Year

2013

Degree Name

Doctor of Philosophy

Department

School of Medicine

Abstract

Dietetic practice is continuing to develop and evolve within a context of changing health paradigms. These paradigms are currently shifting, moving from a ‘medical illness’ paradigm to a ‘wellness and wellbeing’’ paradigm. In this newly evolving paradigm ‘holistic’ outcomes are valued and lifestyle behaviours such as healthy food choice are recognised to play an important role in achieving optimal health. These shifts are also reflected in changes in other areas of society such as the access and ownership of health care. This ownership is moving from being predominantly managed by health professionals to more proactive management by the individuals themselves. The changes in health care ownership recognise the individuals’ rights to information as well as their pivotal role in the health decision-making process. In keeping with this change, the Dietetic discipline globally recognises the person or patient-centred model as being fundamental to effective practice. (American Dietetic Association (ADA) 2002a; World Health Organisation(WHO) 2005) (American Dietetic Association (ADA) 2002a; World Health Organisation(WHO) 2005) (American Dietetic Association (ADA) 2002a; World Health Organisation(WHO) 2005) However it is not clear how the change in the health paradigm is being understood by the Dietetic practitioner, or by those with whom they work, with respect to food choice behaviour.

Examination of discourse and language is a methodology that help reveal the possible meanings attributed to changing phenomena and how those meanings are being interpreted by individuals and groups within society. In particular, the keywords ‘wellness and wellbeing’ appear to have significant agency within this newly evolving holistic health paradigm and are found embedded in a number of discourses such as social and professional practice about food. Thus these terms are worthy of examination from within a dietetic context to ascertain how they might be interpreted by individuals in relation to food choice behaviour. In this thesis women were considered the dominant gender in the procurement and serving of food and so were targeted for study on the ‘how and why’ individuals might consider changing their behaviours in areas relevant to Dietetic practice. Hence the aims of this thesis were to:

1. Describe the meaning of ‘wellness’ and ‘well-being’ attributed by stakeholders and women commonly involved in nutrition interventions; 2. Identify the relevant dimensions of those terms that might contribute to food choice decisions; and 3. Evaluate those dimensions identified in a particular dietetic context of a dietary weight loss trial.

To address these aims a collective of five case studies with women participants was undertaken using qualitative methodologies. These series of case studies were combinative to build textual data around the dynamic influences impacting food choice in the current wellness and wellbeing paradigm. This studies included a combination of 15 focus groups (n= 80), and in-depth interviews (n =183) which were conducted using semi-structured guides. A synopsis of the case studies follows:

- the first case study examined how female consumers interpreted nutrition messages differentiated by use of ‘scientific’ and ‘lay person’ keywords to communicate food benefits. These messages were identified from contemporary food advertisements reflecting the current health paradigm incorporating wellness and wellbeing concepts.

- the second case study explored female consumers beliefs, attitudes and understanding around the incorporation of an exemplary core food promoted by health authorities as contributing to improved health and wellbeing – baby leafy green vegetables. This case study was designed to gain a better understanding of contemporary food choice behaviours within the evolving health, wellness, wellbeing paradigm.

- the third case study explored if the terms wellness and wellbeing were meaningful to groups of women typically targeted for nutrition interventions and identify if there were any perceived relationships with food choice and these terms. - the fourth and fifth case studies were ethnographic in nature specifically exploring the perspectives of the meaningfulness of the terms wellness, wellbeing and its relationship to food choice with: women involved in a weight-loss trial to manage overweight and obesity; and the dietary-trial dietitians’ working with these women.

Hence to address the second aim the first two case studies provided data around food choice decisions and purported behaviours through examining how nutrition messages are being interpreted and how food choices appear to be enacted. The third case study provided data on how these terms were being interpreted by women commonly targeted for nutrition intervention to address the first aim. The fourth and fifth case study provided data on interpreting how dietary change implementation might be interpreted within the evolving paradigm of wellness and wellbeing to address the first and third aim. These final two case studies included in-depth thematic analysis of female participants’ interviews (n =34) in a 12 month weight loss trial at initial and end stage time points as well as Dietetic practitioner stakeholders (n=7) delivering dietary advice as part of the weight-loss trial. Inductive analysis of qualitative data was used to describe the way these terms were perceived to be related to food behaviour.

The findings from these studies have been used to develop a new theoretical framework of wellness, wellbeing and food choice for use in Dietetic practice with overweight and obese women. The framework involves reference to four dominant themes: Desired outcomes (most sought after result); Attaining Control (selfmanagement strategies); Internal Influences (various personal inner factors influencing behaviours); and External Influences (plethora of peripheral factors influencing behaviours).

In conclusion ‘wellness and wellbeing’ appear to be meaningful terms for contemporary Australian women. Assisting women to articulate their own notion of a satisfying life with respect to their perspectives of wellness and wellbeing as well as their individual indicators for successful outcome/s for enacting dietary change is a useful starting point for supporting dietary change. Identifying an individual’s specific set of influences that may support or impede change may also provide an opportunity to develop and/or enhance capacity building that would enable health goals to be achieved. This research will contribute to the understanding of patient centred Dietetic practice and the effective use of language within food-health communications. There are opportunities to develop and evaluate the theoretical framework identified as a tool for practice for both patient self-evaluation and Dietetic practitioner use in weight loss settings. This can occur with women as well as a broader representation of gender, and cultural backgrounds.

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Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.