RESEARCH ARTICLE

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Healthy Eating:What Does It Mean to Adolescents?

JILLIAN K. CROLL, DIANNE NEUMARK-SZTAINER, AND MARY STORY

Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota
55454

ABSTRACT

Objective: The objective of this study was to investigate the meanings of “healthy” and “unhealthy” eating and the
importance of healthy eating among adolescents.

Design: Twenty-five structured focus groups were conducted.

Subjects: These focus groups consisted of 203 adolescent girls and boys enrolled in three senior high schools and one
junior high school.

Variables Measured: The variables measured were adolescents’ self-report of perceptions of healthy and unhealthy
eating and their descriptions of the importance of healthy eating to adolescents.

Analysis: Data analysis was done by general content coding and specific content coding.

Results: Adolescents have a significant amount of knowledge regarding healthy foods and believe that healthy eating
involves moderation,balance,and variety.Despite this knowledge,they find it difficult to follow healthy eating
recommendations and frequently consume foods that they perceive as unhealthy.Barriers to healthy eating include a
lack of time,limited availability of healthy foods in schools, and a general lack of concern regarding following healthy
eating recommendations.

Implications: These findings suggest that healthy eating messages based on the Dietary Guidelines for Americans are
reaching adolescents,but interventions are needed that assist adolescents with the translation of this knowledge into
healthy behaviors.Interventions should help make healthy eating easy for youth to apply and explain the consequences
of unhealthy eating in terms that they value, stressing meaningful short-term benefits.

KEY WORDS: adolescent nutrition, healthy eating, nutrition knowledge in adolescence

(JNE 33:193–198, 2001)

INTRODUCTION growth and development, with total nutrient needs

higher than at any other period during the life
Eating behaviors are central to an adolescent’s cycle.Thus,adequate intake of nutrients and energy is
physical development, health, and identity and critical to healthy development.In
are determined by a wide range of factors, addition,behavioral patterns developed in
including knowledge, attitudes, sociodemographic adolescence are likely to influence longterm
characteristics,and behavioral,familial,and behaviors, given the development of identity and
lifestyle factors.1,2 Adolescence is also a time of
increased autonomy and independence during adolescents. Studies to date show a lack of concern
this time.3 for healthy eating on the part of young people and
Research shows that adolescents’ eating little normative support for healthy eating. 10,12
practices and nutritional intake may have long- Although health care professionals, educators,
term impacts on health.4 In parents, and others encourage teens to “eat
healthily,” it is essential to understand how
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . adolescents perceive healthy eating
Address for correspondence: Jillian K. Croll, M.S., R.D., M.P.H., Division of
Epidemiology, School of Public Health, University of Minnesota, 1300 South Second recommendations and the associated health
Street,Suite 300,Minneapolis,MN 55454;Tel (612) 626-8602;Fax:(612) 626-7103;implications.This E- understanding can facilitate the
mail: [email protected].
©2001 SOCIETY FOR NUTRITION EDUCATION development of effective interventions to create
an effort to help adolescents optimize health normative support for healthy eating among
and decrease the risk for chronic diseases adolescents and assist them in adopting the
such as obesity,heart disease,and recommendations.
diabetes,nutrition and other health
professionals are encouraging incorporation The aim of this study was to examine the
of healthy eating practices into the lifestyles perceptions of adolescents regarding “healthy
of youth.Nutrition professionals have set eating,” “healthy” and “unhealthy” foods and the
guidelines and definitions for the terms importance of healthy eating during adolescence.
healthy and unhealthy eating, but this does Focus groups were employed as a strategy for data
not necessarily mean that adolescents collection.The focus group method was chosen to
represent or perceive healthy eating in the give adolescents the opportunity to discuss their
same way.5 opinions, understandings, and needs in more detail
than typically allowed in traditional surveys. Focus
Current recommendations for healthy
groups facilitate data collection that enables
eating are in accordance with the Healthy
programs and messages to be subsequently
People 2010 Objectives for Improving Health6
customized to meet the specific needs of the target
and are summarized in the Dietary Guidelines
group and can provide a rich understanding of a
for Americans.7 Among other things,these
target group’s personal motivations, environments,
guidelines encourage people to choose a diet
and needs.13,14
low in saturated fat and cholesterol; choose a
variety of fruits,vegetables,and grains each
day,with an emphasis on whole grains;and be METHODS
physically active each day. Despite the
widespread dissemination of these guidelines
and the importance of healthy eating in Study population. Twenty-five focus groups were
adolescence, nutritional problems are conducted with 138 adolescent girls and 65
prevalent among adolescents.Many youth adolescent boys in grades 7 to 12 from three senior
engage in unhealthy dieting practices and high schools and one junior high school in the
have erratic eating patterns that include high St.Paul,Minnesota,public school district. The schools
intakes of fast foods and other foods high in were selected because they serve an ethnically and
fat and sugar,as well as low intakes of socioeconomically diverse population. Approximately
fruits,vegetables,and cal- half of the focus group participants were Caucasian
and onethird were African American; the remaining
193
participants were Asian American, Hispanic, or Native
cium-rich foods.9–11 The message of healthy eating American. Five focus groups were conducted with
has not been put into practice by many junior high students (n = 59) and 20 with high school
students (n = 144). Sixteen groups consisted of names were used in the focus groups and subsequent
girls (n = 138) and nine of boys (n = 65). The mean data processing to maintain confidentiality.
group size was eight students. In each focus group,a series of questions were
Description of focus groups. Focus groups were asked pertaining to healthy
held during the school day in classrooms, typically eating,exercising,dieting,and binge eating
during health or home economics classes.The behaviors.Questions of interest for this study
groups lasted 45 to 60 minutes,were included the following:“We hear a lot about ‘healthy
audiotaped,and were facilitated by moderators eating.’What does the term ‘healthy eating’mean to
and comoderators from the research team who you?”“We often hear the term ‘junk foods’ and/or
completed a training course in focus group ‘fattening foods.’ What do these terms mean to
methodology and moderating.14 The moderators you?”“What foods do you see as ‘healthy foods?’
facilitated the group discussion while the ‘Unhealthy foods?’How important is healthy eating to
comoderators operated the tape recorder, took you?” These questions were asked near the
detailed notes and,at the end of the beginning of the focus groups,after a warm-up
session,verbally summarized the main points question about participants’favorite foods,and
made by the group for each question. comprised approximately 10 to 15 minutes of the
focus group session.The moderators probed for
Multiple moderators were used for the 25 additional information based on the responses from
groups with consistency between moderators each group. For example, if students gave only
facilitated by group training, use of a structured cursory answers regarding foods considered in each
question guide, and periodic observation of all group,a moderator asked the group to think of the
moderators by one of the authors (DN-S). foods typically found in their home or school and
how they would describe them in terms of healthy or
A consent form explaining the study was sent
unhealthy. This protocol was approved by the
to the parent or guardian of each student prior to
Institutional Review Board of the University of
the day of the focus group.Parents were
Minnesota.
requested to sign the form and return it with the
student only if they did not wish the student to Data analysis and interpretation. Focus group
participate in the focus groups. Each participant discussions were transcribed verbatim from
also signed an assent form immediately preceding audiotape and were then coded and analyzed using a
the focus group indicating willingness to content analysis two-step method: general content
participate in the group. In signing the assent coding and specific content coding.15
form,students also agreed to follow focus group
Coding phase 1:general content coding. The aim of
ground rules (e.g.,information discussed in the
the first coding phase was to provide a broad
group is to remain in the group, participants
framework for analysis, organize responses by
should show respect for each other). Alternative
content area, and exclude extraneous dialogue not
activities were planned for students not
relevant to the research questions.Transcripts were
participating in the study;however,all students
read carefully for overall content and identification of
chose to participate.
major categories.A master coding template was
Immediately following each focus group,the developed around the major categories that
moderators and comoderators discussed and emerged from the groups, including perceptions and
recorded their impressions of the group,including descriptions of healthy and unhealthy eating and the
content,atmosphere,nonverbal importance of healthy eating to adolescents.Based
communication,and group dynamics.Only first on this master template,a separate coding template

Journal of Nutrition Education Volume 33 Number 4 July • August 2001 195

was created for each focus group with statements perceptions of foods and behaviors as healthy and
and phrases from transcripts placed directly into unhealthy, four subthemes emerged:food
the coding template according to the established characteristics,situations,eating behaviors, and
content areas. Comments or phrases that fit in benefits and barriers. Each of the themes and
more than one category were placed under each subthemes that emerged from the analysis of focus
appropriate category on the template.This phase group transcripts are described below.
of coding was done by two graduate students Perceptions of healthy and unhealthy foods and
who assisted in moderating the focus groups. eating behaviors. Participants were asked to explain
Revisions in the coding system and in coding what “healthy eating,”“healthy foods,”and
styles were made until a high degree of inter-rater“unhealthy foods”meant to them. Healthy eating and
reliability (97%) was attained. healthy and unhealthy foods were discussed in terms
Coding phase 2:specific content coding. The aim of characteristics of foods, situations, behaviors, and
of the specific content coding phase, done by the perceived benefits of and barriers to healthy eating.
first author, was to identify major themes Food characteristics. Healthy eating was most
regarding adolescents’definitions and perceptions frequently described in terms of foods that were
of healthy and unhealthy eating.Transcripts and central to healthy eating using either summary
coding templates for each of the 25 focus groups statements,such as “the right types of food” and
were read and categories of interest were “just the natural stuff,” or by naming specific foods or
highlighted to create a synopsis of the group. food groups,such as “fruit,”“like salads and yogurts
Each synopsis was reviewed carefully for relevant and shakes,”and “stir-fry.”Fruits and vegetables were
themes.Recurring themes in a particular group the most commonly mentioned healthy foods.Other
were coded only once per group as the objective foods considered healthy were salad; carbohydrate-
was to gather information regarding the opinions rich foods (especially rice, pasta, and bread); lean
of each group, not the number of times a meats (particularly baked chicken and turkey);and
particular theme was mentioned. An overall grid tofu.Also mentioned were natural foods;specific
was then established that allowed for vegetables,such as home-grown
examination of the codes and themes across and vegetables,greens,corn,and celery;juice;peanut
within groups and comparisons across age and butter;fluids;and vitamins.Almost no one included
gender.Of interest was the number of groups in milk in their description of healthy foods,and lowfat
which the theme was expressed, with particular and fat-free foods were mentioned infrequently.
attention given to themes communicated by the Some descriptions of healthy foods from the
majority of groups.The goal was to gain a sense of participants included “not lots of heavy sauce . . .
overarching concepts cross-cutting gender and [but] lots of vegetables and salad,” “bread,meat,but
age groups. not a whole lot of meat,healthy foods,”and

“some healthy foods are like

RESULTS carbohydrates,vegetables,fruits.”

Students offered numerous foods that they

The results reflect a compilation of information
considered to be unhealthy,many more than they
gathered from the focus groups for the questions
considered healthy.Many named chips, candy, fast
of interest to this study. Two overarching themes
food, and soda pop as unhealthy foods. Also
emerged: perceptions of healthy and unhealthy
considered unhealthy were pizza, sugary foods,
foods and eating behaviors and the importance of
butter/oils,junk food,hamburgers,and McDonald’s TM
healthy eating. Under the broad heading of
food. These kinds of foods were described more the time and don’t care about . . .I don’t care that I’m
globally as “ . . . like artificially made,with like eating them. I mean . . . they’re just good.You know,
grease and stuff.Stuff like that.” Adolescents also I’m concerned about my weight and all but . . .”
determined snack foods such as TwinkiesTM and Another commented,“Stuff that y’know taste [sic]
Little Debbie’sTM and HostessTM cakes unhealthy, excellent that you want all the time,but it’s like you
and as one student stated,“if it comes in the little know you should stay away from it, but then again,
red plastic bags that you get for a quarter, it is I’m young, so who cares?”
probably junk food.” In addition, baked goods
Eating behaviors. Healthy eating was also described
such as pies,cakes,cookies,and
in terms of dietary practices that emphasized some
brownies;chocolate;ice cream;meats,specifically
behaviors and discouraged others, such as “eating
steak,beef,ribs,chicken with skin, and pork; high-
vegetables without butter because butter makes
cholesterol and high-calorie foods; peanut butter;
them fattening,”“watching fat and calories,”“limiting
and monosodium glutamate were considered
caffeine,”and “not eating a bunch of junk.” Students
unhealthy.Participants were quick to point
commonly emphasized “eating less junk food”and
out,however,that unhealthy foods are much more
“not eating greasy or fattening foods”as a behavior
readily available than healthy foods and generally
central to healthy eating.Additional behaviors
look much more appealing.
discussed included taking vitamins, eating breakfast,
Situations. Some participants described healthy dieting, and eating less fast food.Whereas many
foods as having a place in some situations,such as discussed specific behaviors to describe healthy
at home or a relative’s house (“when I’m at home eating, some participants used more global terms
my dad cooks greens”),but not in others (“at fast- such as “eating right” and “eating nutritious foods.”
food places”).Healthy eating and foods were often Of interest, rarely was following the Food Guide
mentioned in connection with family members, Pyramid included in a description of healthy eating.
especially parents or older relatives,and less with
The idea of balance in relation to eating was
friends and other social situations.
discussed in terms of eating behaviors.To
As with healthy foods, some unhealthy foods some,healthy eating was summed up as a
were described as situational,such as place of balanced,varied diet and eating foods in moderation.
purchase.One older boy described this as “yeah, Students described balance and moderation as
like at a Saints [baseball] game, anything like “eating three meals a day,”“eating food,but just the
hotdogs.”Others described unhealthy foods as right amount,”“like eating when hungry and not
“anything out of a vending machine” and “all fast- when you’re not hungry,”and “eating from all of the
food places.” food groups.”Other descriptions of moderation and
balance included “Like having a balanced diet.You
Participants also broadly discussed unhealthy
know, not eating too much of one thing and not
foods in terms of what they perceive that they or
enough of another” and “Three balanced meals a day
others think they should be eating or how healthy
or eating modest. Eating three times a day, not
eating may be important to others,such as their
necessarily junk food.” Some respondents discussed
family and friends,but not to them.One student
the idea of balancing unhealthy foods with healthy
explained,“Unhealthy foods are stuff that your
foods.This idea of balancing foods allowed them to
parents don’t like you eating.” Some students
include all types of foods,while still maintaining what
described apathy toward eating unhealthy foods,
they considered a healthy eating pattern. Students
inferring that they were foods they did not think
described balancing unhealthy foods in these
they should eat but ate anyway.A senior high girl
terms:“I mean,they’re not terrible if you eat enough
described unhealthy foods as “foods that I eat all
good stuff with them”and “It’s not as bad to eat They indicated that foods they considered
meat if you mix it with other foods.” unhealthy,such as fast food and candy, are
commonly eaten because they are readily available
Benefits and barriers. Some participants
and require little to no preparation. Some students
described healthy eating in terms of how they
found healthy eating too difficult to incorporate into
could benefit from eating healthily. Specific
their lives. One student remarked,“I just can’t do it.”
benefits mentioned were healthy growth and
energy as in “stuff that will give you energy for Importance of healthy eating. When asked to
the rest of the day.”These benefits were also discuss the importance of healthy eating to them,
discussed in more allencompassing terms such as respondents varied in their opinions.The majority of
“it’s good for you” and “something that does students indicated that healthy eating was not
something good for you.” important to them,summarized as “I don’t really care
Only a few described long-term benefits to what I eat right now.”Others reported that healthy
healthy eating and expressed attempts to limit eating was important to them. Sometimes, healthy
certain foods owing to their potential effects on eating became important as the result of some
health. Students discussed this as “. . . like if it’s nutrition and health education,“after seeing . . .the
going to give you a heart attack if you eat a lot of dying of arteries . . .I don’t like that at all,” as one
that” and “not eating . . . something that would student stated.
clog your arteries and make you at high risk . . . ” In general,healthy eating was not important to
To a small extent,healthy eating was discussed teens as a group, but a few students indicated that it
in negative terms, referring to taste, appearance, was important to teens.Students made statements
acceptability, and practical applications. Healthy regarding the relative unimportance of healthy eating
eating in terms of taste was described as “eating a such as “Not at our age! At this age,you just eat and
lot of low-fat stuff with no taste” and “not really eat whatever . . .it doesn’t matter,”indicating that
tasting that good to begin with” and in terms of healthy eating was not to be a priority for
appearance as “’cause they got some nasty old adolescents.A few students did concede that healthy
looking stuff . . .and that was low fat!”To some eating might be beneficial to long-term health (“it’s
participants,healthy eating was also seen as sorta [sic] important”) but said that it was difficult to
“uncool” or undesirable and a behavior do.
susceptible to peer pressure. Certain foods were Balance was again a key component of making
considered healthy but were not foods that would healthy eating important.Students indicated that
be common choices in social situations with balance is an important message when encouraging
friends.This dilemma is illustrated by an older healthy eating.Adolescents thought that a message
adolescent girl’s comments:“It’s just like when all of balance would reinforce the recommendations to
your friends are eating chips, Doritos TM, and pop, follow healthy eating guidelines but not mean that
you don’t want to bust out with like the carrots “junk foods” or favorite foods had to be completely
and celery . . .” eliminated from the diet. In addition, most students
Healthy eating was also seen as time indicated that they had received enough information
consuming (“I always picture it as taking like hours about healthy eating and did not necessarily need
to cook”) and characterized by limited availability more information about recommendations to follow
at restaurants,especially fast-food restaurants (“if them.
you want fast food . . .you can’t get healthy Differences among age and gender groups. In
food”). general,older students articulated their ideas in more
detail than younger students, but no striking adults in qualitative and quantitative studies. 2,16–19 In
differences in age groups were noted. Although these studies,“healthy eating”was predominantly
there were no strong differences in perceptions of defined as eating more fruits,vegetables,and pasta
healthy and unhealthy foods and eating habits and grains and achieving a balanced diet,16 less
between girls and boys,adolescent boys tended to fat,more fruit and vegetables,balance and variety, 2,17
focus more on energy and appetite when and high fiber.18 It was also described in terms of
describing healthy eating, whereas girls tended to beneficial effects, with “helps maintain weight” and
focus more on appearance as a motivator for “helps clear skin” described as characteristics of
healthy eating. In boys, healthy eating was healthy foods.19 Behaviors such as “watching what
considered an important component in sports, one eats,”limiting intake of high-fat, high-calorie
expressed by some senior high boys as “that’s foods, and avoiding processed foods were discussed
really important for sports” and “yeah,it’s by adults asked to describe concepts of healthy
important before a game.”Healthy eating was also eating.16 The adolescents in this study mentioned
linked to energy, as in “things that make your similar behaviors associated with healthy eating,
body healthy or give your body energy.”In namely, limiting “junk” or high-fat food and
girls,appearance concerns were more evident. “watching fat and calories.”
Girls discussed healthy eating in regard to weight
Descriptions of unhealthy foods in this study are
loss and appearance for special events such as a
also reflected in other studies.In a study exploring
prom or other school social events. Sports or
interpretations of healthy and unhealthy eating in an
other activities in which they were involved
adult British population,Povey et al.found that adults
affected their perceptions of healthy eating,
most frequently described unhealthy foods as chips
expressed by a senior high girl as follows:
(French fries),burgers,sausages,and sweet foods,
“because I’m a dancer, you know I have to stay
including cake, sweets, and chocolate. 16 Chapman and
thin and I don’t really eat a lot of fattening
MacLean,in their qualitative study with adolescent
foods.Now if I feel like after eating healthy for a
females, reported characteristics associated with
while now . . . I can eat chips or something
junk food, such as high in sugar,fat,salt,and
now.”Another senior high girl remarked,“you
calories;containing preservatives; and fattening. 19
should stay away from [unhealthy food] . .
They also reported that adolescents associate eating
.sometimes you know if it gets out of hand like
unhealthy foods predominantly with their
prom is coming up,so you start doing crunches
peers,whereas healthy foods are eaten in the home
and stuff.”
with family,19 as was seen in the situational
determinants of healthy eating shown in this study.
DISCUSSION
In addition to the study done with female
The concept of “healthy eating” was fairly adolescents by Chapman and MacLean,19 a large pan-
consistent across adolescents and was generally European Union (EU) study and a study using the
described in terms of specific foods, behaviors Spanish subset of the pan-EU study sample 2,17
that lead to eating these types of foods, the included subjects 15 years and older.Adults and
benefits of eating in this manner, and “balanced” adolescents alike have a general understanding of
eating. Healthy eating was occasionally discussed healthy eating recommendations as set forth by
with a negative connotation. Previous work in this nutrition and health professionals.
area has been done primarily with adults, with
only a few studies focusing on or including However, despite this understanding, adolescents
adolescents. Prior research has reported “healthy do not consistently follow the
eating” to be defined in a similar manner by recommendations.1,10,12,20 This inconsistency suggests
that although the understanding of healthy eating findings from previous research and the current
guidelines and recommendations may be fairly study show youth to have little concern for healthy
strong, there must be other constraints on eating during adolescence. Given this low level of
adolescent action to engage in healthy eating concern and the strong influence of peers on eating
rather than general lack of knowledge.These practices,future messages urging adolescents to
constraints may include peer norms that do not adopt healthy eating recommendations need to
support healthy eating.The adolescents in this include components of peer acceptance and
study commonly cited lack of time and peer- promotion and a method of promoting the
related social pressure as barriers to healthy immediate benefits of healthy eating. Doing so can
eating. serve to increase the importance of healthy eating in
the eyes and minds of adolescents.Nutrition
This peer norm of low support for healthy
educators may be more successful in their pursuit of
eating has been documented to a limited extent
imparting recommendations for healthy eating to
in the literature. In a California study, Evans et al.
adolescents by including adolescents into the
found low support for healthy eating by
preparation and delivery of healthy eating messages
adolescents to be relatively uniform across age
and consulting with adolescents on effective methods
groups and varied slightly among ethnic
of initiating norm changes.Peer education may be an
groups,with Hispanic and Asian teenagers in
effective strategy in establishing new peer norms and
California more likely to report concern regarding
disseminating information in a manner meaningful to
healthy eating than their Caucasian
teenagers. Targeting perceived barriers to healthy
counterparts.12 In fact,the study revealed that the
eating such as the lack of availability and
major health norm among 85% of surveyed
affordable,appealing healthy foods in school and the
Californian teenagers was weight control among
time involved in preparation of healthy foods may
girls of their own age.12 Only 8.5% indicated a lot
serve to increase teens’ willingness and ability to
of concern about eating healthily.In their
incorporate recommendations into their lifestyles.
study,Evans and her group compared California
data with national data from the National Health A strength of this study was the rich, in-depth
Interview Survey Teenage Attitudes and Practices information gathered from youth using focus group
Survey21 regarding health concerns,which revealed methodology.If messages and interventions about
that weight concerns among teenagers ranked healthy eating are to be effective with
second in priority, after avoiding drunk driving, adolescents,they must be targeted specifically to
and the importance of youth and address the points they express as critical.
Other strengths include the ethnically diverse
eating healthily ranked last.12
population encompassed in the groups and the age,
Similarly,a survey in a Tasmanian high school gender, and grade diversity among participants. A
showed that students’perception of a food being potential limitation of this study was that the
healthy had little influence on consumption of the characteristics of the classrooms agreeing to
food,except for meats and some snacks. 22 In participate in this research, health and home
addition,a Danish study of nutrition attitudes of economics, did result in a sample with a higher
adolescents indicated that peer influence and the percentage of girls than boys and a larger number of
desirability of unhealthy foods contribute to older students than younger. Although health and
adolescents’ food choices and limit their home economics teachers were the most supportive
conformity to healthy eating recommendations. 23 of participating in this research and felt it beneficial
In spite of most adolescents having adequate to their curriculum,fewer junior high classes were
knowledge of healthy eating recommendations, taught and available than senior high classes in these
subject areas, resulting in an uneven distribution that make healthy eating easier,more
of age and gender among subjects.Although this appealing,perceived as more beneficial in the short
information is not representative of all term, and more supported as a peer norm.This study
adolescents,the ideas presented here held also illustrates the importance of knowing how teens
together across and within the majority of the 25 perceive healthy eating so that Healthy People 2010
groups of varying ages,ethnic groups,and or other largescale public health promotion
gender.Data collection and analysis procedures objectives can be more successfully reached by
were carefully planned and executed to maintain establishing appropriate interventions tailored to the
the validity of findings. However, it is important to needs of adolescents.
remember that although focus groups provide in-
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