviours of
others (Robinson and Higgs, 2013).
Advertisements of foods have further been highlighted as influencing individual’s
food choices, furthermore logos and brandings of foods within media advertising are
21
shown to prompt people to make poorer food choices (Nestle et al, 1998), as the
foods advertised are often what is considered ‘junk food’ and the impact of
advertising can promote these foods as well as trigger a desire to eat even when
they are not physically hungry (Harris et al, 2009). We can consider from this brief
exploration that the influence of the media is huge as it influences everyone’s life on
a daily basis and although it can play a positive role in promoting healthy initiatives
globally, in some cases can be dangerous and conflicting in regards to nutritional
knowledge (Daine et al, 2013)
There are many bodies of work that recognise the barriers that individuals can face
when making healthy food choices, SES and inequalities are often focused on as the
primary cause of poor nutritional intake, however the research often focuses on the
issues faced by the individual or the family rather than the wider societal issues that
persist today, therefore further research is needed to consider this factor as a gap in
research when looking to provide effective interventions to overcome poor nutritional
choices.
Section Two
Advances in science and nutritional knowledge have meant that in recent years vast
amounts of strategies and interventions have been introduced in order to try and
help individuals make better life styles choices to improve the nation’s health and
prevent health issues and inequalities. This literature review will now explore some
strategies and interventions that have been introduced in order to promote healthier
eating choices to society.
Packaging/ labelling
The way in which food is labelled and packaged has changed dramatically in recent
years, the new standardised food labels are now displayed on the front of food and
drink products use a traffic light colour code system to display the reference intakes
per portion of food as well as how much of the maximum daily intake a portion of
food accounts for (NHS, 2017). The reference intakes include the amount of energy
(presented in kilojoules (kJ) and kilocalories (kcal) and the amount of fat/saturated
22
fat, sugar and salt. The purpose of the traffic light system that has been recently
introduced in 2012 is to provide a visual aid that informs the consumer if the food
product has high, medium or low amounts of fat, saturated fat, sugars and salt (See
Appendix B).
The new packaging of products was a government initiative aimed at reducing
obesity levels, previous strategies of displaying Guideline Daily Amounts (GDA’s)
were argued as confusing and time consuming to read. The new format therefor
aims to make it easier for consumers to recognise healthier food choices, as well as
to encourage manufacturers to change the ingredients within their foods so they are
not within the red category (NHS, 2013). This system is part of the government’s
efforts along with the department of Health that are working in conjunction with
supermarkets and manufacturers through a programme called the responsibility
deal. The responsibility deal aims to highlight that everyone has a responsibility to
change the way food is produced and to encourage individuals to make healthier
food choices in order to challenge and tackle obesity within the UK.
Despite the aims of the initiative it has its limitations, it could be argued that
providing such a basic colour coding system that it is that it is not enabling
individuals to increase their nutritional knowledge (Temple and Fraser, 2014). It
could be argued that the scheme is providing people with false confidence regarding
their knowledge on food guidelines as it does not encourage individuals to increase
nutritional knowledge.
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Education/schools
The government have recognised the need for nutritional intervention in the early
stages of childhood and education due to high rates of childhood obesity within the
United Kingdom (GOV. UK, 2017). Some of the strategies implemented within
schools that aim to promote healthy eating habits will now be discussed.
There is an early impact of having healthy eating within children as it is essential for
overall good development both physically and mentally (WHO, 2003). An unhealthy
diet such as the consumption of energy dense, sugary and nutrient poor foods and
drinks within babies and children can increase an individual’s likelihood of having a
NCD such as diabetes or hypertension in adulthood as well as being a large
predictor for obesity (Ofsted, 2006). Governments have recognised the vital role of
schools in utilising education and promotions of healthy eating in the early years to
establish healthy eating behaviours that can be learnt and carried into adulthood.
Health promotion within school is essential as it is both a strategy to tackle childhood
obesity as well as a preventative measure to try and prevent obesity and NCD’s
associated with obesity later in life.
One way in which strategies have aimed to overcome this problem is by focusing
interventions at the eating habits of the next generation, by helping young people to
gain the life skills and knowledge they need to live healthier lifestyles (The Caroline
Walker Trust, 2009). Birch and colleagues (1987) recognised that in order to improve
primary school children’s healthy food preferences, experiences and strategies need
to increase availability and accessibility to maximise exposure to those foods, which
will then affect their willingness to taste. The exposure to a variety of different healthy
foods is a strategy schools are now implementing striving towards better food
choices for children’s meals which overall is a great improvement. However this
could be improved through also teaching children how to prepare a healthy meal,
encouraging children to be interested in food preparation and what foods they are
consuming. These are essential skills which are transferable into the family home
and play a positive role in helping children understand food and nutrition in order to
hopefully influence their lifestyle choices as adults (Spence et al, 2013).
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One way in which the government has implemented education in food for children is
through the food provided within school cafeterias. The change to school meals was
introduced and brought in through the Department for Education as part of the
school food standards, School Food Plan implemented in 2015. The plan was
brought in after recognising that many school meals were high is salt, saturated fat
and sugars and negatively impacting on children’s diet, education and overall health.
Regulations became mandatory in all maintained schools, and new academies and
free schools from January 2015. The new school food standards are designed to
make it easier for school cooks to introduce a wide range of tasty and healthy foods
that are low in salt, sat fat and sugar in order to provide children with the best
nutrition and energy for the school day, as well as making meal times an enjoyable
experience with their peers (School Foods Standards, 2016).
Another health promotion strategy introduced is The School Fruit and Vegetable
Scheme which is run within state funded schools in England for children between the
ages of 4-6 (NHS, 2015). The scheme was introduced after research highlighted that
most children are only consuming on average 3 out of their 5 a day fruit and
vegetable intake recommendation, the scheme allows children between these ages
to have one free piece of fruit or a vegetable each day in school. The scheme
recognises that children need the nutrients gained from consuming fruit and
vegetables to maintain a healthy balanced diet, it also encourages children to
recognise the benefit of these foods and identifies that it is just as important to inform
children of the benefit of having a healthy diet as well as providing the resources.
Within Wales however the initiative is not currently running, meaning that there is no
availability of free school fruit or vegetable or snack, instead primary school children
in Wales qualify for free milk in school (Moore et al, 2010). The difference between
two neighbouring countries in what is considered to be most important for children’s
diets; calcium or fibre, again draws attention to how health messages can cause
confusion to society.
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Eligibility based schemes
The government have launched several schemes that aim to promote health to
individuals in lower income groups to aid them in making healthier food choices and
reduce health inequalities. The two schemes that have been chosen to discuss are
Healthy Start and Free School Meals.
Healthy Start is a UK government scheme that aims to tackle inequalities in health
by encouraging individuals within lower income groups who are more likely to
engage with unhealthy dietary patterns to make healthier food choices. This is done
through providing financial aid to purchase fresh and frozen fruits and vegetables,
cow’s milk and infant formula, in addition to information and support from health
professionals. The scheme is means tested which means not everyone is eligible for
the vouchers however it is a strategy that recognises the importance of a healthy diet
right from the start of pregnancy through infancy, aiming to reduce the risk of
communicable diseases in future life as well as providing the families with
encouragement and information of basic nutritional knowledge to improve their
overall health.
Free school meals can be provided by the government in low income families who
meet the eligibility criteria within Wales and children in England are eligible to get
free school meals if they are in reception class or Years 1 & 2 (Gov.UK, 2017). The
system for free school meals for low income families means that the government are
trying to ensure that every child is getting the nutrition needed to prevent inequalities
in both health and education. Within England however it is different and all infants
are eligible for free school meals, this enables equal access to school meals for all
children. However, when children move up through the academic years and into year
3, the free school meals are no longer provided and this could cause problems for
low income families who have relied on the service for many years.
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Sugar tax
Consumption of sugar has shown to be the leading contributor to obesity within the
UK and currently costs the National Health Service (NHS) £5.1 billion per year with
health related illnesses and poor oral hygiene. Despite awareness of the health
consequences sugar can have, most individuals consume diets high in sugar.
Sugary soft drinks have been recognised as a primary cause to members of society
having high sugar diets, as many individuals will consume these on a daily basis
(GOV>UK, 2016). This has led to the government recognising that changes need to
be made in the way it is sold within the UK (GOV.UK, 2016) in order to challenge the
pressures sugar is placing on the nation’s health and therefore health services.
The taxation will be introduced through two levels in 2018; one for soft drinks with
more than 5g of sugar per 100ml and another higher band for drinks with more than
8g of sugar per 100ml. The implementation of the sugar tax is already having a
positive effect on manufactures in reducing sugar content in products, therefore,
may play a positive role in reducing the nations sugar intake and understanding of
sugar within food choices. However many are using the taxation in reference to ‘the
nanny state’, it could be argued that there is an element of control behind the
changes however the drive behind the strategy is not to ban individuals from
consuming sugar, but to draw public attention to practices within the food and drink
industry, reminding consumers of the reality of what they are consuming. It is thought
that this will send out a clear signal of the contents of these products in order to
encourage individuals to make healthier purchasing habits as well as providing the
information available in relation to health consequences (WHO, 2017).
The health promotion strategies discussed have highlighted the need for the
government to encourage healthier eating as essential, in order to try and tackle the
adverse health outcomes of poor nutrition that the nation is facing. Current
programmes discussed are evolving with ever expanding understanding of healthy
eating and nutrition yet obesity is continuing to rise, suggesting that there is a gap
27
within these interventions that is preventing maximum effectiveness within these
strategies.
Chapter 4. Findings
The evidence has been presented to address the question ‘What are the perceived
barriers to healthy eating in the UK and what strategies to encourage healthy eating
are most effective?’ The primary papers selected have been critically analysed in
order to bring together an in depth analysis to answer the research question. The
research process has shown its advantages and disadvantages, by conducting a
desktop study the accessibility of data less ethically challenging has aided the
researcher in accessing relevant literature swiftly, however, qualitative methodology
of critically evaluating data has been time consuming in order to ensure that the
sample studies selected were valid, reliable and relevant to the research question.
There have been several different barriers to healthy eating identified, in addition to
an evaluation of the effectiveness of interventions. Key findings of the five studies
selected will now be reported, the results have been organised into several key
themes. This method of data interpretation has been selected as qualitative methods
often use themes in data analysis in order to ‘define the nature of each theme and
the relationship between themes in order to address the research question being
undertaken’ (Clarke and Braun, 2013).
Pechey and Monsivais (2016) used quantitative research methods within their study
in order to explore the extent to which food expenditure can mediate social
inequalities within healthiness of food choices. The research used multiple
regression analysis to explore the pathways linking SES, food expenditure and
healthiness of food choice in order to examine the potential role of expenditure as a
mediator of socio economic inequalities in healthiness of food choices. Data was
gathered from the Kantor World Panel UK Household Survey (2010), within this
survey the 24, 879 participating households provided recorded information of all food
and non-alcoholic beverages bought over a 52 week period including which retail
supermarket the foods were bought from. The data from the survey also included
28
sociodemographic data of each household and the region of residence in order to
provide representative data of the UK households participating. Ethical approval was
not required as the study was analysing de-identified existing data. Pechey and
Pablos (2016) findings suggest that food costs play an important role in socio
economic inequalities with healthiness of food choices, data identified that
households within the highest quantile had increased expenditure and increased
percentage of healthy foods and lower quantiles fell into lower expenditures and
higher purchases of unhealthy foods in addition to lower percentage of fruit and
vegetables. Mediating analysis showed that supermarket choice was further
associated with expenditure. Limitations of the study consisted of researchers not
considering the participant’s health attitudes and knowledge within food choices.
Additionally, the household data indicated low volumes of food and drink suggesting
that households were unreported. The study identifies a bi-directional relationship
between inequalities and healthiness of food choices and evaluates likely range of
factors that contribute to the motivations of food purchases, suggesting that lower
social groups are more likely to prioritise cost rather than healthiness of foods, thus
cost reduction of healthier food could be one step to challenging the relationship
between SES inequalities and health.
Robinson and Higgs (2013) used quantitative methods within a study that explored
social modelling theory on food choices. The study consisted of 105 female student
participants from the University of Birmingham and aimed to consider how eating
with others can influence individuals food choices. Due to the nature of the question
the research from participant recruitment was advertised as examining mood and
consumer research on eating attitudes. Ethical approval and informed consent was
obtained for each participant. The study consisted of three experimental condition;
unhealthy food, control and healthy food group to which participants were randomly
assigned. Within each group a confederate who was similar to sample population
chose an unhealthy or healthy lunch from a buffet, prior to participation participants
were asked to abstain from eating 2 hours prior to experiment. ANOVA was used to
analyse the groups to examine if eating with a healthy or unhealthy confederate
influenced the participant’s food choices. Findings reported that the number of grams
29
from a high energy dense food (e.g. a sandwich) remained the same throughout
groups, however participant’s in the unhealthy food group consumed higher energy
dense foods than both the control and healthy food group and alternatively
consumed less energy dense foods. The results observed no main effects on intake
of high energy dense foods suggesting that the presence of eating partners can
influence food choice but this is limited and social modelling theory does not
currently provide a strong evidence base for food choice. However the findings do
suggest that intake of healthier foods can be influenced, suggesting that social
modelling theory can be used to encourage healthy eating. Limitations on study
design were recognised due to the lack of selection of healthy foods within the study,
further limitations are the generalizability of the study and it failed to include male
participants and the settings within the study were not natural eating environments
which could have influenced the results.
Pridgeon and Whitehead (2013) conducted a qualitative study using 23 participants
that were staff from two public sector workplaces, the study aimed to provide an in
depth understanding of the perceptions and views of staff on the drivers as well as
barriers to the promotion and consumption of health food choices within two
workplaces. This provided information on workplace structures and how they
influence food choice, running of business, facilities available and workforce
demographics. The study adapted a purposeful strategy sample, to ensure the
representation was transferable by selecting a sample of employees from different
roles, genders, age and contracted hours of work. Qualitative methods were used to
consider complex questions about food behaviour to staff. Ethical approval and
informed consent was gained. Framework analysis was used to analyse data and
develop and explore themes. Findings reported four themes; ‘Workplace structures
and systems’ were reported as a barrier as change to demographics of workplaces
there are more sedimentary roles yet canteens are still catering for manual labour
calorific foods, furthermore the canteens were running as a business preferring to
produce unhealthier foods that were cheaper and more likely to sell -lack of facilities
and work pressures often meant that staff skipped lunch all together and were more
likely to snack at their desk . ‘Cost, choice and availability’ were viewed as poor and
unimaginative by staff, whereas canteen staff felt there was a variety of choice,
30
healthy foods were found to be less likely to be purchased due to higher cost.
‘Personal Vs Institutional responsibility’ highlighted that most staff felt it was their
responsibility to make healthier choices, however some staff felt as a public sector
organisation, healthier food choices should be promoted in the workplace. Lastly
‘food messages and marketing’, lack of facilities meant that vending machines were
implemented which in turn increased staff snacking and encouraged staff to skip
breaks and eat at the desk. Limitations were recognised due to the small size of the
sample as it may not be a representative across the whole workforce. Secondly all
participants were white British, although this was representative of the local
population results may not be generalizable to populations outside of Barnsey.
Moore, Murphy, Tapper and Moore (2010) investigated the influences of health
promotion programmes in the UK that influence Local Education Authority (LEA) and
School Policy on the availability of school foods, their study further explored the
influence of professional practices within schools on food choices of school meals. A
qualitative methodology was undertaken which consisted of the researchers
examining a case study from a LEA in Wales, to explore the uniformity of national
policy and local policy. Semi- structured interviews were conducted, the sample
consisted of 11 schools in which 11 head teachers and 10 catering staff were
interviewed. Ethical approval and informed consent was obtained before interviews
were undertaken. The study found that schools were reflective of nutrient contents
outlined within national policy for school meals, however the LEA and school policies
were often influenced by other competing interests. Findings reported that schools
often prioritised child and parental preference over healthy eating to ensure school
meal uptake, suggesting that policy interventions were limited in effectiveness due to
low level factors effecting implementation of national strategies. The research
highlights that strategic relationships need to be built to reduce conflict over
nutritional content and school meal uptake. Similar findings have been found in
studies across schools in the UK, however this study is limited to its transferability as
it was conducted within one LEA which limits the applicability of findings to Wales.
Sacks, Rayner and Swinburn (2009) used quantitative research methods to examine
the impact of front of label traffic light labelling system on influencing consumer food
choices, the data provides information on the effectiveness of a current health
31
promotion intervention that was introduced by the Food Standards Agency (FSA) in
the UK in 2006 (FSA, 2007). The methodology used supermarket point of sales data
from a major UK retailer and sales were focused on chilled pre-packaged meals and
sandwiches as they are products that are nutritionally diverse and contained the
greatest number of products with the traffic light system. The products tested were not
on offer and not new to the store, for ethical purposes the name of the retailer was
kept confidential. Sales were compared to 4 weeks prior implementation of the system
and the 4 weeks following the new labelling. Researchers used a linear mixed model
to examine: percentage of sale in each category compared with the relative
healthiness of the product using Spearmans rank correlation. Limitations of the study
recognised that only a small amount of products were monitored over a small
timescale following implementation, researchers were further unable to account for all
factors that may have influenced sales. The findings reported that sales of both food
categories following the new traffic light system showed no association between
healthiness of the products and change in sales measured. Further findings reported
that in all socio demographic groups the healthier products increased in sales more
than the sales of unhealthy products, however the sales of less healthy products
increased more than the sale of medium healthy products suggesting that there is no
association between the implementation of the system and healthiness of food
chosen.
Within the five study’s findings, the researcher has identified three key emerging
themes: Cost, Socioeconomic status and Implementation. The themes identified
provide further analysis of the factors identified within the study findings, the three
themes provide a modest contribution to the understanding of the research question,
however it is recognised that there are many further factors that could be considered.
Cost
The cost of healthier food has been identified as a barrier to aiding healthier food
choices, Pechey and Pablo (2016) supported previous research that suggested
lower household income is associated with poorer diets, these findings correlate
with levels of obesity and non-communicable diseases being higher within lower
32
socio economic groups. The findings suggested that individuals with lower
expenditure allowances for food shopping are more likely to prioritise cost over
healthiness of the food choices. Suggesting that cost is a significant contributor and
influence to unhealthy eating for individuals within the UK. Pridgeon and
Whitehead’s (2013) findings further contributed to this theory of financial motivators
in offering perspective from food manufacturers- who from a business outlook,
focus on the profit of food and what sells rather than promoting healthier food
choices. Moore et al (2010) produced similar findings in recognising that policy
interventions were often failing at implementation level due to conflict between
prioritising school meal uptake and children’s food preferences over nutritional
values of food set within national policy. The data identifies a serious concern over
attitude of food production where manufacturers and even schools are facing
extreme pressure to prioritise cost and profit over public health, these findings draw
attention to the fact that challenging attitudes in relation to health consequences
related to poor diet need to be made, as well as ensuring that the schools and
businesses can still run successfully.
Researchers have suggested that lowering the cost of healthy foods would enable
people to make better food choices (Macquire and Monsivais, 2015), however it
could be argued that by suggesting cost alone is the factor that encourages
unhealthy diets, removes responsibility away from individuals and portrays structural
issues as the major problem within society. Undoubtedly from research evaluated
structural issues exists and do play a large role with influencing food choices,
however there are healthier alternatives that are easily identifiable through new
packaging systems that are available at low prices, yet no drastic change has been
recorded (Sacks et al, 2009). These finding suggest that there may be a need to
inform individuals and guide them on how to make healthier changes and change
food purchasing habits to same price healthier alternatives.
Giskes et al (2005) found that individuals with high food expenditures and low food
expenditures can spend the same amount of money within the same supermarket
yet the individuals from low SES will have poorer food choices. Therefore it could
be argued that reducing the cost of healthy foods alone may not be enough to
encourage healthier choices. Further research is needed in order to identify
33
strategies that can encourage and promote ways to shop healthier within the same
spending range, highlighting that health promotion messages are not as effective
as they could be due to lack of communication on how to eat healthier on lower
budgets.
Socio Economic Status
Many researchers often dismiss the notion of social classes in modern society,
however the findings clearly identified a link between health inequalities that different
groups in society can face due to demographic factors (Macquire and Monsivais,
2015). Giddens (2013) suggests that in our modern society the social structures
enable individuals to have more fluidity between different class systems, from this
perspective intervention on a societal level could mean that the barrier for low
sociodemographic groups of expenditure and cost of healthy food choices would be
lessened. However despite national interventions aimed at reducing inequalities,
policies are failing. In an attempt to reduce the association research has looked
extensively at the understandings of health inequalities individuals are experiencing
in low socio groups, of particular reference is the lifestyle behaviours participated in
such as poor food choices that contribute to these health inequalities. Pechey and
Monsivais’s (2016) findings have strongly identified the link between low SES and
unhealthier food choices, however within the data there is a lack of consideration
around how much control these individuals have on food choice. Glasser (1998)
have drawn attention to engagement in unhealthy behaviours as a consequence of
lack of choice. The study recognised the influence of financial motivators and
reported data on how supermarkets are categorised by cost and patronized by
individuals based on difference SE groups. The study identified that 57% of people
within low SE groups patronized low cost supermarkets, however failed to explore
why the rest of the lower groups were not patronizing low cost supermarkets. The
findings could suggest that as discussed previously in the literature review,
individuals in deprived areas may not have the access or facilities to patronize low
cost shops, which is consequently restricting choice of supermarkets, expenditures
and ultimately an influence to prioritise cost rather than healthiness of purchases.
34
Signifying that structural factors are major barriers to healthy food choices within the
UK that need to be addressed.
Furthermore the evidence of SES on food choice in relation to health promotion
messages and interventions has shown poor impact at intervention level. Low SES
groups have been identified to have poorer literacy skills (Giddens, 2013) therefore
health messages on food choices may not be fully understood in terms of the potential
impact on health. Nutritional guidelines are constantly evolving and are often complex,
therefore professionals need to adapt language to aid individuals from different
demographic groups to make informed healthier food choices. Further research is
needed in gathering effective communication skills for professionals on all levels to
ensure that the health promotion messages regarding food choice are heard across
all different demographic groups.
Implementation
The findings considered and evaluated the effectiveness of two studies that looked
at diet related policy interventions that are being implemented within the UK; Traffic
light system food labelling and healthier school meals. The results highlighted that
there were no key findings in the effectiveness of these interventions, suggesting
that there are issues occurring at implementation level that need to be considered.
The traffic light system is implemented at population level in order to create an
environment where nutritional tools can aid people to make healthier choices at an
individual level. Pridgeon and Whitehead (2013) recognised that dietary
interventions are most successful when they are applied within a supportive
environment. There is no doubt that the new food labelling system is a step in the
right direction, however it has shown little impact (Sacks et al, 2009). Changes in
food packaging are used to promote healthier choices but also to remind
consumers of the reality of what they are purchasing and to draw attention to the
effects of marketing and commercial advertising on food purchasing behaviour. As
despite the improvement in classifications of foods, large marketing companies are
still producing and selling high quantities of unhealthy food.
35
It could be argued that this is due to the environment it is being advocated in,
where the strategies implemented are being undermined by market advertising and
availability of cheaper unhealthy alternatives that are not reflective of the strategy.
Pridgeon and Whitehead (2013) recognised that despite the improvement in
awareness of nutritional guidelines and consequences of unhealthy diets the
facilities and food marketing that were in the workplace were not representative of
their perspectives and were a barrier to changing food purchasing behaviours.
(Sacks et al, 2009) found no relationship between the new format of labelling and
healthier food choices, limitations consisted of not being able to account for all
influences on food choice, however one influence that would be consistent within
every supermarket is the lack of discount promotions on fresh food and high
discount promotions on unhealthy food and drinks which could arguably affect the
effectiveness of this strategy (Lowden, 2010). Limitations of the findings are
recognised also due to the date of the study, Traffic light labelling system may now
be considered more effective with more awareness of the system occurring,
however the researcher identified little evidence that evaluated the impact of the
strategy, suggesting there is need for further evaluation.
Moore et al (2010) reported findings that nutritional policies were not adhered too, due
to several undermining factors that reduced effectiveness at implantation level. The
impact on educating young children and implementing healthier food choices within a
school environment have shown to have many benefits such as higher concentration
levels, increased energy for the day and the promotion of healthy foods at young ages
increases the likelihood of healthy food habits in adulthood (School Foods Standards,
2016). Education on nutrition is seen foremost as a prevention strategy to reduce the
already high levels of obesity and diet related diseases from increasing in future
generations. Yet despite the evidence of the benefits to healthy food within schools,
implementation of the government policies has shown to be poor (Moore et al, 2010)
and school meal uptake is shown higher priority than health.
Again within this theme of implementation being poor on health strategies the issue
of conflict between business profitability versus health promotion is evident,
suggestive of that within society and culture of the UK something has gone wrong
in which profit and financial gain is more favourable than the nation’s health.
36
Chapter 5.Discussion
In addition to the findings supporting previous research on how SES and Cost can
act as barriers to healthy eating, they have further identified that effectiveness of
interventions evaluated have been poor. The researcher has identified a gap in the
research where factors such as culture and taste have been recognised as
underlying barriers within the findings, however are not at the forefront of health
promotion interventions. Factors such as taste and the types of foods individuals
consume are embedded into society’s culture, one example would be the ever
expanding availability of fast food chains. These types of food manufacturers are
producing calorific high density foods that are lacking nutritional value and
undermining nutritional policy, yet our society has become accustomed to the use of
these chains in everyday life and these foods are advertised as desirable extensively
(Bourdieu, 2010). This brings us back to Bourdieu’s notion of certain social classes
desiring and consuming certain foods as they can represent their social class and
culture (Kamphuis et al, 2005). The researcher has identified a gap within the study
regarding culture as a barrier, the data provided a strong focus on structural
influences as barriers, however little evidence on individual preferences due to these
factors or how to change the customs we have become used too and desire, as the
cultural norms attached to foods determine the availability of foods and the social
meanings that are attached to them. Further research is needed on how
interventions can address such barriers at both individual and societal level.
Furthermore the researcher identified the lack of data looking at social influences on
food choice, Robinsons and Higgs (2013) found no link between social modelling
and food choice, however Pridgeon and Whitehead (2013) found that workers
perceptions on implementing healthy eating were more likely to succeed if people
within the family home were supportive and participating. Research has identified
how developmental and familial influences can have a profound impact on food
choices throughout life course (Devine, 2008). Further research is needed to identify
a way in which health promotion interventions can aid families as a whole to make
different lifestyle choices rather than focusing on the children, or parents in their work
37
environment, it is likely that more success could be seen if interventions were to
target the families as a whole rather than as separate individuals.
Chapter 6. Conclusion
Food choices are made several times a day, every day by individuals, something as
simple as choosing what meal you’re having for dinner which is often considered to
be an individual choice is widely influenced by many different factors. Recognising
the importance of raising consumer awareness of food choices is vital for public
health promotion and prevention in health and social care services. Findings from
the studies analysed has supported research that has drawn upon obesity levels and
health inequalities that individuals from low socio economic groups are experiences
in relation to food choice (Pechey and Monsivais, 2016).
To conclude the findings from data analysis highlights that there is no single
explanation as to why some individuals in society make healthy or unhealthy food
choices. The research has recognised that cost and SES have a bi-directional
relationship with poorer food choices, highlighting that there are major inequalities
between socio economic groups and food choice which is contributing massively to
poor health outcomes and exacerbating the obesity epidemic (Tiffins and Solois,
2012). The link between SES and food choices has been extensively researched and
despite national policy and intervention at a societal level, initiatives aimed at
promoting healthier food choices are failing to make a noticeable impact on the
nation’s diet- signifying that the effectiveness of the strategies in place need further
evaluation and consideration. This research paper has identified and explored a range
of barriers that can be associated with individual’s food choices as well as exploring
the effectiveness of two strategies that aimed to overcome aspects of the barriers
discussed.
The research has made a small contribution to the ongoing interest of how individuals
can be encouraged to eat more healthily and what barriers individuals face that need
to be overcome. Limitations have been recognised, due to the small scale of the
38
undergraduate study the aforementioned barriers have not been extensively
investigated into the combination of factors that have been identified within this paper.
The barriers that have been identified and discussed within this study have a flowing
relationship between themes, therefore intervention on a public health level would
need to be holistic and cover all perspectives on the influences of food choice in order
to be effective long term. Further exploration is needed to consider the influence of
culture, taste and communication as barriers to healthier food choices.
Chapter 7. Recommendations
1. The researcher would argue that culture and taste play a huge role in
healthy food choices and often fail to be a factor implemented within healthy
eating
strategies.
Recommendations
for
strategies
to
implement
interventions based on the influences of these barriers may be more
successful in aiding change, however it is recognised that to change culture
on a societal level would require drastic action and this would be a difficult
task to undertake.
2. Promoting healthier, more reasonable purchasing habits is not just a matter
of educating individuals but also of sending clear signals for the following
purposes; to offer moral support for changing consumer behaviour and to
remind consumers of the reality of what they're consuming. However the
over provision of information resources alone is not enough, it is more
important to focus on individual’s resources and how they are able to create
health rather than the classic focuses of risks, ill health and disease
(Lindstrom and Eriksson 2006). More research is needed in order to
demonstrate how to shop resourcefully and healthily as it would be
ineffective to provide information without showing them how to utilise this
information.
3. Furthermore it is recommended that for a health promotion perspective,
interventions would prove to be more successful if attitudes on portraying
healthy eating were edited, terminology and labelling of foods either healthy
and unhealthy can sometimes have the opposite effect and make unhealthy
39
foods more desirable to individuals, furthermore it could be argued that
through labelling foods healthy and suggesting you have to eat so many
portions of fruit, vegetables, proteins etc. is making eating a chore rather
than an enjoyable and socially engaging experience.
40
Chapter 8. Reflection
Before undertaking this study the researcher has some basic secondary research
skills, however over the course of this research project those skills have greatly
improved. The research process has been a thought-provoking and interesting
experience, however not without its challenges. The researcher has recognised the
great importance of time within this study. The analysis of secondary data within the
research question brought about a broad scope of data available, this brought about
challenges of time keeping where the researcher had to ensure prioritisation of
literature relevant to the question with the realisation that it was not physically
possible to analyse all the data presented. This particular challenge arose during the
literature review and led to the researcher underestimating the time needed to
conduct this chapter of the study. This is turn highlighted the importance of inclusion
and exclusion criteria to ensure that results were reliable, relevant and time was not
wasted. Additionally with the vast amount of data available the researcher faced
challenges in exceeding the word count which then creating further work in reducing
the word count.
If the researcher was to undertake this study again a stricter timetable would be
created to try and ensure that the research done prior to the study would be done in
the most effective manner and set strict guidelines within each chapter for word
count in order to utilise time more effectively.
Despite the initial struggles of time management within the early stages of the
research process, the research process has enabled the researcher to greatly
improve time management and literature searching skills. The overall learning
experience brought from this study has been challenging and has created a
rollercoaster of emotions throughout the process. However persisting and choosing a
topic of great interest and enjoyment has enabled the researcher to feel great
achievement on the completion of this study and value the experience on a personal
and professional level.
The research question has provided new insight and consideration into an already
existing topic of interest of the researcher and the researcher’s knowledge on
41
barriers to food choice and effectiveness of interventions has grown immensely. With
this gain in knowledge a new appreciation for the importance of health promotion in
relation to food and diet has been gained.
In addition working with David Miller has taught the researcher to always consider
alternative perspectives and his insight and respected guidance has enabled this
experience to be enjoyable and valuable experience as both a student and young
professional.
42
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Appendix B- Front of pack nutrition label example:
52