Influences on eating: a qualitative study of adolescents in a periurban area in Lima, Peru

From the pile sort analysis, six main food item clusters were identified to reflect
the results of the activity that required participants to group foods into piles according
to any system desired. When asked to describe the characteristics of the clusters
of food items and assign a name to each group, participants provided the following
responses: 1) junk food (non-nutritive, tasty, expensive, chemical); 2) grains and
beans (healthy, tasty, lunch foods); 3) vegetables (prevent disease, natural); 4)
meat (favorite, fatty, contain hormones); 5) dairy/breakfast foods (consumed daily,
contain protein); 6) fruit (prevent disease, contain vitamins). The results of the
multidimensional scaling and hierarchical clustering analysis are shown in the Fig. 1. The clusters identified are labeled, with the foods corresponding to each one shown
in the Fig. 1.

When asked to rank foods pictured on the cards from least to most healthy, items such
as beer and hot pepper were generally placed first, followed by processed foods such
as chocolates, soda, and potato chips. ‘Whole’ foods such as fruit, vegetables, beans,
meat and dairy were often placed toward the ‘healthy’ end of the list, with ‘quinoa’
ranked as the healthiest in several cases. Foods often mentioned as healthy but not
pictured included legumes such as green split peas, whole grains such as kiwicha, and fruits; unhealthy foods not pictured included high-sugar processed foods such
as cookies and candy.

In examining responses from both semi-structured interviews and pile sort data, a
number of influences on eating at the individual, social environmental, physical environmental,
and macrosystem levels were identified. Key influences with exemplifying quotes are
highlighted in Table 1.

Table 1. Key Influences on Eating in Adolescents Ages 15–17 years (n?=?14) in Periurban Lima, Peru

Individual influences

Concerns about body image

Participants, particularly females, mentioned concerns about body image and desire
to appear ‘thin’ as affecting food choices. When asked about barriers to eating well,
one female participant said that some may not eat well because “they don’t like certain
foods, or they say ‘this food will make me fat.’” Starchy foods such as bread, as
well as beans, were most commonly cited as foods that may cause weight gain.

Financial resources

Participants also mentioned lack of financial resources to purchase food, particularly
when asked about barriers to healthy eating. When describing what factors may prevent
his peers from eating well, one male participant said, “Maybe they don’t have enough
money to be able to eat well, or maybe their father leaves them money to be able to
cook and they spend it on other things, like games.”

Nutrition-related knowledge

Participants demonstrated knowledge both with regards to eating for maintenance of
health and prevention of diet-related conditions, which may potentially influence
behavior. Participants’ description of ‘eating well for health’ reflected their familiarity
with the concepts of moderation and balance. One participant described eating well
as “not eating too much,” and another cited the importance of “eating a balanced diet—not
eating a lot of fat, starch, or sweets.” There was also mention of consumption of
unprocessed foods; one participant said that healthy eating means “eating good, natural
food, and very little processed or canned food.” Some participants also mentioned
the nutritional value of specific foods. As one participant put it, “healthy eating
means eating dishes that have ingredients with vitamins, like fish, fruit, beans and
vegetables.” When asked about prevention of anemia, participants named foods such
as beans and fish as being important in the diet. Others had less knowledge of valuable
foods for anemia prevention, and mentioned the importance of the consumption of grains
such as wheat and kiwicha, while others cited non-dietary factors such as sleep and
exercise as being most important.

Taste

In both the pile sort exercise and in interviews, participants identified the foods
they perceived to be ‘tasty.’ ‘Junk’ foods such as the Peruvian soft drink Inca kola
(Coca-Cola Company, Atlanta, GA, USA) and other sugar-sweetened beverages, crackers,
and chocolate were often identified as foods pleasing to the taste but also harmful
in excess, a ‘waste of money,’ and ‘non-nutritive.’ When asked about their favorite
food and drink in interviews, many participants identified the seafood dish ceviche and soft drinks as their preferences. In the pile sort activity, when asked to name
‘healthy’ foods that they considered to be tasty, participants most often identified
foods such as fruit, beans, milk and meat.

Social environmental influences

Family

Participants reported that their families’ guidance helped them to make healthy food
choices; parents provided advice on food selection and fostered cooking skills. Parental
advice was related to consumption of foods such as fruit, vegetables, and dairy products.
In addition, parents advised participants to consume a variety of foods and to limit
LNED foods such as sugar-sweetened beverages. Family members also stressed the importance
of healthy, regular meals for disease prevention, and encouraged adolescents to consume
foods prepared at home rather than purchased from street vendors. Adolescents reported
helping their mothers to prepare dishes served at home, and in many cases were able
to list the ingredients and quantities in recipes used.

Participants’ families also provided home-cooked meals. The majority of participants
reported consuming all meals at home, with the exception of foods consumed during
breaks at school. Most participants also reported eating meals in the presence of
family members, most often their mothers and siblings. Both adolescents and their
mothers were responsible for serving food prepared at home; most participants stated
that their mother served them on at least some occasions at mealtime.

Peers

Comments revealed potential peer influences on eating. With peers, participants reported
sharing LNED items such as sugar-sweetened beverages and packaged snacks, particularly
during breaks at school. In some cases, a large bottle of soda was purchased to be
shared among friends. Comments also revealed potential peer influences on desired
body size. When describing barriers to healthy eating, one participant said, “Some
of my friends don’t eat well because they don’t have enough money or because they
want to look thin. My classmates only eat salad at lunch.”

Physical environmental influences

School

Many participants reported consumption of snack foods during the break at school.
Foods available for purchase were generally LNED items such as sugar-sweetened beverages
and packaged snacks. In some cases, prepared food such as chicken soup and fried rice
was also available for purchase during the break. Participants who reported bringing
their own snack to school rather than purchasing more often consumed items such as
fruit.

Fast-food establishments

The majority of participants reported consumption of fast food, such as fried chicken,
French fries with sausage, hamburgers, and pizza. These foods were easily available
for purchase and in some cases were taken home to eat. Among those who reported intake
of fast food, frequency of consumption varied, with some participants reporting that
they more commonly consumed these items on the weekend days, and others reporting
daily consumption. When describing her weekend activities, one female participant
said, “On the weekend I stay at home, help my mother, watch television, and I buy
French fries with sausage.”

Convenience stores and street vendors

A number of products, particularly snack foods, were purchased from stores in the
community and street vendors. Participants reported purchasing items such as popsicles,
toasted corn, chocolate, and soda. Similar to fast food, some participants mentioned
that they more commonly consumed these items on the weekend days.

Macrosystem influences

Media

When asked to describe their daily routines, all but three participants mentioned
the television and/or Internet as part of their schedule. Several participants mentioned
that they had heard information about nutrition and health on television. The messages
ranged in topic from health benefits of specific foods, to food safety, to limiting
food waste.

Nearly all participants said that computers interested them and that they used the
Internet frequently for both schoolwork and social activities. One female participate
noted, “I like to learn new things from the Internet, and play games. I use Messenger
and Facebook.” Another male participant said, “I go with my friends after school.
It’s fun to search for information, play games and watch movies and anime [Japanese
animated productions].” All except one participant had used the Internet search for
nutrition information and viewed Internet sources as credible. One female participant
said, “I looked for information about a balanced diet. I found out that fruit contains
vitamins, and the foods that make up a balanced diet are meat, chicken, eggs, milk
and beans. I used Google, and believed this information because my teacher said it
was right.”