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Promoting healthy food purchasing habits

Sue Baic
MSc RD RNutr
Senior Lecturer in Nutrition and Public Health
Department of Exercise, Nutrition and Health Sciences
University of Bristol

Primary care nurses are well placed to help patients translate public health information into practical food choices, especially in times of economic hardship. Sue Baic explains how you can enable patients to overcome some of the physical and financial barriers they face when trying to shop and cook more healthily.

There is widespread agreement on the healthy dietary guidelines needed to manage many chronic health problems, such as obesity, type 2 diabetes and cardiovascular disease. Unfortunately, surveys show this dietary advice is not widely translated into practice by many patients even during times of economic stability.

Historically, in times of economic recession and rising food costs, consumers have tended to turn towards cheaper, processed foods rather than buy and prepare meals from scratch. Very often, these foods contribute to an overall diet higher in saturated fat, salt and sugar. Recent consumer surveys have shown that, although adults feel healthy eating remains a concern, during this time of economic hardship many are watching their food expenditure more closely.
Patients face a whole host of obstacles as they try to put our dietary advice into action when shopping and cooking. It can be helpful for primary care nurses who offer lifestyle advice to explore with patients ways to translate messages into practical food choices that overcome both physical and financial barriers.

Relevance and application of nutrition messages
Providing clear and unambiguous dietary information can be invaluable in aiding food choices. Patients who are told of the importance of eating more fruit and vegetables may actually be unaware that the message has personal relevance.

Consumer surveys suggest that, although the majority of people are aware of this message, many think they are already eating enough fruit and vegetables.1 Information on specific numeric targets to aim for and portion size can help with this.

The same surveys show people may also be aware that fresh fruit and vegetables count towards intake but less aware of the role that frozen, dried, canned and juiced varieties can play in meeting this need. Guiding patients towards suitable resources with appropriate and attractively presented practical translation of this information can be very useful in increasing understanding and translation into practice.

Nevertheless, the provision of written dietary information on its own may be insufficient to influence behaviour. One randomised, controlled trial (RCT) looked at patients with hypertension given health promotion advice on increasing fruit and vegetable intake by nurses.2 In this study, the provision of an information booklet on its own had relatively little effect on increasing fruit and vegetable consumption above baseline but was considered useful in increasing intake as part of a package including regular face to face lifestyle prompts from health professionals.

Enhancing practical knowledge and skills
There is evidence that enhancing practical knowledge and skills in relation to food shopping and preparation may be useful in influencing behaviour. Many consumers try to use quantitative nutritional information on food labels to make healthy choices.

However, they often report being confused by nutrition label information, and say they would like to know how to interpret the nutrition labels more easily and effectively when they buy pre-packed foods. Helping people to practise navigating and understanding point of sale information, for example, on the food label, can help them make quick and informed food choices at a glance. Traffic light labelling can be used to compare products or brands to see which provides lower levels of sugar, salt or saturated fat.

The confidence in one's ability to obtain and prepare healthy food is strongly predictive of putting these healthy eating behaviours into practice. In one recent study, focus group discussions were used with women of lower educational attainment. These helped identify factors that influenced and improved their food choices.3 The dominant theme of the discussions was a sense that the participants lacked control over food choices for both themselves and their family.

Research from the Department of Health in 2008 showed that some families find food shopping both confusing and stressful. Many reported sticking to a pattern of purchasing the same convenience foods over and over again for ease. Healthy eating store tours can be an efficient and effective means of changing behaviour to promote healthier food purchases.4 These small group nutrition education approaches take place in a local community supermarket, often the patient's usual place of food purchase. They can be run by healthcare professionals such as nurses with a good knowledge and understanding of food and nutrition and an awareness of group facilitation skills. The participants are actively involved in the education process and encouraged to share solutions to problems, and provide personal money saving or practical tips and healthy meal ideas. They are encouraged to critically examine foods they normally eat and consider alternatives where appropriate, enabling participants to view their store with fresh eyes next time they are shopping.

Some of the key barriers to buying healthy foods for home cooking are a lack of cooking skills, anxiety around preparation and the belief that preparing meals from fresh ingredients is too time-consuming to fit into a busy lifestyle. Fruit and vegetables in particular have been identified as causing confusion with patients often unable to identify ways to cook and prepare them. "Cook and eat" groups in primary care settings can address the lack of basic cooking skills. They can teach simple recipes for dishes such as soups, stews and pasta sauces as well as modifications to favourite recipes such as pizza toppings to make them healthier. A healthy recipe competition can be used to generate examples, which can be bound and sold to the group at a low price. Costing comparisons of the recipes showing savings in price and gains in nutrition over ready meals can be instructive.

We also know from consumer surveys that, for many people, the first concern when food shopping is cost rather than health benefit. In particular, low-income consumers spend a greater proportion of their gross income on food than their high-income counterparts, and value for money in relation to food is a key driver of eating behaviour. Low-income families are often heavily influenced by "buy one get one free" offers, which are very often on more processed foods with higher levels of fat, salt and sugar. The Institute of Grocery Division (IGD) research shows there has been a significant rise in the number of shoppers who try new products on promotion (17%, up from 13% in 2004).5 They estimate that around 25% of all consumers look out for promotions as they believe they are getting better savings than they would with constant lower price strategies. However, such price promotions can be detrimental to the diet if they encourage buying of less healthy foods or foods the consumer does not really need. For this reason it can be helpful to alert patients to the strategies used to promote special offers at eye level or end of aisle where traffic is heavy and slower. Some strategies to help purchasing healthy foods more cost effectively are included in Box 1.

[[Box 1 nutrition]]

Reducing food waste not only saves money, it is also more environmentally friendly. In low-income families there is often little economic flexibility to experiment and risk food rejection. Many families on a limited budget restrict the purchase of fresh food in a bid to avoid risking waste as they fear it will deteriorate before it is consumed. The need to balance cost and waste is seen as a recurrent theme in research. In one recent survey on shopping in a recession, nearly a quarter of consumers said they would now value the provision of inspirational recipes on using leftover food; and nearly half wanted ideas on better food planning in a bid to reduce waste.6 Some strategies to help reduce waste when purchasing healthy foods are included in Box 2.

[[Box 2 nutrition]]

Physically accessing affordable healthy food can be a problem if local shops are expensive or poorly stocked and transport is difficult. A food purchaser for a family of four would need to carry home around 8.5 kg or 19 lbs a week of fruit and vegetables just to provide the recommended five a day.

Home delivery of some or all groceries is available from larger supermarkets as well as specialist local providers of fresh produce. In a recent study, women of lower educational attainment highlighted the difficulties they found in transporting heavy and bulky fruit and vegetables.7 They felt that home delivery of locally grown foods would be helpful and that any associated lower costs would help them experiment with less worry about waste.

In a low-income area of the UK, self-reported consumption of fruit and vegetables was shown to increase from 1.5 to 3.3 portions per day in the lowest income group following introduction of a locally grown box delivery scheme.8 Preliminary studies have suggested that commercially available online grocery ordering and home delivery may have the added benefit of reducing access and impulse purchases to high-fat food choices and decreasing the number of high-fat food items in the home.9

Identifying and exploring these barriers to healthy shopping and cooking with a patient can be very effective for promoting dietary change. Discussing a "typical day" is a useful starting point, and can lead to an assessment of motivation and confidence, and identification of personal barriers to change. Individualised goal setting is a valuable technique from the field of counselling, which can usefully be adapted to changing dietary behaviour. Food diaries are another useful tool for self-monitoring of progress and can be use as a discussion point in follow-up sessions.

Several studies have compared the use of these dietary counselling techniques with standard information and advice giving. John et al (2002) carried out an RCT of a brief negotiation method to encourage an increase in consumption of fruit and vegetables to at least five daily portions. This study was conducted in a group of healthy adults in a primary care setting. At follow-up six months later, self-reported fruit and vegetable intake increased in the intervention group, which was verified by antioxidant biomarkers in the blood. In addition, both systolic and diastolic blood pressure fell significantly in the intervention group.10

Dietary counselling techniques seem to be both feasible and effective in a variety of settings, including with low-income and ethnically diverse groups.

Steptoe et al (2003) compared the effect of two 15-minute sessions of standard nutrition education with two brief sessions of individual behavioural counselling, using motivational interviewing techniques with healthy adults in a deprived, ethnically mixed inner GP practice.11 At one-year follow-up, self-reported fruit and vegetable intake, supported by blood biomarkers, showed that both groups had increased intake; but the level of increase was significantly higher in the motivational interviewing intervention group (by 1.5 portions per day). This difference was maintained even when analysis was restricted to participants with the lowest reported incomes. The proportion of participants eating five or more portions a day increased by 42% and 27% in the motivational interviewing and brief counselling groups, respectively.

Conclusion
Primary care nurses are well placed to help their patients adopt healthy lifestyles. Moving beyond a purely "information-sharing" role, they can offer help and support in translating this evidence-based dietary advice in decision-making around healthy food practices when shopping and cooking. They can help identify barriers to dietary change and promote skills to help overcome the practical, physical and financial constraints that patients commonly face.

Recommended reading and resources
Practical translation of this dietary information on fruit and vegetable consumption
W: www.5aday.nhs.uk/topTips/default.html

Useful guidelines on food labelling
W: www.eatwell.gov.uk/foodlabels/trafficlights
W: www.diabetes.org.uk/Guide-to-diabetes/Food_and_recipes/Shopping

Information on ways to shop economically
W: www.moneysavingexpert.com
W: www.lovefoodhatewaste.com

Information on dietary counselling techniques
W: www.motivationalinterview.org

References
1. Food Standards Agency (FSA). Consumer Attitudes to Food Standards: Wave 8. UK Report Final. London: FSA; 2008.
2. Little P, Kelly J, Barnett J, Dorward M, Margetts B, Warm D. Randomised controlled factorial trial of dietary advice for patients with a single high blood pressure reading in primary care. BMJ 2004;328:1054.
3. Barker M, Lawrence WT, Skinner TC et al. Constraints on food choice of women in the UK with lower educational attainment. Public Health Nutr 2008;11(12):1229-37.
4. Baic S, Thompson J. Using grocery store tours as a tool to provide effective nutrition education interventions for clients interested in heart health. ACSM's Health & Fitness Journal 2007;11(1).
5. Institute of Grocery Division. The impact of in-store promotions - the shoppers' view. Available from: www.igd.com/index.asp?id=1&fid=1&sid=8&tid=16&cid=5
6. Institute of Grocery Division. One in four shoppers want leftover meal solutions to help reduce food waste. Available from: www.igd.com/index.asp?id=1&fid=6&sid=25&tid=90&cid=834
7. Pollard J, Kirk SF, Cade JE. Factors affecting food choice in relation to fruit and vegetable intake: a review. Nutr Res Rev 2002;15:373-87.
8. Bremner P, Dalziel D, Evans L. Evaluation Of The 5 A Day Programme: Final Report, April 2006. London: Big Lottery Fund; 2006. Available from: www.biglotteryfund.org.uk/er_eval_5aday_report_evaluation.pdf
9. Gorin A, Raynor HA, Niemler HM, Wing RR. Home grocery delivery improves the household food environments of behavioral weight loss participants: results of an 8-week pilot. Int J Behav Nutr Phys Act 2007;4:58-63.
10. John JH, Ziebland S, Yudkin P, Roe LS, Neil HA; Oxford Fruit and Vegetable Study Group. Effects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: a randomised trial. Lancet 2002;359:1969-74.
11. Steptoe A, Perkins-Porras L, McKay C, Rink E, Hilton S, Cappuccio FP. Behavioural counselling to increase fruit and vegetables in low income adults: randomised trial. BMJ 2003;326:855-8.