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N EW S A N D V I EW S

DOI: 10.1111/nbu.12007

A perspective on the strategic approach to the complexity and challenges of behaviour change in relation to dietary health
C. S. Bestwick*, F. C. G. Douglas*, J. L Allan, J. I. Macdiarmid*, A. Ludbrook and S. Carlisle*
*Rowett Institute of Nutrition and Health, University of Aberdeen, Scotland, UK; Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK

Summary

Understanding the drivers for improving Scotlands dietary health is one of the key objectives within the Food, Land and People component of the Scottish Governments Strategic Research Programme (SRP). Food producer, processor, retailer and consumer behaviour relative to diet and health are investigated through the programmes Healthy Safe Diets theme. The research recognizes both the importance of food to Scotlands economy, health and wellbeing, as well as the challenges faced by the burden of obesity and dietary-related illness. The Healthy Safe Diets themes analysis of diet and behaviour has a focus on the interplay of the social, biological, behavioural and environmental determinants of nutritional health and aims to develop and test prototype policy interventions relevant to improving the health of Scotlands population. Here, we argue the necessity for concerted and coordinated multidisciplinary approaches to understand and inuence dietary behaviour within the changing technological, economic, social and cultural context of individuals within society. The SRPs structure encourages and is developing such interdisciplinary links. Inherent to this is the combining of qualitative and quantitative approaches; using the insights gained from in depth study of small numbers of people, both to provide a better understanding of the results of quantitative analysis and to inform new research questions. Placed in context with the SRPs wider research objectives (such as on physical activity, the role of urban green space, enhancing the health-benecial properties of foods and the environmental sustainability of food production and supply), SRP interconnection offers signicant opportunity to develop synergies and reconcile conicts between research areas to create cohesive policy advice and enhance health and wellbeing outcomes.
Keywords: dietary behaviour, food choice, food environment, food security, public health, strategic research

Introduction
Correspondence: Dr. Charles S. Bestwick, Food Land and People Programme Advisor, Rowett Institute of Nutrition and Health, University of Aberdeen, Greenburn Road, Bucksburn, Aberdeen AB21 9SB, Scotland, UK. Email: c.bestwick@abdn.ac.uk

The Scottish Governments Rural and Environmental Science and Analytical Services (RESAS) Strategic Research Programme (SRP) is focused on achieving outputs and outcomes within major policy agenda areas, such as climate change, land use and food security

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and, to impact on the Wealthier, Healthier and Greener strategic objectives of the Scottish Government (Scottish Government 2011a). The SRP is delivered through two programmes: Environmental Change (EC) and Food, Land and People (FLP). Their core strength is full interdisciplinary collaboration between the Scottish Governments main research providers (the Rowett Institute of Nutrition and Health at the University of Aberdeen, the Moredun Research Institute, The James Hutton Institute, Scotlands Rural College, Biomathematics and Statistics Scotland and The Royal Botanic Gardens Edinburgh). While ordered into research themes, crosstheme research is integral to the programme and regular review identies new research synergies. Embedded within its approach, the SRP actively seeks both to inform and be informed by stakeholders from policy, farming, land use, water and energy supply, food production and manufacturing, non-governmental organisations, voluntary organisations, community groups and the general public (Scottish Government 2011b). FLP is structured on four themes: Food, Health and Welfare (animal/plant and animal, respectively), Healthy Safe Diets (HSD) and Rural Communities (Fig. 1). Understanding the drivers for improving

Scotlands dietary health is one of the key objectives of FLP. Food producer, processor, retailer and consumer behaviour relative to diet and health is investigated through the HSD theme, for which Scotlands National Food & Drink Policy, Recipe for Success (Scottish Government 2009), and the Prevention of Obesity Route Map (Scottish Government 2010) are key policy platforms that recognize both the importance of food to Scotlands economy, health and wellbeing, as well as the challenges faced by the burden of obesity.

Meeting the challenge of multilevel determinants of behaviour and environments

Viewed from a socioecological health perspective, nutrition research must consider the multilevel determinants of behaviour and conditions within society: the economic, cultural and social aspects, as well as the transactions that take place between individuals within the context of their particular situations (Glanz et al. 2008). Many have argued that this perspective is the most appropriate orientation for contemporary health promotion (Swinburn et al. 1999; Stokols et al. 2003; Sallis et al. 2008; Hanlon et al. 2012; Lang & Rayner 2012; Rayner & Lang 2012). Most recently, Rayner and Lang

Figure 1 Food Land & People and the Scottish Government (RESAS) Strategic Research Programme (SRP). The 5-year (20112016) commissioned SRP comprises two interlinked programmes: Environmental Change and Food Land and People to help address major policy agenda issues within climate change, land use and food security. Food Land and People comprises four themes: Food, Animal and Plant Health and Animal Welfare, Healthy Safe Diets and Rural Communities. The research links food produced right across the food chain through to economic output, health and environmental outcomes.

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Figure 2 Rayner and Langs (2012) four dimensions of human existence model. This model recognises that concerted and coordinated multidisciplinary approaches are required to understand and inuence dietary behaviour within the changing technological, economic, social and cultural context of everyday life.

(2012) have presented a simplied ecological framework for public health that outlines four dimensions of human existence (i.e. material, biological, social and cultural), which, they argue, determines human health and wellbeing (Fig. 2). This model is relevant for the HSD theme as it recognises that concerted and coordinated multidisciplinary approaches are required to understand and inuence dietary behaviour within the changing technological, economic, social and cultural context of everyday life. In addition to collaboration on the analysis of diet and behaviour, links with the SRPs objectives on physical activity and the role of urban green space (EC-Land Use, FLP-Rural Communities, HSD Themes) add to the potential to maximise health and wellbeing outcomes. The research may also strengthen opportunities for the uptake of a range of innovations developed through the SRP in support of health improvement and economic growth. This includes the benets to be derived from research on crops and foods with improved human health traits (Food Theme), local food producers (Rural Communities Theme) consumer attitudes to farm animal welfare-friendly produce (Health and Welfare Theme), as well as from identifying and developing environmentally sustainable food choices (HSD and Food Themes). Ultimately, resilient health behaviour change will only take place if we signicantly change the way we professionals, governments and society think and act upon the big health problems that face us (Hanlon et al. 2012; Lang & Rayner 2012). The interaction between the economic, psychological, public health and social anthropological research perspective, combining

qualitative and quantitative approaches, seeks to collectively contribute to that change.

The psychology of healthy eating: Why dont people eat as they intend?
Although intuitively appealing to try and encourage healthy food choice through information provision and education, knowledge alone is typically insufcient to change behaviour. While the vast majority of people know what they should and should not eat (Scottish Government 1996), turning intentions into action is notoriously difcult. Fewer than a quarter of people who embark on a healthy eating plan still stick to it 12 months later (Dansinger et al. 2004) and around 50% of people with good intentions fail to act on them at all (Sheeran 2002). Part of the problem is that humans have a strong preference for energy-dense (i.e. high calorie relative to portion size) foods (Drewnowski 1997). The modern food environment has made these foods more accessible and affordable (e.g. Swinburn & Egger 2004). Consequently, people who know how to eat healthily and who intend to do so, must still be able to resist dietary temptation in the surrounding environment. The psychological processes used to resist temptation and regulate behaviour are the so-called executive functions multiple related but distinct cognitive processes involved in the planning, initiation and monitoring of complex goal-directed behaviour (Royall et al. 2002). It has recently been established that inefcient executive function is associated with elevated body mass index

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and obesity in children and adults (Braet et al. 2007; Cserjesi et al. 2007; Gunstad et al. 2007; Cserjesi et al. 2009) and with a reduced ability to stick to dietary intentions in the face of temptation (Allan et al. 2010, 2011; Hall et al. 2008). Even individuals with extremely efcient executive function cannot perfectly control their behaviour all of the time. Laboratory studies demonstrate that self-control resources are nite and become depleted with use (Baumeister 2002; Schmeichel 2007). In other words, people have a limited amount of the mental energy required to resist temptation. In HSD, research explores this further by following people with healthy intentions in real time as they go about their everyday lives. Dietary choices, mood and current activities are recorded using computerised diaries. Changes in mental energy (i.e. executive function) are assessed using psychological tests programmed into wristwatches and location and surroundings are recorded using Global Positioning System (GPS) trackers and Geographic Information System (GIS) mapping technology. This enables the creation of a detailed, real-time picture of the psychological, social and environmental factors that seem to trigger episodes of unintentional unhealthy eating. Ultimately, health depends on actual rather than intended food consumption, so it is vital to identify when, where and why peoples healthy intentions fail.

What can economics contribute to healthier eating?

The rst things that usually spring to mind when considering economic factors that inuence food choice will be price and income. Within HSD analysis of choice behaviour and potential mechanisms of change, a wider perspective is taken. The cost of acquiring a healthy diet also depends on factors such as the accessibility and availability of food, as well as the time, skills, knowledge and facilities for food preparation. Individual preferences shape how individuals value different foods and, hence, how much they are willing to pay for them. Preferences are inuenced by a range of factors, which may include household behaviour and social norms, as well as past exposure to food items. The research is also concerned with inequalities and exploring the differential impact that different policies to promote healthier diets may have. Food prices and the budget available are certainly important but despite recent price increases, food is generally more affordable compared with the past, and this has contributed to problems with obesity. Increasing female participation rates in employment, leading

to reductions in food preparation time and an increase in convenience and take-away foods, have also been seen as a driver. There has been considerable discussion about whether taxation could be used to reduce consumption of foods that are high in fat, sugar or salt (Tifn & Arnoult 2011; Mytton et al. 2012) and, conversely, whether subsidies on healthier choices would increase their consumption. While price changes will have an effect on what is purchased, the use of tax and subsidy to inuence diet is complicated by other behavioural factors and inuences on choices. Research in behavioural economics (which combines economics and psychology) demonstrates that individuals are more easily persuaded to adopt new behaviours than to give up old ones (Just et al. 2007; Epstein et al. 2012). For example, subsidising fruit and vegetable consumption (the spectrum of the health bioactivity effects for which, are currently under concerted investigation within the HSD and Food Themes) is likely to be more effective in changing behaviour when compared with reducing the consumption of high fat, high sugar products through taxation. Nevertheless, adding fruit and vegetables to the diet may improve nutrition but if other food consumption does not decrease then an amelioration of obesity would be thwarted. Behavioural economics also identies different responses to products, which are considered simply to full a necessary purpose (utilitarian) and those which provide pleasure (hedonic). The way in which UK consumers have responded to recent food price increases illustrates this. Over the period 20072010, the average price of sweets and chocolates rose by 22% but consumers bought slightly more rather than less, while increasing their expenditure by only 15% (DEFRA, 2011). People protected their consumption of these hedonic products by trading down; i.e. purchasing cheaper types of products within the same category. These are just some of the issues that make the economics of food choice more complex than simply considering price and income. HSD research examines how the effect of price and income on food choice may be mediated and inuenced by other factors.

The public health perspective regarding behaviour change and healthy eating
Much traditional public health practice in recent decades has tended to privilege individually focused behaviour change interventions as the primary means of encouraging health behaviour change (Lang & Rayner 2012; Rayner & Lang 2012). Many argue that this approach fails to deal with multiple determinants of

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health and health behaviour in the modern era (Lundy 2010; Rayner & Lang 2012). Furthermore, evidence suggests that recent efforts to persuade people to follow healthier lifestyles have served to benet wealthier sections of society and have widened health inequalities still further (Buck & Frosini 2012; ODowd 2012). The challenge for public health nutritionists within Scotland and indeed globally, is to encourage and support behaviour change that enables all members of society to enjoy optimal nutrition without exacerbating current health inequalities and, increasingly with a requirement to do so in an environmentally sustainable manner. The HSD themes public health research is concerned with understanding the internal worlds of individuals and communities (Wilber 2001), that is, what people think day-to-day, the everyday meanings they ascribe to aspects of daily living (like food purchasing and mealtime practices) and with exploring collective (community) mindsets surrounding such issues. Consequently, research is associated with identifying lay and organisational perspectives relating to food and nutrition (i.e. purchasing choices and practices) with a view to developing policy interventions that might plausibly bring about sustained behaviour change for health. Exploring the perspectives and experiences of disadvantaged populations around these issues is of particular concern given emerging evidence that suggests that more and more people in the UK are experiencing a nutrition recession (The Guardian 2012). For example, work is about to commence that uses ethnographic and action research methods with young marginalised adults living in the north east of Scotland to understand their lived experiences regarding their day-to-day food choices, and to explore plausible policy interventions that might optimise the nutritional value of those choices.

disciplines. In modern Scotland (and elsewhere) food choice at all levels of society is also likely to be inuenced by larger processes, including globalisation (which brings exposure to previously unfamiliar cuisines) and postindustrialisation (which has resulted in widening social inequalities, multiple deprivation, multigenerational unemployment and social exclusion for some). Other widespread social and cultural changes since the middle of the 20th century that impact on food choice are the changing nature of the family and womens role in society, as well as the increase in materialism and individualism. The latter is inextricably linked to the rise of consumerist values, with implications for personal and social identity (Carlisle et al. 2009). Modern society is, for many reasons, both marked by anxiety, insecurity and unease, and is distinctively different from any earlier social form. This is the larger context in which individual food choice decisions are made. From this perspective, the suggestion that we are what we eat has signicance beyond the purely nutritional and, that this signicance demands further exploration at community level. HSD research therefore utilises qualitative methods with individuals, families and groups across Scotland to understand people and the social and cultural contexts in which they live from the participants points of view. This type of knowledge has much to contribute to our understanding of food choice across society and can potentially help shape more successful interventions (Crotty 1993).

Behavioural change and global food security

Food security seeks to meet the challenge of providing the worlds growing population (projected to reach nine billion by 2050) with an environmentally sustainable, secure supply of safe, nutritious food from less land and with lower inputs (Rosegrant & Cline 2003; Garnett 2008; Buttris 2010; Marsh 2012; www.foodsecurity. ac.uk). The SRP is an important component of the Scottish Governments commitment to the UK Global Food Security (GFS) Programme (www.foodsecurity. ac.uk). Improving nutrition, accessibility and consumer behaviour are components of GFS priorities. The 21st century nds human beings living in increasingly complex and dynamic situations that have been shaped and are being shaped by rapid technological, economic and social changes (Hanlon et al. 2010; Lang & Rayner 2012). While those changes have brought undoubted societal and human health benets; there are increasing rates of childhood and adult obesity globally (Foresight 2007), rising food insecurity and malnutrition in both

Perspectives from sociology and social anthropology: Food choice in modern society
Additional insights into the social and cultural complexity of food choice can be gained by drawing on the distinctive perspectives provided by sociology and social anthropology. Prominent researchers in these elds have long insisted that food choice is always a social and cultural act, as much as an individual one (Mennell et al. 1992; Beardsworth & Keil 1997). In contrast to behavioural approaches, sociological and anthropological approaches aim to explain eating patterns in relation to their sociocultural contexts. The symbolic possibilities of food, together with the cultural and material conditions that shape food choice, have been examined by both

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poorer (for which a double burden of disease, arising from both under- and over-nutrition in the same country, is developing) and wealthier nations (Patel 2008), as well as widening health inequalities within and between nations (WHO 2008; Scottish Government 2012). Within the intense climatic and resource pressures on agriculture and food production (Garnett 2008), the GFS agenda poses the need to place food choice and the public health environment within a range of other environments, in particular, the environmental sustainability of food production and supply. This adds another layer of complexity for consumers. The SRP is addressing this issue. Again, the interdisciplinary approach is vital to the understanding, development and uptake of environmentally sustainable healthy diets. FLPs work on food production and supply chains; agricultural resource use; control of farm animal and plant health; diet and human health, including HSDs work on dietary health behaviour; and, rural communities research, are all key transferable outputs to the national UK and global food security level.

Theme Leader) for assistance. The authors acknowledge funding from the Scottish Government (RESAS DivisionStrategic Research Programme). AL also acknowledges funding from the Chief Scientist Ofce (HERU core funding).

Conict of interest
The authors do not have any conict of interest to disclose in expressing the views within this article.

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Conclusion
The analysis of diet and behaviour within HSD has a focus on the interplay of the biological, behavioural and environmental determinants of nutritional health and aims to develop and test prototype policy interventions relevant to improving the health of Scotlands population. Rayner and Langs analytical framework (Fig. 2) emphasises the necessity of making connections between researchers from different academic disciplines. HSD dietary behaviour research is actively developing these connections. Inherent to this is the combining of qualitative and quantitative approaches, using the insights gained from in depth study of small numbers of people, both to provide a better understanding of the results of quantitative analysis and to motivate new research questions. When placed in context with the SRPs other research objectives, such as on the environmental sustainability of food production and supply, these interconnections offer the opportunity to develop synergies and reconcile conicts between research areas to create cohesive policy advice. Through its scale and interdisciplinary structure, the SRP recognizes that major complex challenges with Scotlands policy agenda demand a major coordinated and interdisciplinary response.

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The authors thank Wendy Russell, Peter Morgan and Pieter Van de Graaf for critically reading drafts of the article. The authors also thank Harry McArdle (HSD,

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