POR Registration Number: 116-16
PSPC Contract Number: HT372-16-4602
Contract Award Date: March 1, 2017
Delivery Date: April 18, 2017
Contracted Cost: $148,137.35 (taxes included)
Final Report
Prepared by: Corporate Research Associates Inc.
Prepared for: Health Canada
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For more information on this report, please email: por-rop@hc-sc.gc.ca
Corporate Research Associates Inc.
Contract Number: HT372-16-4602
POR Registration Number: 116-16
Contract Award Date: March 1, 2017
Contracted Cost: $148,137.35 (taxes included)
As part of its mandate to develop and promote evidence-based dietary guidance, Health Canada is currently in the process of revising Canada’s Food Guide. As part of its investigation, Health Canada has commissioned Corporate Research Associates Inc. to conduct qualitative research to better understand how Canadians use healthy eating information to ensure dietary guidance is delivered to the right people in the right format at the right time. The following provides an overview of audiences and the research methodology used for each:
Members from the general public included three audiences, namely youth 16 to 19 years old and adults 19 years and older, divided in two segments (those who have marginal health literacy with scores of less than 4 on the Newest Vital Sign (NVS), and those with adequate health literacy, scoring at least 4 on the NVS). In each of Toronto, Montreal, Winnipeg, and Moncton, one group was conducted with each audience, totalling 12 traditional focus groups (conducted from March 27 to April 5, 2017). Discussions in Montreal were conducted in French, and conducted in English in all other locations.
Health professionals and intermediaries included eight specific audiences: registered dietitians (3 audiences: public health, private practice, and administrative/food service), teachers (2 audiences: elementary and secondary level), community educators, public health nurses, and physical activity specialists. In each of Toronto and Montreal, eight mini-groups were conducted (one per audience), totalling 16 groups across locations (conducted from March 28 to 30, 2017). Discussions were conducted in English in Toronto and in French in Montreal.
Policy makers included individuals identified by Health Canada, with nine in-depth telephone interviews being conducted from March 31 to April 6, 2017.
Caution must be exercised when interpreting the results from this study, as qualitative research is directional only. Results cannot be attributed to the overall population under study, with any degree of confidence.
I hereby certify as a Representative of Corporate Research Associates Inc. that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Directive on the Management of Communications. Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.
Signed:
Margaret Brigley, President & COO | Corporate Research Associates
Date: April 21, 2017
Findings of the Focus Groups on Use of Healthy Eating Information suggest that Canada’s Food Guide, though recognized as a well-respected authority on healthy eating, is considered out of date and lacks relevance to today’s population. While results underscore that Canada’s Food Guide has clearly helped to form a broad foundation of public perceptions towards healthy eating, it is considered a prescriptive tool that directs what people should do without providing any assistance on how to do it, as well as lacking relevance to changing lifestyles and eating habits. At the same time, there is still a need for strong, unified recommendations to guide public education and policy development on healthy eating.
General Public
Focus group discussions with the general public reveal that eating behaviours have changed, with less of a focus placed on healthy food choices and eating habits. Participants consistently described a rushed and busy life, where meals or food consumption are typically scheduled around daily calendars, rather than activities scheduled around mealtimes. Eating seems to have become more of a chore or required task, with less time set aside for planning, preparing and eating meals.
Healthy Eating Behaviours and Perceptions
The frequency of meals is primarily driven by participants’ schedules, whether it be school schedules, work schedules, sleep patterns, or their families’ competing timetables. At the same time, what may have historically been considered traditional family values (i.e., the entire family eating together at a table in the evening) are not necessarily aligned with today’s reality. Indeed, having the entire family eat together at a table was generally an exception rather than standard practice among participants, especially for young adults and those with lower levels of health literacy. Interestingly, participants’ eating behaviours were often in contrast to their stated belief, suggesting that their current eating behaviours do not necessarily reflect their ideal.
Perceptions of healthy eating are generally consistent across audiences and locations. The concept of ‘healthy eating’ is grounded around the premise of Canada’s Food Guide, and is primarily understood as a balanced and varied diet, with limited processed and fast foods. Without exception, fresh food (fruits and vegetables), and locally grown or natural food are deemed to be healthier than processed food. At the same time, the inclusion of additives, steroids, and genetically modified foods is considered problematic. Healthy living also extends beyond food to being active and adopting a healthy lifestyle. Ultimately, it was felt that healthy foods positively contribute to the body’s functioning, while unhealthy foods negative impact a person’s overall health.
The general public consistently and accurately articulated what factors positively and negatively contribute to healthy eating. That said, despite their apparent knowledge, many concurred that their behaviour often contradicts what they know, primarily because of a lack of time, lack of willpower, and lack of ability to make change by not knowing how to apply their knowledge. In essence, they often choose the ‘easy’ and less healthy option because of their life situation or because it reflects the path of least resistance. Despite the perceived inabilities of many to make healthier lifestyle choices, increased knowledge and better understanding of the importance of healthy eating habits are deemed essential across audiences and locations. Consistently, it was felt that it is imperative to tell people why it is important to eat healthy and how they can easily impact change.
It appears that most members of the general public do not base their choice of food on established nutritional guidelines and recommendations, but rather choose their food most of the time based on price, taste, familiarity and availability. Across locations and audiences, findings clearly show that members from the general public generally do not actively seek information related to healthy eating, unless motivated to do so by personal circumstances, including such things as disease, chronic health conditions, allergies, or a specific interest in health or fitness. Those who do look for information on healthy eating do so out of necessity, rather than by choice. As such, there appears to be a continued need for public education campaigns about healthy eating, as well as positioning recommendations to be actionable and easily incorporated into today’s eating habits.
Information Classification
Group discussions revealed three distinct segments within the audiences under study when considering the current use of healthy eating information. These included those who are needs-based information collectors, health-conscious information gatherers, and passive information receivers. Accordingly, each segment’s use of information varies considerably. Needs-based information collectors generally have or live with someone who has a chronic health condition or disease that requires attention, and as such, they place a high degree of attention on food selection. Health-conscious information gatherers have a focus on their personal health, with their interest often driven by weight, body size, or fitness. They are most interested in food content or composition information, including protein, carbohydrates, sugars, and sodium, as well as paying attention to caloric intake. Finally, passive information receivers generally do not seek information on healthy eating to assist with their food choices.
With a few exceptions, most people have an interest in healthy eating information, but at a simplistic or holistic level that holds personal relevance, rather than looking for numeric details (be it calories, daily allotments or portion size). Instead, there is a preference for general guidance on what people should do, why they should do it and how they can do it. Indeed, when considering information on healthy eating, participants across locations and audiences prefer to get advice with a task associated with it that allows them to effectively make changes in their eating habits based on their lifestyle. The provision of realistic tips for healthy snacks or ideas on how to create quick and healthy meals within a limited budget was endorsed and welcomed. In addition, the ability to customize information for themselves holds interest across audiences. Undoubtedly, the internet will play a key role in the provision of such information both as an information resource where the general public can access helpful information, and as a social media tool where they can share useful advice and direction with others.
When asked which resources are considered most trustworthy or reliable on the topic of healthy eating, participants first named health practitioners, followed by media, with television, talk shows, and the Internet (in general) being consistently mentioned. While the Government of Canada was generally not spontaneously mentioned as a regular source of information on healthy eating, it is regarded as a reliable and trustworthy resource that plays an important public education role. Given the general public’s limited interest in seeking out nutrition information, findings suggest such information should be made available to them in a format that is simple to understand and easy to access, with a preference for disseminating information where it is consumed (e.g., television, internet) and where food decisions are made (e.g., grocery stores, schools, restaurants).
Health Professionals & Intermediaries & Policy Makers
The roles of various health professionals / intermediaries varied notably both across and within each audience type. Individual consultations are more customized to clients’ needs, while group education tends to include broader health concepts and recommendations. Moreover, the need for information varies by audience and their respective use of healthy eating information and advice (whether an end-user or an intermediary). Despite a diversity of goals being identified by intermediaries and health professionals based on their respective roles, most aim to help with the adoption of healthy eating behaviours and the prevention or healing of specific illnesses or conditions. Educators often referenced how they created their own tools or games from a variety of collected materials to teach children about healthy eating.
Policy development also plays various roles, from raising public knowledge about healthy eating, to establishing guidelines for the consumption of healthy foods within schools, daycares, recreational centres, hospitals, and long-term care facilities. Not surprisingly given their role, policy makers aim to establish guidelines and sound healthy eating habits to guide food choices made by the general public and administrators of publicly-funded institutions.
While participants recognized the value of the work they do, the promotion and education of healthy eating is challenged by the public’s socio-economic conditions, limited food knowledge, a resistance to change, perceived influences of the food industry, and institutions’ budgetary restrictions (e.g., schools, daycares, hospitals). Similarly, healthy eating policy development and implementation is challenged by both internal organizational limitations (limited resources and political priorities), and external influences. The need to increase public education regarding healthy eating behaviours is clearly recognized across audiences.
To varying degrees, information is relied upon by intermediaries, health professionals, and policy makers. All recognized that there is a wealth of information available which can make it difficult to identify credible sources. As such, it is not surprising to note that participants are interested in a centralized source of reliable and up-to-date information on nutrition. It also speaks to the need for materials that are flexible, simple, attractive, and highly actionable, to provide educators and communicators with tools to effectively engage the public.
Across audiences, most information gathering by participants happens online, either through the use of a search engine, or on specific websites or blogs. Print materials are also useful, particularly to give to the end users as a quick reference. A large part of the information search is conducted to enhance intermediaries’ and health professional’s knowledge for their discussions with patients or clients. There is a reliance on public sector sources, international organizations, and specialists who share their opinions on personal websites or blogs.
Canada’s Food Guide is also used across audiences, although to varying degrees. Primary level teachers make the greatest use of this tool, as its teaching is incorporated into the curriculum. That being said, it was mentioned that there lacks proper educational materials to teach Canada’s Food Guide to younger children. At the same time, the recommendations for children are deemed as targeting an age-group that is too broad. Policy makers are also likely to rely on the recommendations it includes to develop their own policies or to guide the development of more tailored recommendations. In general, the Guide is used because it is the only recognized source of national nutrition guidelines.
That being said, the Guide is criticized for being outdated in both its content and recommendations, and for perceived influence by industry. The concept of precise food measurement to teach food portions is deemed irrelevant, with the use of an imagery or illustration (e.g., palm or hand, thumb, fist, plate image) or using actual props, being most common among intermediaries and health professionals when providing general education on healthy eating. The Guide also lacks an appropriate representation of ethnic foods now available in Canada, which makes it look dated and lacking in relevance. Overall, there is a desire among intermediaries, health professionals and policy makers, to update the Guide and have easy access to supporting resources that are more closely aligned with how people use and interact with healthy eating information today.
In terms of conveying the concept of ‘good’ and ‘bad’ food, categorizing foods based on the frequency of consumption (e.g., foods to eat frequently, occasionally, or rarely) appears most appropriate and is currently applied by many. The idea of food variety (i.e., ensuring a variety of items on the plate) is also an important concept currently being used. Other concepts related to nutrition, such as calories and energy consumption, are rarely introduced in public education, and are primarily used in professional counselling to treat an illness, address a health condition or as part of a physical training regimen.
In general, policy development directed at the general public or community organizations uses knowledge regarding nutrition trends and broad recommendations. By contrast, policy development and implementation directed at meal planning in licensed or educational / health facilities require more detailed nutritional information and guidelines.
It should be noted that the food industry is viewed as having a strong influence on public organizations’ food choices and on the general public’s taste preferences, in addition to being perceived as influencing Governments’ recommendations on nutrition. This situation makes healthy eating policy development challenging. It also makes the work of intermediaries and health professionals more difficult, given the prevalence of junk food, and the perceived misinformation circulated by industry.
At the same time, increased public interest for topics related to food consumption and production was identified as helping with the development of healthy eating policies. The same can be said for having a single reference (i.e., Canada’s Food Guide), and increased knowledge sharing and collaboration across jurisdictions, are important facilitators supporting policy development and implementation.
Finally, evidence-based research is of paramount importance for health professionals / intermediaries, although this information is not related to the end audience. Likewise, understanding the scientific rationale supporting recommendations is valued by policy makers to support their decisions, although it is not consistently referenced in policy documents. Having access to such information is deemed of great importance, but more so as a separate piece for internal reference, rather than for distribution.
As part of its mandate to develop and promote evidence-based dietary guidance, Health Canada is currently revising Eating Well with Canada’s Food Guide and related materials used to communicate healthy eating concepts to the general public and stakeholders. Canada’s Food Guide is currently used as an education tool and a policy tool, and includes recommendations on the amounts and types of foods that make up a healthy eating pattern. As a policy tool, Canada’s Food Guide provides a consistent, science-based foundation for healthy eating policies and programs across Canada.
A previous assessment of Canada’s Food Guide conducted by Health Canada demonstrated high levels of integration into policy, programs and resources, as well as high levels of awareness. That said, stakeholders reported that Canadians are not fully applying recommendations found in the Food Guide. Health Canada also reported that an evidence review of dietary guidance further confirmed that the Food Guide is no longer meeting the varied needs of the different audiences who use it, particularly in terms of the level of detail provided, and the manner in which concepts are communicated.
Heath Canada is currently working on revising Canada’s Food Guide to reflect the latest scientific evidence and to enhance its relevance to the general public and stakeholders. To better understand the general public’s and stakeholders’ use of healthy eating information and guidance to improve relevance of future guidance, Health Canada commissioned Corporate Research Associates Inc. to conduct qualitative research with key audiences. Findings from all related research will help ensure that Canada’s Food Guide and its related materials provide the right information, to the right audiences, in the right format. The research examined Canadians’ and stakeholders’ healthy eating habits, and their patterns of communications or interactions with healthy eating information.
More specifically, the research objectives included, to:
This report presents a high level executive summary and description of the detailed methodology used, the detailed findings of the focus group discussions and in-depth interviews, and a series of recommendations stemming from the research findings. The working documents are appended to the report, including the recruitment screener and the moderator’s guide.
Target Audiences
There were four target audiences for this study, namely:
Research Approach
A mixed qualitative approach was used to reach the four audiences, as described below:
General Public (both youth and adults)
A total of 12, in-person focus groups were conducted, three in each of the following cities: Toronto (March 27, 2017), Montreal (March 28, 2017), Winnipeg (April 3, 2017) and Moncton (April 5, 2017). In each location, one group was conducted with youth 16-19 years old, while two groups were conducted with adults, including one with those deemed as having marginal health literacy (scoring less than 4 out of 6 on the Newest Vital Sign) and one group with adults considered as having adequate health literacy (scoring at least 4 on the Newest Vital Sign). Each group included a mix of sexes, household incomes, education levels, as well as a mix of cultural backgrounds and Indigenous peoples representation, where possible.
In each group, a total of ten individuals were recruited, totalling 120 recruits. Across locations, 100 participants actually attended the discussions. Those who took part in the discussion each received a compensation of $85 (in Toronto and Montreal) or $75 (in Winnipeg and Moncton), as per market requirements. Group discussions each lasted approximately 2 hours.
Intermediaries and Health Professionals
A total of 16 in-person mini-groups were conducted with educators and health professionals; eight groups in both Toronto (March 28-29, 2017) and Montreal (March 29-30, 2017). More specifically, in each location one group was conducted with each of the following segments:
A total of eight individuals were recruited in each group, totalling 128 recruits. Participation across locations totalled 115 individuals. Each group lasted approximately 2 hours and participants each received an honorarium of $150 (in Montreal) or $175 (in Toronto).
Policy Makers
A total of nine in-depth telephone interviews were conducted with individuals selected by Health Canada who are involved in developing, implementing or evaluating healthy eating policies or strategies at a provincial, municipal, or organizational level. Interviews were conducted from March 31st to April 6, 2017, with each discussion lasting approximately 30-40 minutes. Stakeholders from the food and beverage industry and commodity groups were excluded from the study.
Qualitative discussions are intended as moderator-directed, informal, non-threatening discussions with participants whose characteristics, habits and attitudes are considered relevant to the topic of discussion. The primary benefits of individual or group qualitative discussions are that they allow for in-depth probing with qualifying participants on behavioural habits, usage patterns, perceptions and attitudes related to the subject matter. This type of discussion allows for flexibility in exploring other areas that may be pertinent to the investigation. Qualitative research allows for more complete understanding of the segment in that the thoughts or feelings are expressed in the participants’ “own language” and at their “own levels of passion.” Qualitative techniques are used in marketing research as a means of developing insight and direction, rather than collecting quantitatively precise data or absolute measures. As such, results are directional only and cannot be projected to the overall population under study.
The following section provides an overview of the findings from the focus groups conducted with members from the general public in Toronto, Montreal, Winnipeg, and Moncton. Where appropriate, differences in opinions are outlined by each of the key audiences under study, namely: youth (those aged 16-19 years old); adults with low health literacy (Low NVS); and adults with adequate health literacy (Adequate NVS).
Eating Habits and Considerations
The traditional concept of three balanced meals a day lacks relevance to most and does not accurately align with today’s eating behaviours.
Group discussions explored what a typical day looks like in terms of eating, specifically in relation to meal frequency, structure and snacks.
Across locations and audiences, findings suggest there is no typical eating structure consistent across the population. In fact, regardless of audience, the traditional concept of three balanced meals a day appears to be a standard applied by few. In each group discussion, participants described varying eating habits ranging from one larger meal a day, to two or three meals a day, to up to four or five smaller meals a day. Consistently, regardless of audience, the concept of three meals a day was considered an exception rather than the general standard practice. This type of behaviour was particularly prevalent among youth and low NVS adults.
The frequency of meals is primarily driven by participants’ schedules, whether it be school schedules, work schedules, sleep patterns, or their families’ competing timetables.
Indeed, participants consistently described a rushed and busy life, where meals or food consumption typically fits around daily calendars, rather than activities scheduled around mealtime.
Breakfast:
What constitutes a meal warrants consideration, particularly in relation to breakfast. Across audiences, many did not reportedly eat breakfast, primarily because of a lack of time (e.g., sleep is chosen over a meal), lack of interest, or lack of hunger first thing in the morning. While participants readily acknowledged the importance of ‘starting their day off right’ with food, many simply forgo a ‘breakfast’ in the interest of time. Most defined their breakfast as a ‘grab and go’ consumption as they travelled to school or work. For them, breakfast often included a coffee or breakfast sandwich (purchased), a yogurt, a muffin, or a smoothie. There are a few interesting differences that warrant mention across audiences:
Lunch:
The concept of lunch is perhaps most consistent with the traditional perception of meals across audiences – namely that it occurs mid-day and is structured by their work environment or school schedule. This meal structure was most common across audiences, particularly among those who work during the day or among students.
For most, lunch generally takes the form of a lighter meal (e.g., sandwich, soup, salad, leftovers, burger) and has limited variety in terms of the number of elements included in the meal. For many this is the first meal of the day, and is typically eaten outside the home, most notably purchased, although brought from home in a few instances. As would be expected, those at home generally described a more robust or varied lunch than those outside the home at lunchtime.
Those eating and packing lunches typically plan their lunch the ‘morning of’ or the night before. For the most part, participants reportedly make (or buy) their own lunch, and this is also especially the case for most young adults. Lunch preparation typically involves preparing a sandwich based on what is available in the house, or packing leftovers from a previous dinner. Lunch often included one or two additional components such as a cookie / sweet or fruit. Reflective of people’s busy schedules, participants often spoke of lunch being eaten on the go, at their desk, or less commonly in a social setting with others.
Dinner:
Discussion of dinner varied notably across participants and findings clearly show that there is no ‘typical’ time or format for a dinner. Once again, findings confirm that what would have been traditionally considered ‘suppertime’ is not standard for most. In fact, with extended days (driven by work, sports or extracurricular schedules, commuting, or competing interests within the home), meal times vary dramatically, ranging from early to late evening. For many, dinner reflects the largest meal of the day, and the one that involves the greatest level of preparation and planning. That said, the degree of preparation varies notably by participant, largely dependent on the abilities and interests of anyone in the home and special dietary needs.
Snacks are prevalent throughout the day for most, with snack selection primarily driven by desire, taste and convenience / availability.
The number and types of snacks consumed daily varies dramatically across audiences. For many, snacks are prevalent throughout the day and evening, while for others, a snack in the afternoon is common to curb hunger until a later meal. Snacks in the evening are common practice for many, and a habit that typically accompanies television / movie viewing, online searching or homework.
Many intentionally choose healthier snacks (perceived by participants as fruit, nuts, yogurt, muffin, and granola bar) during the day, and opt for less healthy options in the afternoon or evening (e.g. chips, popcorn, chocolate, ice cream). Across locations, participants openly discussed having a snack drawer or cupboard in their home or at work that they turn to on a regular basis.
Snack selection is driven by a range of factors, most notably a desire (or ‘cravings’), taste preference and availability, rather than an informed choice based on healthy eating knowledge. For some, diet restrictions are a key consideration when choosing a snack, namely ensuring that it meets special dietary considerations (e.g., allergies or health conditions). Across groups, participants reported that the type of snacks selected are often driven by mood, with the frequency and type of snacks being negatively influenced by stress, depression, anxiety and overall health.
When asked to consider the difference between a snack and a meal, participants offered clear and consistent input. For the most part, primary differences between the two relate to size, preparation time and convenience. Participants consistently acknowledged that all snacks are not created equally.
Findings confirm that what might have historically been considered traditional family values (i.e. the entire family eating together at a table) is not necessarily aligned with today’s reality and that technology plays an important role during meal consumption.
Across locations, having the entire family eat together at a table was generally an exception rather than standard practice, especially for young adults and those with lower levels of nutritional literacy. Rather, common practice prevailed whereby participants spoke of eating ‘on the go’, in more of a ‘help yourself’ fashion as meals are prepared. Participants were as or more likely to eat their dinner in front of the television or computer or in their bedroom (primarily youth), as they were at a dining table. Young adults, particularly those in lower socio-economic households, spoke of eating on their own in their bedroom or in front of a computer or television, even when other family members were eating on their own elsewhere in the home. For most participants, eating seems to have become more of a chore or required task than a regular occurrence that brings the family together. Interestingly, participants’ behaviours were often in contrast to their stated belief, suggesting that their current eating behaviour does not necessarily reflect their ideal.
Without question, technology has infiltrated mealtime. Findings show that television and the computer are staples to mealtime for many, as is the presence of smartphones. It warrants mention however, that in each group there were a few participants who spoke of mealtime rules whereby phones are not allowed to be present at the table. This was most often mentioned among those who make eating at a table as a family a common practice in their household, whenever possible. That said, it is clearly not the practice of most among the audiences under study.
Several parents of young children spoke of feeding their family while they cooked dinner and often eating their own meal while standing and preparing food. Across audiences and locations, participants mentioned that a sit-down meal occurred infrequently and often only on the weekends. At the same time, ‘Sunday dinner’, or large gatherings with extended family members are rare occurrences. Eating practices were largely driven by competing schedules and habit, whereby participants have simply gotten used to eating sporadically and inconsistently given their hectic agendas.
Meal Planning
The extent of meal planning varied among participants in each group, with some planning their meals by the day and others having a scheduled plan a few days ahead. Many openly spoke of deciding what they were going to eat only an hour ahead of any main mealtime. Only a few in each group planned their meals for a week at a time. There is minimal to no planning of breakfasts and lunches.
For some, planning was a necessity based on scheduling challenges within the home, while for others planning was tied to their budget, grocery shopping trips, and to ensure they could live within their means.
Regardless of the advance time for meal preparation, there were several consistencies associated with planning that warrant mention. To begin, when planning a meal, many commented that they consider a balanced meal that includes a protein, vegetables and carbohydrates. In fact, participants consistently referenced the terms ‘protein’ and ‘carbs’ or ‘carbohydrates’ across audiences. This was mentioned across locations, and was interesting in that many intentionally discussed these concepts in terms of proteins and vegetables rather than speaking of the ‘traditional’ meat and vegetables.
For others, when planning meals, they focus on the type of food they need to have in the house to provide for meal preparation throughout the week. This is especially the case when considering ‘staples’ such as pasta, rice or potatoes, meat / protein or vegetables.
It should be noted that while adults are most concerned with meal preparation, youth are generally not involved and simply eat what is served by their parents. Exceptions included those with a health condition (theirs or someone else’s in the household) and the few youth that expressed an interest for nutrition.
Food Selection Considerations
When choosing food, participants consistently reported that their selection is driven by a variety of considerations, notably taste, availability, routine, and cost.
Food choice at home and outside the home is primarily driven by taste (or personal / family preference), availability of food items in the home or while on the go and routine, namely foods purchased or eaten out of habit. Another key consideration is cost, with many indicating that they regularly reference sales flyers or ads to determine what they might buy during any given grocery trip. As would be expected, this consideration is more prevalent among lower social-economic individuals, where they are more tightly constrained with budget considerations. In most instances, grocery shopping is done once a week or at most 2-3 times a week, and not commonly associated with meal planning. Indeed, food is purchased primarily based on the considerations named above, and to a lesser extent based on meal planning considerations.
Other key considerations when selecting food included dietary restrictions (including health conditions), and what food is seasonal. Convenience is also key to many, particularly given their families’ busy schedules. Many spoke of resorting to prepackaged or frozen options that allow them to prepare a meal in quick fashion.
Without exception, participants agreed that their eating choices change if they are planning or preparing for an eating occasion with their family or friends, versus eating on their own or preparing a meal that is consumed during the week. Consistently, participants reported that they put more effort and consideration in preparing a healthy meal when cooking for a special occasion. This increased effort was primarily driven by a desire to impress their guests, so many look to include a wider variety of food, and place greater focus on presentation, and quality. Of course, these meals are consumed at the table, with everyone sitting together. Overall, members from the general public spend more time planning, preparing, and eating meals prepared for special occasions, and clearly put less effort in their daily food consumption.
In terms of choosing non-alcoholic beverages, three key considerations were consistently mentioned across groups and locations, including sugar content (in juices, soft drinks), caffeine content and other additives (chemicals, colouring agents, sweeteners like aspartame). Water appears to be a common choice for hydration, particularly among adults.
Awareness and Knowledge
There are some variances in perceptions regarding healthy eating across audiences, with those who have adequate health literacy having healthier habits.
To assess personal opinions prior to group discussion, participants were asked to consider a series of seven opposing statements concerning healthy eating and to identify which most closely aligns with their personal eating habits. This exercise helped to assess participants’ perceptions of healthy eating, and provided an analysis of findings across audiences. When considering eating behaviours, findings highlight several interesting points, as illustrated below:
Participants shared a similar definition of ‘healthy eating’, primarily consisting of eating fruits and vegetables, limiting processed and fast foods, and living an active and healthy lifestyle.
Participants generally shared a similar definition of what ‘healthy eating’ means to them. To many, healthy eating consists of a balanced and varied diet, limiting processed and fast foods, in addition to living an active and healthy lifestyle. Eating fruits and vegetables, and aiming to focus their diet around the broad principles of Canada’s Food Guide was cited by many participants in each region across audiences (e.g., variety of foods, selection from different food groups). That said, this premise typically reflected a general learning or foundational understanding of the basic food groups learned in elementary education, rather than ongoing reference to dietary guidelines. Regardless of age, or health literacy levels, eating fruits and vegetables was by far the most commonly mentioned response related to a healthy eating definition. This was often accompanied by reducing the amount of sugars and fats in their diet. Of note, healthy eating being regarded as expensive and a large time commitment was cited by some, specifically, adults with low health literacy.
Caloric intake is another commonly mentioned definition of healthy eating, especially by adults with adequate health literacy and youth. Of note, these audiences consistently cited having a caloric intake appropriate to their personal needs as a consideration of healthy eating, rather than a specific daily value. For these individuals, there is a general understanding of caloric balance, and many have established such understanding based on participation in a specific type of diet, fitness regime, weight watchers, or advice from a nutritionist or coach.
When asked what makes a food healthy, participants generally concurred that key factors influence whether or not a food is healthy including: how it is made (i.e., naturally grown food is the healthiest); if it is processed (i.e., packaged); if it is genetically modified or inclusive of / influenced by steroids or antibiotics; and based on the number of ingredients (with fewer being better); types of ingredients (including such things as sodium, sugars, chemicals, trans fats, additives, and ingredients that are unknown / unfamiliar); and where it is from (with a general perception that local is best and that products from some foreign countries are notoriously less healthy).
Without exception, participants agreed that fresh food (e.g., fruits and vegetables), and locally grown or natural food are healthier than processed food. Similarly, the inclusion of additives, steroids, and genetically modified foods are deemed problematic. Ultimately, it was felt that healthy foods positively contribute to the positive functioning of your body, while unhealthy foods negatively impact a person’s overall health.
There was a general perception across groups that eating healthy is more expensive than choosing unhealthy options.
Positive Healthy Eating Habits
A variety of eating habits related to food choices, preparation and consumption are considered as positively influencing healthy eating habits.
When asked what eating habits positively influence healthy eating, responses were generally consistent across locations and audiences. Good eating habits typically included such things as regularly planned eating occasions, having breakfast, drinking plenty of water, portion control, plate size, only having one serving / helping, eating at the table (in the absence of television), eating with others, eating slowly, and avoiding packaged or processed food. Eating from each food group, and ensuring a balanced meal was also consistently mentioned, although most expressed a broad understanding of food groupings (vegetables, meats / protein, carbohydrates) rather than citing specific food groups by name.
Food content was considered key, with consistent mentions of cutting down on sugar, avoiding fast foods or fried foods, eating lots of vegetables (especially greens), ensuring protein intake, and limiting soft drinks or juice beverages. Other ‘general rules of thumb’ were suggested as positively influencing healthy eating habits, including drinking a glass of water before having a meal, never going grocery shopping when hungry, or eliminating things like sugar and salt.
For the most part, participants do not actively seek out information on healthy eating, unless looking for an answer to a specific question they might have or seeking a recipe idea. When doing so, most turn to the internet to perform general searches for information. While participants appreciate that general Google searches may not all be reliable, online information authored by health professionals is typically perceived as credible.
In fact, across audiences, participants attributed their knowledge of health behaviours to personal experience or upbringing, education (primarily elementary years – where they were taught ‘the basics’ through the Canada Food Guide), the influence of others in their lives (family and friends), either through conversation or social media interaction, or media influence. In fact, information on healthy eating is generally received from information provided by others (school, family, media, etc.),
Challenges to Eating Healthy
Lifestyle habits and a lack of knowledge are considered the greatest barriers to healthy food choices.
By contrast, habits that negatively impact healthy eating consistently included such things as poor sleep, missing meals, mental health issues or illnesses, irregular eating times, lack of knowledge of how to apply healthy eating advice, lack of money, eating food that lacks nutrient content, and overeating. Similarly, knowing how to prepare food in a healthy manner was also considered challenging.
Snacking too often, exercising at night, and eating food late into the evening were also seen as negatively impacting healthy eating. Eating out was also deemed problematic. Finally, the negative influence of media, industry marketing, and inconsistent information on the internet was consistently mentioned.
Furthermore, an individual’s lifestyle (including their daily routine, ongoing habits and behaviors) and socio-economic situation was considered to present real challenges for eating healthy. Similarly, the prevalence of eating in front of the television or computer and a lack of planned mealtimes together as a family was deemed counterproductive to healthy eating.
When asked how they knew what factors negatively impact eating healthy, most considered it to be general knowledge, or cited information that was readily promoted through the media. Further, many commented that they have experienced a direct reaction to the food they have eaten, whereby they have felt poorly after eating unhealthy food.
Healthy Eating Decisions
Across locations and audiences, there is a general perception that people somewhat understand what constitutes good eating habits and understand that they should eat healthy, despite that not being reflected in their behaviours.
Participants consistently and accurately articulated what factors positively and negatively contribute to healthy eating. That said, despite their apparent knowledge, many concurred that their behaviour often contradicts what they know, primarily because of a lack of time, lack of willpower, and lack of ability to make change. They often choose the ‘easy’ and less healthy option because of their life situation or because it reflects the path of least resistance.
Across audiences, most agreed that participants do not base their choice of food on established nutrition guidelines and recommendations, but rather choose food based on price, taste, familiarly and availability. Those most inclined to make an informed choice primarily refer to information on the product label.
Unfortunately, most agreed that they are simply unable to choose healthy eating habits because of a variety of key barriers, including: a lack of willpower; an addiction or current dependency (to sugar, caffeine, salt, junk food); lack of knowledge (of how to apply healthy eating recommendations); lack of affordability; and a lack of awareness or appreciation of the consequences of unhealthy eating.
Across locations, adult participants voiced frustration with the fact that today’s education system no longer includes home economics, where youth are taught to cook. This was considered to be of real concern, especially in terms of preparing young people to make the right choices later in life.
Despite the perceived inabilities of many to make healthier lifestyle choices, across locations and audiences, participants agreed that it is important, and in fact essential, that everyone (across age groups, regions and ethnicity) better understands healthy eating recommendations, how to apply them and why healthy eating is important. Consistently, it was felt that it is imperative to tell people why it is important to eat healthy and how they can easily impact change.
Changes in Eating Behaviours
Across locations and audiences, many participants agreed that they have experienced changes in their eating habits within the recent past primarily due to health conditions, changes in life circumstances, or an enhanced focus on health.
Across groups, changes (be it positive or negative) in healthy eating habits over time were primarily influenced by three key factors:
Health Conditions: Across audiences, when faced with a personal or family health circumstance or crisis, eating habits were a key element that was impacted. Diagnosis of disease (e.g., cancer, kidney disease), or health conditions (e.g., diabetes, IBS, eating disorders, allergies, pregnancy) resulted in mandatory changes. This was the case regardless of whether it was affecting them personally or an immediate family member. Similarly, some commented that aging has resulted in changes that have required different eating habits.
Change in Life Circumstances: A variety of changing life circumstances were mentioned as having resulted in changed eating habits, both personally and for the entire family. Retirement, a change in family structure (e.g., new baby, children moving out, divorce / change in relationship, new family members, children more actively involved in activities), a move, or a new work situation / work hours clearly impacted eating habits.
For many, recent years have become busier and more hectic, with people commenting that they simply have less time than they did in the past. Accordingly, they have found it necessary to take whatever short cuts they can as a coping mechanism to adapt to their busy schedules. In addition, for some, stress has become a factor negatively impacting eating habits, as unhealthy food becomes a solace during trying times.
Regardless of reason, participants concurred that as they have placed increased focus on health, they have found that there is better information more readily available than was in the past. Access to information has facilitated a change in eating behaviours or habits.
Current Use of Information and Resources
Unless driven by personal circumstance, members from the general public do not actively seek information when choosing food. Most passively absorb information on healthy eating.
Across locations and audiences, findings clearly show that members from the general public are generally not actively seeking information relating to healthy eating, unless motivated to do so by personal circumstances, including such things as disease, chronic health conditions, allergies, or a specific interest in health or fitness. For many of those seeking information on healthy eating, such information has become common practice out of necessity, rather than by choice.
When considering how healthy eating information is received and / or collected, three distinct behaviours or segments within the audiences under study were revealed. More specifically, these include those who are needs-based information collectors, health-conscious information gatherers, and passive information receivers. The following discusses use of information for each of these three distinct segments, including which information tools are used and how.
Needs-Based Information Collectors
Across age groups, locations and health literacy levels, some participants placed great importance on the need for and use of healthy eating information. For this group, information is needs-based, in that they have a specific chronic health condition or disease that requires attention. Across groups a variety of health conditions were cited including such things as allergies or food intolerances (e.g., peanut, dairy, or wheat), chronic health conditions / disease (e.g., cancer, diabetes, kidney disease, IBS, or high blood pressure) or eating disorders. In each situation, members from the general public have placed great attention on the need to understand their condition and, where appropriate, collect information related to food selection and preparation.
As would be expected, depending on the nature of the condition, this group places a high degree of attention on food selection. With clear repercussions to choosing food that could negatively impact their condition, these members of the general public are typically well-informed and place priority on food content.
Resources Used: A variety of resources are relied upon by this group to provide information on healthy eating, most notably the advice and guidance of health practitioners (doctors, dietitians, nutritionists, etc.), as well as product label information (ingredient listings and the Nutrition Facts table).
Health-Conscious Information Gatherers
Within each location and audience, another distinct segment was also evident, namely those who have a focussed interest on their personal health. This group’s interest is often weight, body size or fitness-related, and sometimes associated with a specific type of diet. Many of them expressed an interest in adopting a healthy eating lifestyle. With that in mind, their healthy eating information needs are slightly different than those for needs-based information collectors, with more focus on caloric intake, protein, carbohydrates, as well as a focus on sugar and sodium. For this group, eating habits are typically goal-related (e.g., weight loss, or personal training) and sometimes focussed on a change in general eating habits and physical activity to reach their end-goal. Across locations, this segment was more prevalent among the adequate health literacy audience, as well as with youth who were actively engaged in sports.
Resources Used: This segment relies on a limited number of specific resources to guide their healthy lifestyle information. Across locations, mentions of ‘My Fitness Pal’ app was frequent, as it allowed them to monitor physical activity levels, as well as food and water consumption each day. Some also made use of other electronic tools such as a Fit Bit to guide their efforts. This audience is largely influenced by other individuals sharing the same interest (e.g., coaches, athletes, or family members) and to a lesser extent, guidance from a nutritionist or dietitian.
This group also has a keen interest in food and food preparation in general. They consistently referenced online searches for recipes and ‘how to’ videos for meal preparation ideas. YouTube was often mentioned by this group as an interesting source referenced, as was ‘tastemade’ (on YouTube and Twitter) and ‘snacktime’. This segment pays attention to both ingredient listings and Nutrition Facts table.
For this segment, information is adapted to their specific needs in a customized format to reflect specific goals, with a greater focus on meal planning and preparation. The internet proved to be a regular information resource for this group, primarily for conducting searches for recipes. Information for this group is primarily used to direct food purchase or product selection, and to guide meal preparation.
Passive Information Receivers
As mentioned earlier, most members of the general public appear to passively absorb information on healthy eating rather than actively seek out detailed information on the topic. For them, information is not sought after but rather received primarily through unprompted information through such things as media (including general media coverage, traditional advertising and social media like Facebook and twitter), conversations with friends and family, in-store marketing, and through schools. Across audiences, youth are most inclined to be passive information receivers, purporting to not actively seek out any information on the topic, unless they fall within one of the other two segments mentioned above. This segment professes a perceived lack of need for information as it relates to healthy eating.
It warrants mention that both needs-based information collectors and health-conscious information gatherers, expressed some frustration with food labels as currently provided. Most concurred that information as presented is confusing and convoluted to many, particularly when it does not relate to the specific package size.
Sources of Information
Aside from food labels, information on healthy eating is primarily received online or through health professionals.
As mentioned, participants currently rely on a limited number of information sources regarding healthy eating. When selecting food, without question, food labels play a key role in communicating information details to members from the general public. For most, in-store signage and promotion also influences product selection and purchase decisions (for such information as food origin and health benefits of foods).
Members from the general public are clearly headline-driven, in that they migrate to information that is available in quick, memorable facts, or bite-sized pieces that they see or hear on social media, television (news and advertising), talk shows, or in printed materials.
To better understand information sources, participants in each group were asked to individually record what their primary sources of information were regarding healthy eating.
As discussed earlier, information sources vary notably depending on which segment (needs-based information collectors, health conscious information gatherers, and passive information receivers) is looking for information. That said, overall, when looking for advice on healthy eating, participants usually go online for generic searches on the topic of interest, or to established relationships with health professionals (doctors, dietitians, nutritionists) or family and friends.
Results of this exercise highlight several interesting differences by audience. To begin, as mentioned, youth are least likely to use multiple sources to receive information about healthy eating. In fact, youth and adults with low health literacy in Winnipeg, rely on the fewest number of sources. This is in contrast to adults with adequate health literacy who generally rely on a greater number of information sources. Further, print materials and health professionals are more commonly cited among adults, especially among those with adequate health literacy.
Websites and social media are the two most common means to get information about healthy eating for both youth and adults. Across locations, the use of social media for information is more common among youth, while websites are more commonly utilized by adults.
Very few individuals use mobile apps to receive information about healthy eating, although those residing in Toronto were more likely to do so. Receiving information from health professionals is also common among adults in all four regions, and youth in Toronto and Montreal.
Adults, with both low and adequate levels of health literacy, are more likely than youth to make use of printed materials. Some participants also noted receiving information from television, friends, family, signage, and advertisements. Without question, health or nutrition courses at school play a key role in providing basic information on healthy eating to youth. Many adults also commented on having learned the basics of healthy eating in school through home economics, or through their parents’ modeling behaviours.
Reliable Sources of Information
Health professionals and media news stories and reports are considered among the most credible sources of information on healthy eating.
When asked which resources are considered most trustworthy or reliable on the topic of healthy eating, participants consistently named health practitioners (including doctors, nurses, dietitians and nutritionists). The media is considered the primary unsolicited source of credible information to most with television, talk shows, and the Internet (in general) consistently mentioned. Of note, one talk show deemed credible and identified across English-speaking groups included the Dr. Oz Show. In Montreal, the television show, ‘L’Epicerie’ was held in high regard.
It warrants mention that the Government of Canada was generally not mentioned, unaided, as a regular source of information as it relates to healthy eating. That said, when prompted, most acknowledged that the government is generally a reliable and trustworthy resource that has an important role to play in educating the public on healthy eating practices. More so, the federal government was deemed to be the authority on food and nutrition in Canada, particularly given its responsibility for ensuring the safety of food in the country and in providing educational content on healthy eating.
Participants consistently agreed that it is important for the Government to provide information to Canadians on the “real facts”, as the true authority on food. It was felt that there are many contradictions related to food in the market today, primarily driven by media, the internet and advertising. Accordingly, they were unsure what the truth is, and what they should believe. For most, it was perceived that the Government must take the lead role in ensuring that the public is educated on the truth about food and about healthy eating practices in general.
Despite a desire for government leadership, across locations, some participants voiced skepticism in relation to the Government of Canada’s position on food. Consistently, discrepancies were mentioned, whereby it was believed that the Government has supported and promoted industry, despite ‘perceived proof’ that food security or the ultimate health of Canadians may be compromised. More specifically, across locations and groups, participants cited the grain industry (i.e. increased prevalence of GMO products), the seafood sector (farmed versus fished), and the dairy sector (i.e. how prominent dairy should be in a diet, or presence of growth hormones in milk), as examples where government appears to be taking the side of industry.
Eating Well with Canada’s Food Guide
Eating Well with Canada’s Food Guide, though recognized as a well-respected authority on healthy eating, is considered out of date and lacks relevance to today’s population.
Across locations, it is important to note that Eating Well with Canada’s Food Guide was consistently mentioned as historically being a reliable and respected source of information on healthy eating in Canada. Indeed, findings show that Canada’s Food Guide has clearly helped to form a broad foundation of public perceptions towards healthy eating (primarily the importance of eating a balanced meal, prominence of fruits and vegetables and broad advice on amounts of food through imagery – i.e. palm of hand or plate).
Many consistently referenced Canada’s Food Guide’s different food groupings in general and its discussion of how prominence should be given to vegetables on your plate. However, despite frequent reference to this tool, few have referenced or seen Canada’s Food Guide in recent years. Rather, many cite it as a pillar in their general understanding of eating based on curriculum in their school years. This was consistent across locations, and age groups. Some, in fact, demonstrated a lack of familiarity with Canada’s Food Guide specifics, and a more general understanding of its broad food groupings.
More importantly perhaps, Canada’s Food Guide was criticized for lacking relevance to today, primarily because of its directed approach to food groupings, amounts of food, and healthy eating advice that is not aligned with current eating habits and behaviours. Further, Canada’s Food Guide was described as a tool that directs what people should do without providing any assistance or direction on how to do it.
It was felt recommendations are misaligned with the population’s eating habits (e.g., assuming three meals a day, recommended dairy or grain allotments given the prevalence of lactose intolerance or gluten free diets, or meat (rather than protein requirements)). Furthermore, as mentioned, some criticized the Government for perceived alignment with, or influence from, industry (e.g., grain or dairy industries) rather than being grounded in sound health research and practice.
In addition, Canada’s Food Guide was considered too narrow in its focus on traditional Canadian food, and not adequately representing the full range of multicultural food now available in the country or the diversity of the population. The presumption that meats are required was considered off-putting to some, particularly given that they considered protein to be a more important requirement than meat.
Furthermore, for some, the presentation of food labels and serving size information was considered overly complex and lacking relevance to them personally.
Preferred Information
Members from the general public prefer to get general guidance information that enables them to act, and that can easily be incorporated in their current lifestyle.
Consistently, participants across locations and audiences prefer to get advice with a task that allows them to effectively make changes in their eating habits. The provision of realistic tips for healthy snacks or ideas on how to create quick and healthy meals within a limited budget was both endorsed and welcomed. Similarly, participants prefer tangible examples of how to prepare healthier food through easy recipes or cooking tips. The importance of general advice was considered paramount in guiding overall habits, though any advice must be well rounded and supported by fact.
While most do not look for information on healthy eating, they do have interest in such information, but at a simplistic or holistic level that holds personal relevance. Most have little to no interest in numeric details (be it calories, daily allotments or portion size), unless required by their health condition or interests. Instead, they prefer to get general guidance on what they should do, why they should do it and how they can do it. They are looking for advice on how they can be enabled to make change. Simple information on what to eat, what to avoid, and how to enact change that helps to direct more healthy choices was deemed most useful. At the same time, recommendations must be simple and adaptable to people’s lifestyle and socio-economic conditions.
When asked what information they need to know, participants across locations and groups outlined a wide range of topics, most of which focussed on information to empower or guide their own personal healthy eating decisions. While a variety of responses were provided, the specific suggestions that pertain to the current study included:
General Information on Food
Content:
How To:
Risks / Consequences:
When considering how information should be presented, findings consistently revealed that preferred information would be short, concise, fact-based, and actionable.
Across audiences, participants underscored the importance of simple guidance that provides straight forward, realistic actions supported by impactful imagery that is easy to understand. Provision of videos on application of healthy eating information were considered especially helpful in demonstrating how to do something. Similarly, quick and easy recipes were consistently suggested across locations.
Aside from practical applications, participants concurred that they would like to have information that is relevant to them personally through customization. Having the ability to personalize information to best meet their needs (i.e., based on age, taste, activity level) was deemed useful, as was having easy access to searchable information online that would allow someone to ask questions about specific conditions that might be relevant to them.
The following section provides an overview of the findings from the focus groups conducted with intermediaries and health professionals in Montreal and Toronto, as well as from the in-depth telephone interviews conducted with policy makers across Canada.
Current Role and Target Audiences
The roles of the various health professionals / intermediaries vary notably both across and within each audience type.
Across health professionals (dietitians and public health nurses) and intermediaries (teachers, physical activity specialists, and community educators), roles in terms of the promotion or education of healthy eating fluctuate notably depending on if nutritional information is being provided directly to an individual or to a group. Those providing consultation at the individual level typically provide a more customized or personalized approach that is geared with a patient’s or client’s specific needs in mind. Information is usually client-centric, directed by client-specific goals.
By contrast, when providing information at the group level (e.g., to facility administrators or students), information tends to be used in a more general way, discussing population health overall or the general needs and health implications of specific audiences of interest (e.g., residents in long-term care, those with diabetes, etc.).
Primary audiences vary depending on the role, including either patients / clients / students, their families or larger groups as outlined above. As may be expected, with the exception of public health nurses in Montreal, health professionals are more likely than educators to provide more detailed information.
Policy makers also play various roles, from raising public knowledge to establishing guidelines for the consumption of healthy foods at provincially-funded institutions.
Policy makers also held a variety of roles, primarily in terms of developing and implementing nutrition policies, guidelines, strategies, and action plans. While most were focused on public education campaigns about healthy eating in general, a few policy makers within provincial governments were working on establishing more precise healthy eating guidelines for public-sector organizations, including childcare facilities, schools, or long-term care residences. Most stakeholders played a role in informing the policy development or implementation through research-based recommendations, most notably as a member of internal working groups or advisory committees within their respective organizations.
Audiences targeted by policy development included members from the general public , as well as a variety of facility operators (including operators of childcare facilities, municipal recreational centres, community centres, hospitals, schools and long-term care residences), and health care professionals (e.g., nutritionists and nurses).
Goals to Communicating or Promoting Healthy Eating
Despite a diversity of goals being identified by intermediaries and health professionals based on their respective roles, most aim to help with the adoption of healthy eating behaviours and prevent or heal specific illnesses or conditions.
The specific roles of intermediaries and health professionals in terms of healthy eating education and promotion varies notably, although they share the ultimate goals of improving people’s health conditions, and influencing the development of healthy eating and lifestyle behaviours. The following provides an overview of the research audiences’ respective goals:
Not surprisingly given their role, policy makers aim to establish guidelines and sound healthy eating habits to guide food choices made by the general public and administrators of publicly-funded institutions.
For the most part, policy makers develop and implement nutritional policies for schools, childcare facilities, recreational facilities, hospitals and long-term care facilities, to guide internal policy development and menu elaboration within each respective organization. Less commonly, policy makers work on public education materials for the general public to influence food choices. In a few instances, policy makers are involved in the development of nutrition assessment guidelines to be used by public health nurses when providing guidance to parents of infants and young children, via provincially-funded health services.
Challenges and Facilitators to Promoting Healthy Eating
The promotion and education of healthy eating is challenged by socio-economic conditions, limited food knowledge, perceived influences of the food industry, and institutions’ budgetary restrictions.
Intermediaries and health professionals identified a wide range of challenges or barriers to promoting healthy eating in their respective roles. Interestingly, perceived barriers were generally applicable across audiences, with health professionals / intermediaries consistently mentioning: audiences’ limited income; lack of practical knowledge; mental illness or disease (e.g., Alzheimer’s, dementia); cost of healthy food (less healthy is cheaper); limited food knowledge and education (ability to understand /myth busting); nutrition being a low priority for individuals and institutions; and the poor influence of media / celebrities embracing processed food products or unhealthy food trends.
Other key challenges identified included: access to dietitians; the public’s uncertainty as to who is the expert; a mistrust of government (primarily because of its perceived alignment with private industry); and a lack of home economics in public schools. A few dietitians also identified cultural barriers faced when dealing with immigrants, particularly in terms of their different perceptions of healthy eating concepts. The negative influence of media and perceived reputable resources (e.g. Dr. Oz) was also considered problematic, as was an increased tendency and acceptance of eating out.
In addition, when working with institutions (e.g. schools, daycares, hospitals, long-term care facilities) budget restrictions and other context-related limitations were identified. For example, a ‘soft’ textured diet is most appropriate in long-term care facilities where senior citizens may experience issues with their dentition or digestive system. Similarly, allergens must be avoided in school settings, thus influencing the types of foods recommended.
Healthy eating policy development and implementation is challenged by both internal organizational limitations, and external influences.
Policy makers also identified a number of challenges to the development, implementation and evaluation of healthy eating policies. Most notably, they face organizational challenges, such as limited resources (time and funding) and conflicting political priorities or direction. Not having a common protocol for policy evaluation was also identified as a systematic challenge to properly informing policy development.
In addition, a number of external challenges make their work difficult at times. Specifically, learned behaviours from both the general public and meal planners / preparers in institutional organizations; an acquired taste for salty, sugary, and fatty foods; social habits, and changing eating behaviours were identified as challenges to policy development and implementation. More and more, people eat out and purchase prepared foods, thus leading to their taste preference changing.
At the same time, the overwhelming amount of nutritional information available to policy makers, and the resulting risk of misinformation, makes the process of identifying good food choices more difficult. It was also mentioned that food portion sizes not being aligned between resources (i.e., food labelling and Canada’s Food Guide) and portion sizes eaten by people, cause confusion and likely lead to unhealthy choices. Finally, the food industry is widely seen as having a strong influence on Canadians’ choices through advertising and marketing initiatives.
Policy makers also concur that there is a lack of comprehensive, reliable, and up-to-date information adapted to the health and nutrition needs of niche audiences (e.g., children under 5 years old), specific health-related topics (e.g., nutrients, vitamins), and the evidence-based health impacts of applying nutritional recommendations. Little research is available on these topics and on the contextual effect of nutrition on people’s health. For example, it was mentioned that the health impacts of lowering sugar consumption in jurisdictions where strict policies apply is not well documented. At the same time, scientific research on how the availability and accessibility to healthy food choices impacts people’s choices and health situations was identified as a topic of interest.
In terms of what facilitates policy making, increased public interest for health and nutrition, including local food production, was identified as supporting their efforts, especially when translated into governments’ priorities. Collaboration across stakeholders and jurisdictions was also deemed important, both in terms of working towards a common goal and with knowledge sharing. Finally, Canada’s Food Guide was viewed as a national standard to aim for, thus providing direction and focus to policy development efforts.
Resources Used by Intermediaries and Health Professionals
To various degrees, there is a wealth of resources used across disciplines in the education and promotion of healthy eating concepts, which underscores intermediaries and health professionals’ need for information.
The following provides an overview of some resources used by intermediaries and health professionals to inform their work. The use and applications of these resources across audiences are discussed later in this report.
While a wide variety of sources are used for information on healthy eating, a general search on the internet is by far the most top-of-mind resource to address ad-hoc queries. The complete list of resources identified is provided in Appendix A.
Type of Information Used By Intermediaries and Health Professionals
The following provides an overview of select topics that are most commonly used by intermediaries and health professionals when promoting healthy eating to their respective audiences. Where relevant, mentions of the specific resources used to address the topics are made, including an explanation of how these tools are customized. It should be noted that tool customization is limited among intermediaries and health professionals, with the exception of adapting materials for students. At the same time, the bulk of the resources are used to inform intermediaries and health professionals and increase their own knowledge about healthy eating, with very few being distributed to the end audiences.
Registered Dietitians in Community or Public Health Settings
These health professionals primarily provide support to institutions and patients with a focus on enhancing broad healthy eating behaviours, as well as providing advice tailored to individual needs. As such, they incorporate a variety of topics related to nutrition, with varying levels of details. There is limited customization of the tools used to teach healthy eating behaviours, although customizations of meal plans is frequent. The following provides an overview of the ways each topic is relayed by these dietitians.
| Healthy Eating Topics Most Commonly Included | Resources/Tools | |
|---|---|---|
Food Types |
While the general benefits of consuming certain foods over others is discussed by dietitians, particular attention is afforded to speaking of the importance of protein intake for children and seniors. Dietitians mentioned that they no longer speak of concept of ‘good’ or ‘bad’ foods, but rather speak of the frequency at which certain types of foods should be consumed, categorizing foods as ideally consumed, frequently (healthy alternative), occasionally (less interesting foods), or rarely/exceptionally (unhealthy options). Detailed information is collected and customized to present nutrient specific information. Food categories (i.e., general food groupings) are discussed more broadly with intermediaries (e.g., school administrators) while the four food groups from Canada’s Food Guide are used to discuss the concept with children in schools. |
|
Processed Foods |
This topic is also widely discussed as an alternative to talking about ‘good’ or ‘bad’ foods, with advice to minimize the amount of processed foods in the diet. Advice is given whereby the less a food is processed, the more it should be consumed. |
|
Foods Quantity |
In many instances, the frequency of food consumption is a more important concept to convey than the quantity of foods to consume. The notion of quantity is introduced by speaking of satiety and in terms of the proportionality of the different food groups, particularly with children. That being said, in a few instances where minimum nutritional needs (e.g., amount of proteins) are to be fulfilled either as requested by policy (e.g., daycare facility), or based on a health condition, specific quantity of foods are incorporated in the advice provided. Frequency of consumption is also discussed on a daily basis rather than by meal. In general, the concept of quantity is approached more broadly with intermediaries (e.g., school administrators), while it is more specific when speaking directly with the end audience (e.g., patients, children). |
|
Food Variety |
The topic of food variety is primarily communicated to kitchen staff in institutions or to people with specific health conditions (e.g., diabetes) by providing examples of foods to consume. |
|
Beverages |
With teenagers, particularly those suffering from diabetes, the topic of energy drinks and fruit juices is addressed. |
|
Registered Dietitians in Clinical or Private Practice
These health professionals use a variety of information in their work to provide education and counseling on healthy eating habits. It warrants mention that in Toronto, Registered Dietitians (RDs) were notably more specialized in their approach and presentation of information compared to nutritionists. In fact, RDs criticized the quality of input or direction typically provided by nutritionists, and felt strongly that efforts should be made by the government to more clearly position RDs as the dietary experts when considering nutrition.
Most commonly discussed topics among this audience are presented in the following table.
| Healthy Eating Topics Most Commonly Included | Resources/Tools | |
|---|---|---|
Food Types |
This topic is approached by speaking about the variety of foods available, and that each category has a place in a balanced diet, with some foods being more or less important than others. Discussions on foods to limit, including sodium, sugar, and fat, among others, are common among this audience, especially when dealing with patients who have a weight control issue, and those who are diabetic. |
|
Processed Foods |
This concept appears to be frequently discussed with patients as a means to introduce foods to limit. |
|
Foods Quantity |
In terms of quantifying the food to eat, dietitians across audiences use visual references if required. Rather than speak of food quantity, some dietitians prefer to use the concept of energy density of foods as a point of comparison. |
|
Food Variety |
The concept of food variety, by discussing or showing images of a variety of foods available within each food group, is a commonly discussed topic between dietitians and their patients. One of them also mentioned speaking of eating a rainbow of colours daily to achieve food variety. |
|
Macronutrients |
To explain the value of the food groups and certain types of foods, many dietitians refer to the concept of macronutrients. Apart from discussing fat, proteins, and carbohydrates, a few dietitians also introduce concepts such as dietary fibers. |
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Administrative and Food Service Registered Dietitians
These health professionals have a narrow focus on specific products or line of products. The following table provides an overview of the topics and resources they use as part of their work.
| Healthy Eating Topics Most Commonly Included | Resources/Tools | |
|---|---|---|
Nutritional Information |
Most focus on demystifying selected concepts regarding nutrients or ingredients, most notably in terms of sugars and sodium content. Discussions on the nutritional value of the products are also frequent, as is providing information on what choices or alternatives might be available. |
|
Public Health Nurses
These health professionals heavily rely on their academic knowledge to provide information to patients as a means to supplement advice they received from a dietitian. The following topics are most commonly discussed as part of their work with patients and intermediaries:
| Healthy Eating Topics Most Commonly Included | Resources/Tools | |
|---|---|---|
Food Types |
Categories of foods or general food groupings as referenced in Canada’s Food Guide are used by nurses working with school officials (teachers and administrators) and with homecare patients, to discuss food groups and variety of foods. |
|
Foods Quantity |
General advice provided to seniors, encouraging them to eat regularly every day and to increase their protein intake. Specific advice provided to diabetic patients and their family in terms of carbohydrate consumption (using the exchange system). Reinforcing the dietitians’ meal plans that reference food measures (grams, ml, etc.) and using a personal measure at other times (bowl from patient’s kitchen) as a common measure of foods. |
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Physical Activity Specialists
These educators primarily target clients who wish to control their weight through a combination of an exercise regimen and a balanced diet. In many instances, nutrition recommendations are presented as a means to optimize the physical performance goals. Most physical activity specialists have developed a questionnaire they use to assess their clients’ situation and identify their healthy living goals. Most of their recommendations and discussions with clients are informed through personal or more general knowledge of nutrition. As such, these educators look for broad information on nutrition that provides general advice, rather than detailed scientific papers. For the most part, they do not distribute information to clients, but rather incorporate the basic topics in discussions with their clients, with the level of details based on the clients’ level of interest. The following provides an overview of the topics they discuss and the tools they use.
| Healthy Eating Topics Most Commonly Included | Resources/Tools | |
|---|---|---|
Food Types |
Most of these educators present the types of foods to consume by speaking of macronutrients. Most also focus on the types of foods that are most interesting to support a training schedule (e.g., protein intake). In a few instances, superfoods are discussed, as well as ‘trendy’ foods. The number of calories is also part of some discussions, particularly with clients who are on a strict training schedule. |
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Food Supplements |
Which food supplements – including vitamins and minerals - to consume and their impact on physical performance are also commonly discussed with clients. |
|
Foods Quantity |
In cases of high performance training, precise food quantities are discussed, although most meal plans are designed by dietitians. In terms of general discussions on food portions, physical activity specialists use imagery (e.g., palm of the hand, thumb, and fist) to illustrate discussions. More often than not, unless measuring or weighting foods is required, the discussion on quantity of foods is trumped by a discussion on the quality of the foods to consume. One physical activity specialist mentioned using Basic Metabolic Rate and Body Mass Index calculators found online as part of the physical assessment to determine the amount of calories needed. |
|
Food Variety |
The concept of food variety is only broadly introduced by physical activity specialists. This is not a commonly discussed topic. |
|
Community Educators
Those working or volunteering in community organizations with a focus on nutrition (e.g., community or recreation centres, shelters, and soup kitchen) primarily aim to make healthy foods more accessible and available, thus focusing mostly on expanding people’s knowledge of food offerings, as well as creating occasions for people to taste and discover new foods. The following table provides an overview of the topics most commonly discussed and how they are introduced each one with their respective audiences.
| Healthy Eating Topics Most Commonly Included | Resources/Tools | |
|---|---|---|
Food Types |
This topic is key in educators’ work, as they are trying to increase their audiences’ (most notably those in lower socio-economic stratus) knowledge of healthy food options, including affordable alternatives to foods high in sugar, fat, and sodium. To do so, they prefer a hands-on approach, engaging their public to either taste new dishes or foods (through soup kitchens) or to enhance their ability to cook. As such, community educators make frequent use of recipes and are always looking for simple and accessible options. Part of their work also entails demystifying food myths and providing education regarding where foods come from. |
|
Food Groups |
The concept of food groups is only informally introduced by speaking of those considered most lacking in people’s diet, including fruits and vegetables, and grains. A few community educators presented the concept as achieving a balance between proteins and vegetables, while other educators spoke of having a ‘main dish’ and a ‘side’ to present the idea of incorporating vegetables in a meal. |
|
Foods Quantity |
Most community educators do not speak of the quantity of food to consume. When they do, it is to reference food quantities needed to prepare a recipe. Soup kitchens also portion the meals they serve for economic reasons. |
|
Food Variety |
This is an important topic for community educators, though one that proves challenging to apply given their audience’s socio-economic status. Many promote the benefits of a colourful diet as one way to ensure a variety of foods is consumed. |
|
Elementary Level Teachers
The role of primary level teachers is to raise students’ awareness of healthy eating habits, and introduce basic nutrition concepts. Canada’s Food Guide is an important teaching resource and tool, as mandated in the curriculum. For the most part, teachers customize their teaching tools (e.g., worksheets, games, puzzles, posters), as they are not able to find materials developed specifically for young children. The following table provides an overview of the topics most commonly included in the classroom teaching, along with resources used by teachers.
| Healthy Eating Topics Most Commonly Included | Resources/Tools | |
|---|---|---|
Food Types |
Teaching healthy eating begins with a presentation of the four food groups with younger children, usually in primary, first and second grades. A copy of Canada’s Food Guide is distributed to each student. Many teachers create their own games and exercises from clippings, photos and food labels. |
|
Food Variety |
The concept of food variety is also introduced with younger students, around grades 1 or 2. The concept is introduced by speaking of the importance of having different foods. In later grades (5 or 6), students can take part in occasional cooking classes in the school. |
|
Foods Quantity |
Portion sizes are introduced with students in grades 3 or 4 to build on concepts of the food groups and variety introduce with younger students. |
|
Secondary Level Teachers
In Quebec, the high school curriculum does not include specific teaching regarding healthy eating, but rather, physical education teachers incorporate concepts related to healthy habits in general, in which they cover some aspects of healthy eating. Overall, very little time is afforded to this topic, and there are no guidelines to follow or established objectives. As such, secondary school teachers determine what to teach and how to teach it.
In Toronto, a few mentions were made of nutrition classes, although discussion primarily centered around physical education class and its relationship with healthy eating discussion. Given the limited time afforded to this topic, it is not surprising to see that physical education teachers make very little use of resources to assist with their teaching. The following table provides an overview of the topics presented in the classroom, along with the resources or tools used by teachers.
| Healthy Eating Topics Most Commonly Included | Resources/Tools | |
|---|---|---|
Food Types |
In a few instances, physical education teachers spoke of the types of foods to choose and those to minimize. A number of times, these concepts are incorporated in discussions about physical activity or performance (e.g., impact of certain foods on performance). One teacher mentioned that superfoods are introduced, with a discussion on how they can be beneficial for young people’s health. Others, related food discussion on the importance of quality food to properly energize or fuel the body, particularly when considering physical activity or sports engagement. Several mentions were made of students following professional athletes / celebrities (e.g. star athletes in the sport they are engaged) on social media, primarily to follow what they were eating. |
|
Processed Foods |
Fast foods is also a topic included in teaching, particularly highlighting why it should be avoided. |
|
Foods Quantity |
Several teachers referenced use of videos or documentaries (e.g. Supersize Me) to demonstrate the impact of food quantity and selection. |
|
Food Variety |
Discussion of both the overall concept and names of the four food groups is consistently addressed |
|
Macronutrients |
In some instances, teachers focus on macronutrients (particularly proteins and carbohydrates). Sugar intake is also a topic commonly addressed, with teaching of the various types of sugar and the respective health impacts being most common. |
|
General Advice |
Other concepts covered include the impact of healthy eating on the body (e.g., more energy, better concentration), food label reading, the pleasure of eating, and being cautious about food claims and advertising. |
|
Beverages |
Proper hydration, as well as energy drinks are discussed. |
|
It should be noted that in Montreal, a number of teachers who were not required to teach healthy habits as part of the curriculum decided to incorporate the topic into the classroom based on a personal interest for the topic. A personal and social development teacher mentioned introducing selected topics that bring students to reflect on society and its values, such as responsible food consumption, food advertisement, and the influence of industry on food choices and guidelines. Similarly, an English as a Second Language teacher incorporates the topic of healthy eating to teach vocabulary. Websites such as ‘Busy Teacher’ provide relevant curricular activities in that regard.
Topics Less Frequently Included
Food measurements, calories, and energy consumption are concepts rarely introduced in public education, and are primarily used in professional counselling to treat an illness, address a health condition or as part of a physical training regimen.
It should be noted that across audiences, the concept of food quantity is rarely approached in terms of an exact measurement, with the exception of times where an illness or health condition needs to be treated or controlled. Rather, health professionals and intermediaries, and most policy makers, educate the public to recognize the signs of satiety as a means to determine the amount of food to consume on a daily basis. In a few instances, particularly when treating specific health conditions, dietitians will provide patients with a detailed nutritional plan, using exact measures.
Likewise, concepts of calories or energy consumptions are rarely discussed, as they have a negative connotation and can too easily lead to creating or exacerbating an eating disorder. The concept of frequency of food consumption is more commonly referred to than the concept of food quantity.
Information Used By Policy Makers
Policy development directed at the general public or community organizations uses knowledge regarding nutrition trends and broad recommendations.
In instances where government representatives work on educating the public about nutrition (by developing jurisdiction guidelines), or informing community organizations on food guidelines (e.g., what foods to donate to a food bank), the need is more acute for general nutrition trend or food-related information.
Policy development and implementation directed at meal planning in licensed or educational / health facilities requires more detailed dietary guidance.
Individuals involved in developing and implementing policies for facilities such as hospitals, schools, long-term care facilities and licensed daycare look for more precise nutrition information to guide their policy work. Specifically, scientific studies, other jurisdictions’ policies, national recommendations, and international guidelines from reputable organizations are all considered in this process. Most commonly, research and decisions are task-based (e.g., developing guidelines on limiting sugar consumptions; recommendation on the intake of vitamin D; guidelines on number of food group per meal/day), with very specific information needed at a point in time.
This type of policy development also involves consideration of the context in which food is consumed, and how it aligns with specific conditions. For example, schools require more guidance on snacks and meal development with considerations to allergies, while seniors’ homes require guidelines on special diets (e.g., soft or liquid foods), and amounts of food to serve.
Regardless of the type of information required, policy makers most likely begin their search online, either sourcing information on familiar websites or using a search engine as a starting point.
Canada’s Food Guide is also heavily used to establish provincial guidelines or recommendations, notably in terms of food groups, the amount of food they serve, and for some of the healthy eating habits recommendations. It is mostly used in public-facing education initiatives, as well as in establishing nutrition guidelines for institutional environments (e.g., schools or long-term care facilities). The idea of a rainbow of foods to visually communicate the importance of eating a variety of foods is also appreciated. A few policy makers mentioned having used the directional statements as the foundation for the development of more precise recommendations on what foods to choose most or least often, especially in schools and daycare environments.
In some instances, policy makers expressed a preference for more abstract concepts to explain food quantity than what is available in Canada’s Food Guide, either using the hockey puck or hand image. In fact, a number of them indicated that the concept of portion size may be outdated for public education campaigns, with a discourse on satiety being more appropriate. This approach was deemed especially important when targeting children.
Other sources of information used by policy makers include, among others:
Canada’s Food Guide
Canada’s Food Guide was criticized by most audiences for being outdated in both its content and recommendations and perceived influence by industry.
As mentioned earlier in this report, Canada’s Food Guide is a widely used source of healthy eating information across stakeholders, though its application varies. Although it is considered a reliable and credible source of information, it is often criticized for being too restrictive, prescriptive, and not reflective of how members from the general public’s eating habits have changed.
Usage of Canada’s Food Guide varied notably across the groups under study. As would be expected, teachers and public sector employees (i.e., those working in hospitals, public health or educational institutions) generally purport to make greater use of Canada’s Food Guide, with most professing that it is mandated as part of their roles. For the most part, elementary level teachers believe that Canada’s Food Guide is a good reference tool for teaching healthy eating concepts, although it lacks age-appropriate teaching tools. Those outside mandated realms were consistently dismissive of Canada’s Food Guide and more critical of the applicability or relevance to the population. Even those mandated to use Canada’s Food Guide consistently acknowledged that it has many limitations that prove problematic in their various roles. Health professionals working with chronic care patients or long term care patients were especially critical of the generic application of Canada’s Food Guide and its inappropriateness to audiences with special health needs.
For many intermediaries and health professionals, Canada’s Food Guide is deemed not particularly useful given its lack of customization suitable for their client-centric approach. Many health professionals / intermediaries work closely with audiences on very health-specific goals (e.g., dealing with IBS, cancer, diabetes, kidney failure, disabilities, or clients with a goal of weight loss or gain) and accordingly, have found other resources that provide a more specific focus. At the same time, many mentioned that Canada’s Food Guide is not a useful tool to work with young children in daycare or earlier school grades, as it does not consider how their unique nutritional needs may differ by age or size. The level of language and concept explanations are not adapted to children’s levels.
Further, Canada’s Food Guide was criticized for being too traditional in approach, lacking diversity, and not being reflective of typical eating habits or dietary concerns that their clients’ experience. The categorization of foods does not take into consideration all of the new foods consumed and does not illustrate less-frequently consumed foods (e.g., dragon fruit). Many suggested that a more holistic approach, with the ability to extend with further detail. A few also questioned the justification for the food categorizations, notably why certain foods are part of one food group but not of another (e.g., milk).
As such, it is not surprising to see that the use of Canada’s Food Guide varies across audiences. As mentioned, those in the public sector (i.e., public health, hospital settings, or school settings) were mandated to use Canada’s Food Guide and accordingly were more likely to use the tool as an ongoing reference. For most, Canada’s Food Guide was typically one of many resources, used to present general approaches to healthy eating (namely a visual reference for the four food groups, and examples of items in each group), or to direct general meal planning.
It was also mentioned that select topics, such as the types and importance of dietary fiber, how to achieve a balanced diet, and an explanation of the different types of sugar are not properly explained in Canada’s Food Guide. These topics, among others, are deemed highly relevant to people’s life today. Finally, a few intermediaries noted that the recommendations and guidelines presented in Canada’s Food Guide are sometimes difficult to adapt to select audiences (e.g., seniors being sensitive to the texture of foods) or organizational restrictions (e.g., budgetary constraints in institutions).
It warrants mention that across locations, discussion of Canada’s Food Guide often included reference to using information in the structure of a food pyramid or triangle. In multiple cases and locations, participants across audiences cited adaptation or use of information in this format for ease of discussion or education. By contrast, mention of Canada Food Guide’s rainbow was typically uncommon, with the exception of those in the public sector (i.e., those mandated to use Canada’s Food Guide in their role).
It is important to note that participants did not suggest that the Canada Food Guide include a pyramid, but rather that the triangle or pyramid format is something they have used in the past. Altogether, this suggests that usage of Canada’s Food Guide as a tool is often combined with other established resources to best meet their needs.
Importance of Rationale
Evidence-based research is of paramount importance for health professionals / intermediaries, although this information is not related to the end audience.
Findings suggest that any type of information provided by the government must be well grounded in fact, and supported by the appropriate evidence and study methodology, including providing a rationale behind that policy or statement. While most professed that they are not likely to share methodological details with their clients / patients, such information increases their comfort level with the information and confidence in sharing it with others. Moreover, given that studies of opposing views are regularly released by reputable sources, providing the facts helps to establish credibility. Indeed, the need for rationale provision was deemed important across audiences.
Educators, particularly those teaching dietitians or nutritionists, felt strongly that full details on research methodology must be provided to ensure any information taught is well-grounded and evidenced. That being said, this information is used for their reference only, or to support a recommendation to institutions’ administrators, and seldom communicated to patients.
Understanding the scientific rational supporting recommendations is valued by policy makers to support their decisions, although it is not consistently referenced in policy documents.
Most policy makers look for scientific validation of information they use, notably in terms of understanding the research methodology. This information is used in guiding the policy development, and in some instances in supporting documents used for policy approval, although it is not always referenced when implementing the policies. Nonetheless, access to such information is considered paramount. At the same time, adding a reference to Health Canada or to Canada’s Food Guide holds value, with many using this terminology in policy communications.
Information Difficult to Find
Registered dietitians working in administrative functions or in private practice identified a number of types of information that are difficult to find, some of which are mentioned below:
Policy makers also noted that selected topics of interest are not easily available, including:
Evolution of Teaching Approach on Healthy Eating
For the most part, intermediaries and health professionals believe that the manner in which they promote healthy eating has changed in the past five years. Most notably, with foods being front and centre in the media, and the increased access to information, members from the general public are more aware, knowledgeable and interested in nutrition. Furthermore, there appears to be a greater prevalence of special dietary considerations, because of increased focus on lactose intolerance, gluten-free dietary needs, allergies and IBS. As such, health professionals and physical activity specialists deal with patients/clients who are more demanding of explanations.
Teachers mentioned that young people’s food skills are given less importance or priority in the education system than a decade ago, with the elimination of the home economic classes. In addition, the abundance and ease of access to sugary foods has caused a surge in obesity and has shifted the discussions on nutrition at school. Despite the removal of soft drinks from many schools, the increased presence of fruit beverages (which are high in sugar content) was deemed problematic.
In terms of their outlook on how their approach to healthy eating education or promotion will evolve over the next five years, there is a sense among physical activity specialists that the incidence of child obesity today will impact the discourse on nutrition and healthy habits when they grow up to be young adults. In essence, deteriorating health conditions will necessitate some having to place a concerted focus on healthy eating. At the same time, teachers believe that young people will have to make increasingly complex decisions on what to eat, based on new research coming out. New foods (e.g., chia seeds, kale), imported produce being more readily available, and genetically modified foods will introduce a layer of complexity to children’s food decisions, thus requiring teachers to remain aware of changes in nutrition to adequately prepare their students.
Access to Information
The main facilitators to healthy eating policy development or implementation entails collaboration between jurisdictions, having a national standard, government priorities, and increased public interest.
Having national standards (Canada’s Food Guide and various Health Canada recommendations) was identified as a means to establish minimum standards across the country, a sort of ‘starting point’ that facilitates provincial and municipal policy makers’ work. At the same time, government priorities in terms of nutrition also help direct policy development, both in terms of having a focus and resource allocation. Furthermore, collaboration across jurisdictions and levels of government helps with resource sharing and informs decisions. Finally, the public’s increased interest in nutrition and food production is facilitated with the implementation of nutrition policies.
Intermediaries and health professionals identified a number of common elements that make information easier to use, both for themselves and their respective audiences. These include:
Nurses, dietitians and teachers all mentioned that Health Canada should work with the professional associations to provide information to intermediaries and health professionals.
Information Format
Health professionals, intermediaries and policy makers are looking for flexible access to health and nutrition-related information, with information available online, centralized or linked, and in formats that remain flexible.
Across groups, professionals identified that they would ideally like to have one central resource available online which brings together a wide range of resources and tools. Furthermore, there is strong appetite for online access of information to develop and implement nutrition policies, with a desire for a centralized database or at least a network of information sources. Accessibility is key. Suggestions were made to create a nutrition section and specialized teaching section on Health Canada’s website. Notification systems are also appealing to many, especially dietitians and public health nurses, to be made aware of new scientific research being released, nutrition guidelines, or recommendations.
At the same time, professionals and intermediaries are looking for flexible information formats, including detailed research and scientific papers, summary of findings, printable documents that can be emailed or given to patients in support of their recommendations, and simple messaging to be used to communicate rationale for support. In addition to a desire for accessible and flexible information, it has to be comprehensive, timely, and accurate.
Nurses expressed a desire for printable information that could be provided to parents by school-age children, thus expanding the reach of school education about healthy eating concepts.
There is some appeal among health professionals and policy makers for a notification system that would inform them of new research or recommendations being published. Interest in this kind of regular government communication is far less common among other groups.
Clinical or administrative dietitians expressed a preference for online documents that are simple, visually-pleasing, and easy to print and distribute. Suggestions included:
When asked what the Government of Canada could to make information about healthy eating available and how it could be presented to make it more useful, a variety of suggestions were made:
List of Resources Used by Intermediaries and Health Professionals
While a wide variety of sources are used for information on healthy eating, a general search on the internet is by far the most top-of-mind resource to address ad-hoc queries. Some of the websites used by health professionals and intermediaries for information include:
Widely-Used Resources Across Intermediaries and Health Professionals:
Resources Primarily Used by Dietitians:
Resources Primarily Used by Physical Activity Specialists:
Resources Primarily Used by Community Educators:
A few mobile applications were also useful to intermediaries and health professionals, including:
A number of blogs written by dietitians and physical activity specialists are also consulted, particularly among dietitians and physical activity specialists in Montreal, including:
A variety of print and audio visual resources were mentioned, including:
Health Canada – Healthy Eating Strategy Screener (Consumers) – FINAL
Name:
Daytime phone:
Evening phone:
Email:
Group 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
| Toronto, ON (ENGLISH) | |||
|---|---|---|---|
| Date: | Monday March 27, 2017 | Location: | Consumer Vision |
| Time: |
|
2 Bloor Street West 3rd Floor |
|
| Montreal, QC (FRENCH) | |||
| Date: | Tuesday March 28, 207 | Location: | MBA Recherche |
| Time: |
|
1470 Peel Street Suite 800 |
|
| Winnipeg, MB (ENGLISH) | |||
| Date: | Monday April 3, 2017 | Location: | NRG Research |
| Time: |
|
213 Notre Dame Avenue Suite 804 |
|
| Moncton, NB (ENGLISH) | |||
| Date: | Wednesday April 5, 2017 | Location: | Corporate Research Associates |
| Time: |
|
68 Highfield Street Suite 101 |
|
Specification Summary
Hello/Bonjour, my name is [name] and I am with Corporate Research Associates, a market research company. We are conducting a study on behalf of the Government of Canada, specifically for Health Canada, and we are looking for people to take part in a small group discussion. We would like to speak with someone in your household who is at least 16 years of age. Would that be you? IF NO, ASK TO SPEAK WITH SOMEONE ELSE AND REPEAT INTRO
Would you prefer that I continue in English or in French? Préférez-vous continuer en français ou en anglais? [IF FRENCH, CONTINUE IN FRENCH OR ARRANGE CALL BACK WITH FRENCH INTERVIEWER: Nous vous rappellerons pour mener cette entrevue de recherche en français. Merci. Au revoir.
The purpose of the study and the small group discussions is to hear people’s views on the food choices they make. Those who qualify and participate in the group discussion will receive [WINNIPEG AND MONCTON: $75] [MONTREAL AND TORONTO: $85] in appreciation for their effort.
May I ask you a few quick questions to see if you are the type of participant we are looking for to take part in this small group discussion? This will take about 6 or 7 minutes. The information you provide will remain completely confidential and you are free to opt out at any time. Thank you.
THANK & TERMINATE WHERE REQUIRED IN THE SCREENER: Unfortunately, we will not be able to include you in this study. We already have enough participants who have a similar profile to yours. Thank you for your time today.
Gender (By Observation):
Female - (1) Recruit 6 per group
Male - (2) Recruit 4 per group
QUOTAS:
GROUPS 1, 4, 7, 10: ALL ARE 16 TO 19 YEARS OLD – RECRUIT MIX OF AGES
GROUPS 2, 3, 5, 6, 8, 9, 11, 12: RECRUIT MIN 2 IN EACH AGE CATEGORIES, AS INDICATED
IF YES TO ANY OF THE ABOVE, THANK AND TERMINATE
QUOTAS:
RECRUIT MIX IN EACH GROUP.
AIM FOR 1 ABORIGINAL AND MIN 2 NON-CAUCASIANS IN EACH GROUP
IF THEY HAVE BEEN TO A GROUP IN THE PAST 6 MONTHS - THANK & TERMINATE,
IF THEY HAVE BEEN TO 3 OR MORE GROUPS IN THE PAST 5 YEARS - THANK & TERMINATE
IF PARTICIPATED IN A PAST GROUP ON FOOD OR NUTRITION – THANK & TERMINATE
IF 16 TO 19 YEAR OLD IN Q1 SKIP TO INVITATION
IF 20+ YEARS OLD IN Q2, CONTINUE TO Q14
INTERVIEWER INSTRUCTIONS:
If yes – Email nutrition label email and confirm they can view the label before proceeding with asking the remaining questions on the screener.
If no - Set-up time for a call-back when they are able to have the email in front of them during the recruitment call and continue with the screening questions.
ONCE THEY HAVE RECEIVED THE EMAIL AND ARE LOOKING AT THE LABEL, PROCEED WITH THE INTERVIEW:
The label you are looking at appears on a 500 ml container of ice cream. Please keep it open on the screen while I ask you some questions about the information on the label. Some other people said they found it useful to have pen and paper in front of them for some of the questions.
NOTE TO INTERVIEWER:
Ice Cream Container Label for Respondent
| Answer | Correct | Not Correct | Correct Response Must Be |
|---|---|---|---|
| Q.14A | 1,000 | ||
| Q.14B |
|
||
| Q.14C | 33 | ||
| Q.14D | 10% | ||
| Q.14E | No | ||
| Q.14F | Because it has peanuts/peanut oil | ||
| Total Correct |
INVITATION
Based on your responses, it looks like you have the profile we are looking for. I would like to invite you to participate in a small group discussion, called a focus group, we are conducting at [#] PM, on [date]. As you may know, focus groups are used to gather information on a particular subject matter; in this case, the discussion will touch on the food choices you make. The discussion will consist of 8 to 10 people and will be very informal. It will last approximately two hours, refreshments will be served and you will receive [WINNIPEG AND MONCTON: $75 / MONTREAL AND TORONTO: $85] as a thank you for your time. Are you interested and available to attend?
The discussion you will be participating in will be audio and video recorded for use by the research team only to analyse the findings. Please be assured your comments and responses are strictly confidential. Are you comfortable with the discussion being recorded?
The discussion will take place in a room that is equipped with a one-way mirror for observation, allowing Health Canada employees who are involved in this research to observe the discussion without disturbing it. Some people may also be observing the discussion remotely [SPECIFY ONLY IF ASKED: via web streaming, through the use of a secure online portal]. Your participation will be anonymous and only your first name will be given to these people. Would this be acceptable to you?
During the group discussion, participants will be asked to read materials and write out short responses. Is it possible for you to take part in these activities in English (French) without assistance?
Terminate if person gives a reason such as verbal ability, sight, hearing, or related to reading/writing ability.
Since participants in focus groups are asked to express their thoughts and opinions freely in an informal setting with others, we’d like to know how comfortable you are with such an exercise. Would you say you are…?
Thank you. Just a reminder that the group discussion will be held on [DATE] from [TIME] to [TIME]. To make sure that the discussion begins on time, we ask that you arrive 15 minutes before the start. We will not be able to include you if you arrive late and you will not receive the financial incentive.
Please bring your glasses if you need them to read, and anything else you need to take part in the group discussion. Also, everyone is asked to bring a piece of I.D, picture if possible.
Someone from our company will call you back one or two days before the group discussion. To do that, we will need your contact information. RECORD AT THE TOP OF THE SCREENER
As these are small groups and with even one person missing, the overall success of the group may be affected, I would ask that once you have decided to attend that you make every effort to do so. If something comes up and you are unable to attend, please call [#] (collect) at [#] as soon as possible so we can find a replacement.
Thank you, and we look forward to hearing your thoughts during the group discussion.
Attention Recruiters
Confirming – DAY BEFORE GROUP
Health Canada – Healthy Eating Strategy Screener (Educators & Health Professionals) – FINAL
Name:
Daytime phone:
Evening Phone.:
Group 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16
| Toronto, ON (ENGLISH) | |||
|---|---|---|---|
| Date: | Tuesday, March 28, 2017 | Location: | Consumer Vision |
| Time: |
|
2 Bloor Street West 3rd Floor |
|
| Date: | Wednesday, March 29, 2017 | ||
| Time: |
|
||
| Montreal, QC (FRENCH) | |||
| Date: | Wednesday, March 29, 2017 | Location: | MBA Recherche |
| Time: |
|
1470 Peel Street |
|
| Date: | Thursday, March 30, 2017 | ||
| Time: |
|
||
Specification Summary
Hello/Bonjour, my name is [name] and I am with Corporate Research Associates, a public opinion and market research firm. I am calling today on behalf of Health Canada. We are conducting a study on food and nutrition and are looking for health professionals, educators and communicators to take part in a focus group discussion. The findings from the study will inform Health Canada’s decisions in its work on Canada’s Food Guide.
Would you prefer that I continue in English or in French? Préférez-vous continuer en français ou en anglais? [IF FRENCH, CONTINUE IN FRENCH OR ARRANGE CALL BACK WITH FRENCH INTERVIEWER: Nous vous rappellerons pour mener cette entrevue de recherche en français. Merci. Au revoir.
May I ask you a few quick questions to see if you are the type of participant we are looking for in this study? This will take about 4 or 5 minutes. Please note, the information you provide will remain completely confidential and you are free to opt out at any time. Thank you.
[ONLY IF REQUIRED] Those who qualify will receive [MONTREAL: $150] [TORONTO: $175] in appreciation for taking part in the focus group discussion.
Gender (By Observation):
COMMUNITY LEVEL EDUCATOR (CODE 8 IN Q3) ASK Q6 TO Q8
IF REGISTERED DIETITIAN ( CODE 1 IN Q3) ASK Q9
NOTE TO INTERVIEWER – FOR RESPONSE IN Q9, CLARIFY THAT THEY MEET THE FOLLOWING CRITERIA:
PUBLIC HEALTH OR COMMUNITY NUTRITION :
If you work in public health, please confirm that you work in the public sector in areas including such things as policy development, food laws and regulations, development of Canada’s Food Guide, and regulation of food labels. Work for health authorities, public health units, or school boards for example.
If you work in community nutrition, please confirm that you work with the general public in community settings (in places such as grocery stores, health authorities, community centers, etc) by assessing and promoting healthy eating.
CLINICAL OR PRIVATE PRACTICE:
If you are a clinical dietitian, please confirm that you work in hospitals, nursing homes, or other health care facilities. If you are a consulting dietitian, please confirm that you work in private practice, providing counseling and expertise on healthy eating and disease prevention to individuals or small groups.
ADMINISTRATIVE/PUBLIC FOOD SERVICE:
Please confirm that you work in facilities that provide food to large organizations; such as school/university cafeterias, hospitals, or other businesses to develop menus, work in sales, develop nutrition policies, order food products, oversee or manage kitchens, among other things.
IF REGISTERED NURSE (CODE 2 IN Q3) ASK Q10
IF PHYSICAL ACTIVITY SPECIALIST (CODE 5, 6 OR 7 IN Q3) ASK Q11 AND Q12
IF TEACHER (CODE 3 OR 4 IN Q3) ASK Q13 AND Q14
INVITATION
Just a few more questions
I would like to invite you to participate in a small group discussion, called a focus group, we are conducting at [#] PM, on [date]. As you may know, focus groups are used as research tools to gather information on a particular subject matter; in this case, food and nutrition. The discussion will consist of 6 to 8 people and will be very informal. This group will last approximately two hours, refreshments will be served and you will receive [MONTREAL: $150] [TORONTO: $175] as a thank you for your time. Are you available and interested in attending?
The discussion you will be participating in will be audio and video recorded for use by the research team only. Please be assured your comments and responses are strictly confidential. Are you comfortable with the discussion being audio and video recorded?
The discussion will take place in a focus group room that is equipped with a one-way mirror for observation, allowing members from Health Canada to observe the discussion while it is happening. Some people may also be observing the discussion remotely [SPECIFY ONLY IF ASKED: via web streaming, through the use of a secure online portal]. Would this be a problem for you?
Participants WILL be asked to read materials AND write out responses. Is it possible for you to take part in these activities in English (French) without assistance during the group discussion?
We ask everyone who is participating in the focus group to bring along a piece of I.D., picture if possible.
As these are small groups and with even one person missing, the overall success of the group may be affected, I would ask that once you have decided to attend that you make every effort to do so. In the event you are unable to attend, please call [#] (collect) at [#] as soon as possible in order that a replacement may be found.
Please also arrive 15 minutes prior to the starting time. The discussion begins promptly at [TIME] and we will not be able to include those who are late.
Please bring with you reading glasses or anything else that you need to read with or take part in the discussion.
Attention Recruiters
Confirming – DAY BEFORE GROUP
Consumers Moderator’s Guide – FINAL
Healthy Eating Strategy – Dietary Guidance Transformation
Focus Groups on Use of Canada’s Food Guide
To begin, I’d like to learn about your personal eating habits… As part of our discussion today, I’ll be asking each of you to do a few exercises. These will help me get your personal opinions, before our general discussion. I’ve put all the exercises on one placemat. [MODERATOR DISTRIBUTES PLACEMAT]
First, please take a minute to fill out the two boxes at the top of the placemat with information about your home (How many people live in your home; who shops for groceries).
Exercise #1 Now take just a minute or two and write down what healthy eating means to you – just a few words that come to mind. There are no right or wrong answers.
Exercise #2: Please take a few minutes to do the next exercise, called ‘My Eating Habits’. Put an X where you think you fit between each pair of statements. Try not to think about these too much; I am interested in your first reaction. We’ll walk through this together so you’re clear on how to do it. Then I’ll give you 5 minutes.
AFTER THE EXERCISES: Now let’s set that aside for a few minutes.
I’d like to learn more about what you eat and your eating habits.
Let’s start with what you eat…
Eating includes more than just choosing foods…
Every time you eat, regardless of where you are, you’re making a choice (for instance if you are choosing a snack, you could grab an apple, or a bagel, or a bag of chips, or a cookie…). I’m interested in understanding why and how you choose the foods you do.
You mentioned a variety of different types of information that you look for. Thinking about the food information you use…
As you mentioned, there is information available to help people with their food choices. For the rest of our discussion, I’d like to hear how you find this type of information.
Exercise #3: Think now about how you get your information…. On your placemat, please take a moment and check off which ways you prefer to access information related to healthy eating. I’ll give you a moment.
To finish up, I would like you to write down any recommendations you have for the Government of Canada on what it can do to make information about healthy eating available and interesting to you. MODERATOR CONSULT WITH BACKROOM TIME PERMITTING
That ends our discussion. Thank you for your time and ideas. Direct them to the hostess to receive the incentive
Educators and Communicators Moderator’s Guide – FINAL
Healthy Eating Strategy – Dietary Guidance Transformation
Focus Groups on Use of Canada’s Food Guide
The goal of the research is to learn about users, their healthy eating tasks, and their patterns of communications/interactions with healthy eating information. Specific objectives include:
To begin, I’d like to understand your role in educating or promoting healthy eating. Tell me a little more about the role you play in healthy eating, nutrition and/or dietary guidance.
Now let’s talk a little bit about what you do; that is how you use healthy eating information in your various role(s).
Let’s talk a bit about the tools and resources you use to help you in each of these roles.
For the remainder of our discussion, I’d like to hear your ideas on what might improve information on healthy eating. …
To finish up, I would like you to jot down your recommendations for the Government of Canada on what it can do to make information about healthy eating available to you, and how it could be presented to make it most useful. MODERATOR CONSULT WITH BACKROOM TIME PERMITTING
That concludes our discussion. Thank you for your time and input. Direct them to the hostess to receive the incentive
Policy Makers’ Interview Protocol – Final
Healthy Eating Strategy – Dietary Guidance Transformation
I would like to begin by thanking you for taking the time to help us with our market research study. Our discussion should take about 30 minutes.
As you may recall from the information provided when we first contacted you, Health Canada is working to provide the right information on healthy eating to the right people, in the right format at the right time. The Canada Food Guide is well-integrated into policies and programs, and consumer awareness is high, but stakeholders report Canadians are challenged in interpreting and applying guidance. The current format, an all-in-one policy and education tool is not meeting the needs of all audiences.
Currently, we are conducting research with consumers, educators, communicators and health professionals and policy makers across the country, to understand how information on healthy eating is used and what is needed going forward. In our conversation, please share your responses from the lens of the policy setting discussed during our initial contact with you.
With your permission, I’d like to audio tape our discussion, so I don’t have to take detailed notes. I will be the only person who will listen to the tape, and it will only be used to help me write a report on the study findings. Everything you say will be anonymous and confidential. Your comments will be combined with those from others that I interview, as part of a detailed report. Any questions before we begin?
To begin, I’d like to understand what you do; that is how you use or need healthy eating information for policy development implementation and evaluation.
Thinking about the information you use to help you with your work.
That’s all my questions. On behalf of Health Canada, thank you for your participation.