Motivations to eat healthily in older Dutch adults - a cross sectional study

Western populations are aging and this will have significant social and economic consequences. In the Netherlands, 17% of the population is aged 65 years and older [1]. This is around the European average, but higher than the proportion in the United States (13%) [2]. Nowadays, an average Dutch person aged 65 years is expected to live another 20 years [3]. Life expectancy continues to increase throughout the world. It is estimated that in 2040, 26% of the population will be aged 65 or older [2]. This will lead to a greater awareness of the importance of improving the quality of life of older adults by all parties involved.

Studies examining lifestyle characteristics in relation to health among older adults showed that nutrition is an important modifiable determinant of health and that a healthy diet can add years to life, as well as improve the quality of life in old age [4]-[7]. Despite continuous efforts to promote a healthy diet, the dietary intake of older adults still does not meet the recommendations [8]-[10].

Healthy food choices are influenced by a complex combination of many factors. Studies in younger adults showed that health motivations and expectations are of major importance to people’s food choice [11],[12]. The later adulthood is a critical period for healthy eating as chronic diseases will typically present themselves during this stage in life and the consequences of dietary change may be noticed more directly. However, few studies have investigated the underlying motivations for older adults to eat healthily. This information provides insight in why older adults want to eat healthily and is important for the development of effective interventions aimed at improving the dietary quality and subsequently the health of older adults. Two qualitative studies showed that the desire to stay healthy, to regain or maintain fitness and to preserve general health positively influenced food choice in older adults [2],[13]. Others showed that the desire to improve the quality of life, to increase longevity, and to prevent diseases were strong motivating factors for eating healthily in older adults [14].

The older population in particular is a heterogeneous group and behaviors may differ by subgroup, i.e. socio-economic position (SEP) or health status. Therefore, it is not only important to know what motivates older adults to eat healthily, but also to identify potential differences in motivations between these subgroups. It has been suggested that motivations for healthy eating may play a role in explaining SEP differences in diet [12]. A previous study in older adults showed that those with higher education levels were more likely to report the prevention of disease as a motivation for healthy eating [14], suggesting that they acknowledge the link between healthy eating and health. Others showed that adults with lower incomes place more importance on price than health in their food choice compared to those with higher incomes [15],[16], but very few studies have tested this in older adults.

The aims of the current study were first to identify what motivations older people have to eat healthily in a large population-based sample and second, to investigate to what extent these motivations are particular to specific subgroups according to SEP and other demographic, lifestyle and health characteristics.

The frequencies of the reported motivations to eat healthily are presented in Figure 1. The most reported motivations were “feeling fit” (51.7%, N = 543), “current health” (49.7%, N = 522), “body weight” (39.2%, N = 412) and “to prevent diseases in the future” (28.7%, N = 301). The least reported motivations were “appearance” (2.6%, N = 27), “current disease” (8.5%, N = 89) and “taste preference” (14.5%, N = 152). Most respondents (78%, N = 920) reported two motivations to eat healthily and 96 (9.1%) respondents reported a single motivation. Despite the instruction to choose a maximum of two motivations, 34 (3.3%) respondents indicated more than two motivations. Six (0.6%) respondents indicated to have other motivations to eat healthily: my vegetarian lifestyle, tradition, not important, attention to and care for food, never thought of it and avoidance of feeling guilty.

In additional multivariate analyses we investigated the role of specific diet related chronic diseases (CVD, hypertension and DM) and nutritional knowledge in motivations to eat healthily. Older adults with CVD were less likely to report “to prevent diseases” (OR: 0.68, 95% CI: 0.48-0.97), but were more likely to report “current disease” (OR: 2.59, 95% CI: 1.54-4.33) as motivations than those without CVD. Those with hypertension were also more likely to report “current disease” (OR: 1.67, 95% CI: 1.03-2.72) as a motivation than those without hypertension. Older adults with DM were less likely to report “feeling fit” (OR: 0.53, 95% CI: 0.34-0.84), but more likely to report “current disease” (OR: 3.85, 95% CI: 2.12-6.99) as motivations than those without DM. Older adults with a higher nutritional knowledge score (≥10 points) were more likely to report “to prevent diseases” (OR: 2.17, 95% CI: 1.37-3.45) as a motivation than those with a lower score (≤5 points). We observed no other associations between nutritional knowledge and motivations to eat healthily.

In this study we aimed to identify what motivations Dutch older adults have to eat healthily in a large population-based sample and to investigate if these motivations were associated with SEP and other demographic, lifestyle and health characteristics. We showed that the top three most reported motivations were: “feeling fit”, “current health” and “body weight”. More importantly, the reported motivations did largely depend on the characteristics of the older adults. Older adults with physical health problems and a poor self-rated health were more likely to report “current disease” as a motivation to eat healthily. Older adults with lower SEP were less likely to report “to prevent diseases” and those with obesity were less likely to report “current health” as motivations to eat healthily.

In our study “current health” and “feeling fit” were the most reported motivations for the overall sample. This is consistent with other studies that showed that health status is an important motivation to eat healthily in adults [11],[15],[26] but also important in older adults [14],[27] This is not surprising, because older adults are most likely to suffer from diseases and their consequences. It is not clear from the literature whether having health related motivations to eat healthily is more strongly associated with a healthy diet than other motivations. Previous research did show that health related motivations are important determinants for a healthy diet [28],[29]. However, Satia et al. showed that health related motivations were not associated with dietary change after a 12 month randomized intervention trial among adults [26]. It should be noted that the study was performed in a relatively healthy sample, and health concerns therefore may have played a minor role. In our study “current disease” was especially important for those with chronic diseases and for those with a poor self-rated health. This may indicate that those with chronic diseases and a poor self-rated health are aware of the link between nutrition and health and that the presence of a disease is an important motivation to eat healthily in older adults.

Special attention should be paid to lower SEP groups. Those with lower incomes and lower education levels were less likely to report “to prevent diseases” as a motivation to eat healthily, even after adjusting the SEP indicators for each other and the other factors. A study among US older adults also found that those with lower education levels were less likely to report preventing disease as a motivation to eat healthily [14]. A study among adults showed that a lower income was related to less importance of health considerations in food selection [12]. These results are remarkable because it is known that low SEP is associated with a higher risk of diet-related chronic diseases [30]. One explanation could be that higher levels of education provide greater access to health information, knowledge and cognitive benefits that are preventive for diet-related chronic diseases [31]. Indeed, lower education levels are associated with a lower nutrition knowledge including the diet-disease links [32] and this knowledge was found to be a mediator in the SEP variation in dietary intake, especially for vegetables and fruit [33]. A second explanation could be that our findings reflect the fact that older adults with higher incomes have more financial freedom to take health aspects into account in their food choice, because of the higher costs of healthy foods [34]. This is confirmed by others who showed that adults with lower incomes and education levels place more importance on price than on health in their food selection [35]. These findings might indicate that in low SEP groups more immediate problems, such as a shortage of money to buy healthy foods are barriers for focusing on long term issues related to food, such as the prevention of diseases in the future.

Older adults with overweight and obesity were more likely to report “body weight” as a motivation to eat healthily than those with normal weight. This is consistent with other studies that showed that body weight or reducing body weight are important motivations to eat healthily [19],[26]. However, older adults with obesity were less likely to report “current health” as a motivation to eat healthily. Furthermore, the motivation “to prevent diseases’ was not associated with weight status. From a public health perspective this is surprising, because the relationship between body weight and health status is well established [36]. From a well-being perspective this might be less surprising, because obesity is a complex and multifactorial disease. It also impacts physical function, self-esteem and quality of life [37],[38], which may provide additional motivations to eat healthily for people with obesity, compared to the prospect of improving future health only. This might reflect that the presence of overweight or obesity and their direct consequences are more important motivations to eat healthily than possible future health consequences.

In the overall sample, the prevention of disease was chosen by only 28.5% of the older adults, while almost half (49.2%) of the older adults were free from diet-related chronic diseases and 71.1% rated their self-perceived health as excellent or good. One might expect that prevention of disease as a motivation to eat healthily would be of more importance in older age as the risk of chronic diseases in old age is relatively high and a healthy diet can prevent diet-related chronic diseases [39]-[42]. Healthy eating is not only of importance in younger aged; also in older aged it is associated with increased life expectancy [5],[6]. In additional analyses (data not shown) we found that older adults with a higher nutritional knowledge score were more likely to report “to prevent diseases” as a motivation than those with a lower score. This might indicate that some older adults remain unaware of the link between healthy eating and disease prevention.

The results of our study should be considered in the context of its strengths and limitations. This study is one of the first that presents underlying motivations to eat healthily in the old aged and more importantly showed that the reported motivations largely depend on the characteristics of older adults. This adds information to the existing literature and provides further insight in why older adults eat what they eat. Furthermore, the LASA study is a well-characterized study with a high response rate. This enabled us to study a large sample of community dwelling older Dutch adults. Respondents were selected on having a normal cognitive status, which has the important advantage that recall bias due to poor cognitive functioning with regard to self-reported data is limited. Moreover, only six of the 1,050 respondents reported other motivations to eat healthily than the ones presented in the questionnaire, which suggests that the most important motivations to eat healthily were included in our study. Furthermore, to study the independent associations between the factors and motivations, we adjusted the factors in the multivariate analyses for each other. However, this does not justify the underlying causal structure of all factors in their association with eating healthily via complex relations of confounding and mediation. However, it should be noted that our goal was not to test complex causal structures, but to identify subgroups and their particular sets of motivations to eat a healthy diet. Furthermore, we asked respondents to indicate their most important motivation to eat healthily. This answer might depend on the interpretation of the concept of healthy eating by the older adult in question. A final limitations is the cross-sectional design of this study and any causal associations can only be inferred.

The findings of this study suggest that promotion messages to eat a healthy diet should differ between subgroups of older adults. The message to older adults with a disease or poor self-rated health needs to focus on the presence of disease or health problem and the link with eating healthily, because this appears to be an important reason for them to eat a healthy diet. For low SEP and obese older adults disease prevention seem to be a less important motivation to eat healthily, even though a healthy diet could improve their health. Promotion messages aiming at disease prevention and eating healthily might therefore be less effective in these groups. Information and coaching about weight status and the ways a healthy diet contributes to weight loss may be more effective for the obese group. Future research should find out why low SEP groups find disease prevention of less importance. Do these older adults lack necessary knowledge about the link between nutrition and disease or is the low SEP and its associated problems a bigger issue than eating a healthy diet? Before developing tailored interventions based on motivations to eat healthily, a complete understanding of the pathway between the motivations and characteristics of the older adults is necessary.

In conclusion, the results of our study suggest that “feeling fit”, “current health” and “body weight” were the most important motivations to eat healthily in a large sample of older Dutch adults. Multivariate analyses showed that the importance of the reported motivations largely depended on the characteristics of the older adults. The presence of a disease seems to be an important motivation to eat healthily, which indicates that older adults with self-perceived or reported health problems are aware of the link between their disease and nutrition. Special attention should be paid towards lower SEP groups and obese older adults, because disease prevention seems to be a less important motivation for these older adults.