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Abstract
Objective Although stroke is prevalent among older people, there is a rising incidence among the younger subpopulations, particularly middle-aged adults. A healthy diet is one of the key modifiable factors to primary prevention of stroke among these subpopulations, yet there is limited understanding of the dietary habits among middle agers who have the risk factor(s) but no occurrence of stroke. This study aims to explore the views on perceptions and the self-management of middle-aged adults at risk of stroke on a healthy diet and to identify the enablers and barriers that could inform the future development of dietary interventions.
Design This study used an interpretive descriptive qualitative design, employing semistructured purposive sampling for focus group discussions. Thematic analysis was conducted on the transcribed interviews and field notes, facilitated by NVivo 12.0 Plus software.
Setting Community settings in Zhengzhou City, Henan Province.
Participants Middle-aged adults (aged 45–59) were identified as at risk of stroke due to the presence of one or more modifiable risk factors.
Result A total of seven focus group discussions were audio recorded. Four main themes emerged, which were: (1) cognitive understanding of a healthy diet; (2) dietary practices; (3) knowledge acquisition and (4) barriers to dietary adherence.
Conclusions The middle-aged adults at risk of stroke were generally aware of the risk and attempted to practise healthy eating. The existing educational programmes on following a healthy diet in the prevention of disease need to be made more comprehensible, accessible and equitable, especially for those from socioeconomically disadvantaged communities.
- risk management
- stroke
- nursing care
- nutrition & dietetics
- primary health care
- primary prevention
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THE STUDY
This study gained a deep understanding of the dietary experiences and self-management of middle-aged individuals at risk of stroke in northern China.
This study attempted to reach maximum variation for the participants to provide the information needed to address the research objectives effectively.
This study aids in understanding collective perceptions of diet and how individuals are influenced by group dynamics in dietary decision-making.
Other provinces in northern China were not included in the selection process.
Introduction
According to the Global Burden of Disease Study, 90.5% of the worldwide burden of stroke can be attributed to modifiable risk factors,1 2 such as3–5 hypertension, diabetes, hyperlipidaemia, cigarette smoking, alcohol abuse and physical inactivity. In a study involving 43 685 men and 71 243 women in the USA, unhealthy behaviours accounted for half of the stroke risk. Participants who adhered to all 5 healthy lifestyle choices experienced an 80% reduction in stroke risk.6 Embracing a healthy lifestyle is a crucial strategy for effectively preventing disease, with diet being a key modifiable factor that plays a vital role in averting a stroke.7 In a prospective study conducted in 32 countries, diet quality was identified as one of the 10 modifiable risk factors for stroke, based on analysis of 13 447 cases of acute first stroke and 13 472 age-matched and sex-matched controls with no history of stroke.2 Diet quality was evaluated using the modified Alternative Healthy Eating Index, which considered the consumption of fruits, vegetables, nuts and soy protein, fish, meat, eggs, whole grains and fried foods daily. The Dietary Guidelines for Chinese Residents (2022) serve as a foundational document for health education and public policies, providing critical technical support for initiatives such as the Healthy China Action (2019–2030) and the National Nutrition Plan (2017–2030).8 These guidelines outline eight principles for a balanced diet, which include recommendations to ‘Eat diversified and balanced meals’, ‘Consume plenty of vegetables, fruits, dairy, whole grains, and soybeans’ and ‘Incorporate fish, poultry, eggs, and lean meat’, among others. Participants who have a higher score on the modified Alternative Healthy Eating Index are associated with a lower risk of cardiovascular disease.9 This positions diet quality as one of the primary targets for interventions aimed at both the primary prevention and management of stroke. However, with the rapid development of the economy and lifestyle changes, Chinese dietary habits have also undergone some changes, with some benefits but also some downsides.
Unhealthy eating habits are among the significant risk factors for cardiovascular disease deaths and disease burden in China.10 The traditional Chinese dietary staples of grains, vegetables and legumes are gradually being supplanted by meat, dairy products, fats and processed foods, resulting in elevated protein and fat consumption. As income levels rise, Chinese consumers are expanding their spending habits, accordingly, showing a preference for more indulgent, varied and convenient food choices, such as dining out and purchasing processed and fast foods. Current dietary shortcomings encompass an overdependence on processed foods, alongside imbalanced dietary patterns characterised by excessive consumption of high-fat, high-sugar and high-salt items, coupled with insufficient intake of fibre-rich and vitamin-rich foods such as vegetables, fruits and whole grains. These trends reflect notable shifts in dietary habits.11 The first, large-scale, international study showed that nearly 20% of global deaths were attributed to unhealthy eating habits.12 In China, approximately 2.6 million deaths from cardiovascular diseases in 2017 were attributed to dietary factors, representing a 38% increase compared with the previous year.13 According to the statistics, China had the highest rates of cardiovascular disease and cancer deaths caused by dietary patterns among the top 20 countries in the world. The top three contributors to these deaths were high sodium diets, low whole grain consumption and low fruit intake.12 Due to the increasing rates of chronic diseases and mortality caused by long-term unhealthy dietary habits, the WHO has issued guidelines for the prevention and control of non-communicable diseases, which include ‘reducing unhealthy diets’ as one of the most cost-effective interventions.14
People of all ages and backgrounds can have a stroke.15 According to the 2016 China Stroke Prevention and Control Report, 65.0% of stroke populations aged 40–64 years old, and the average age of onset was more than 10 years earlier than in the USA, showing a younger trend.16 The age-standardised prevalence of hypertension, diabetes, dyslipidaemia, atrial fibrillation and obesity in the Chinese population aged 40 years and older were 35.24%, 9.55%, 58.72%, 1.57% and 4.09%, respectively.17 The health issues among middle-aged individuals not only affect their personal quality of life but also have broad impacts on families and society. At this stage, individuals may have developed certain lifestyle and dietary habits, yet they are also at a crucial juncture for prevention and change. Hence, investigating the influence of dietary factors becomes especially important. Additionally, dietary factors18 also contributed to the geographical variability in stroke morbidity and mortality. A geographical north–south gradient was evident, with a higher prevalence of hypertension, stroke incidence and mortality observed in the northern regions as compared with the southern parts of the country.19 Population-attributable fractions for 12 significant cardiovascular risk factors were computed, considering exposure and relative risk by province. The findings unveiled those northern Chinese residents who had a higher consumption of high-sodium foods, lower vegetable and seafood intake, and a tendency towards being overweight.20
However, the general dietary habits of community populations in northern China with chronic diseases and potentially unhealthy lifestyles are currently unclear. These people receive dietary guidance to improve their health and their understanding, and the prioritisation of healthy eating is yet to be determined. The level of adherence to a healthy diet in their daily lives is unknown. Therefore, we hypothesise that by studying the relationship between the dietary habits of middle-aged individuals and the risk of stroke, we can provide more targeted recommendations and guidance for relevant health policies and interventions. We excluded patients with a history of prior stroke, primarily to focus the study on primary stroke prevention. In doing so, we can more accurately explore whether dietary factors have a preventive effect on stroke among individuals who have not previously experienced a stroke. This study aimed to explore the perceptions towards self-management of a healthy diet, including its enablers and barriers, among middle-aged adults with risk factors of stroke. The findings from this study will inform the development of culturally appropriate dietary interventions.
Method
Patient and public involvement
Patients or the public were not involved in this study.
Study design
An interpretive descriptive qualitative design21 was employed for the study. The interpretive approach22 offers an accessible and theoretically flexible approach to gain a deeper understanding of the perceptions towards self-management of a healthy diet, including its enablers and barriers, among middle-aged adults with risk factors of stroke.
The face-to-face, semistructured discussion sessions were audio recorded. To mitigate the risk of certain participants dominating the discussion while others are marginalised, homogenous focus group discussions (FGDs)23 were conducted with smaller groups consisting of four to seven participants each. This approach24 aimed to foster more balanced participation and facilitate in-depth qualitative data collection.
The interview script for the FGDs was meticulously drafted in Chinese language to align with the study’s objectives. Its content was meticulously curated, drawing insights from reviews of the literature,25 26 and preliminary interviews with three research subjects. Our methodology was firmly anchored in the Health Belief Model,27 a widely recognised theoretical framework in health behaviour studies. This model has proven highly applicable in addressing the modification and maintenance of health-related behaviours across various contexts. Following that, the interview guide was evaluated and revised by two nursing experts with qualitative research experience. The process of translating the interview guide from Chinese to English was carried out by a professional translator (WLL) with excellent proficiency in both Chinese and English translation. The translated English version was then reverse translated into Chinese by another translator (MCC) proficient in both the source and target languages. The translated Chinese interview guide underwent internal discussion and review within the research team to confirm the applicability and accuracy of the interview questions in the Chinese context. The topic guide included the following questions (table 1).
Topic guide for focus group discussions
Participants
For the study setting, we invited middle-aged adults residing in both urban and rural districts of Zhengzhou City, Henan Province. Henan Province, situated in the heart of China, plays a pivotal role in the northern region of the country. Its unique geographical location has fostered a diverse culinary culture, influenced by neighbouring regions. Renowned as a culinary epicentre in northern China, Zhengzhou, the capital of Henan province, boasts not only a sizeable local population but also attracts a significant number of rural migrant workers. This demographic distribution enhances the comprehensiveness of our research.
We used a combination of purposive and convenience samplings28 to attempt to reach maximum variation regarding age, gender and cultural background for the participants to provide the information needed to address the research objectives and effectively supply the most information for the research problem chosen under the study goal.
Participants were recruited with community assistance, where they were provided with background information on the study’s purpose, seeking their support in identifying potential participants. Additionally, recruitment information was shared via social media platforms and online communities to attract individuals or groups interested in participating. Through these channels, we expanded our reach and invited a broader audience to engage in our research project.
The inclusion criteria were adults of 45–59 years old, having no history of stroke (previously described in the Introduction section) but having one or more modifiable risk factors of stroke29 (hypertension, diabetes, cardiovascular disease, dyslipidaemia, atrial fibrillation, being overweight or obese (body mass index ≥25), physically inactive (less than 150 min of moderate-intensity activity per week, or equivalent),30 smoking; and/or consuming excess alcohol). Persons with a medical illness, serious health complications or comorbidities that rendered them unfit to participate were excluded from the study.
Data collection
Between February and April 2022, the FGD sessions with the researcher team and participants were held in a community conference room for privacy and to provide a setting that was both convenient for the interviewees to find and conducive for a relaxed chat. The semistructured FGDs were conducted in Mandarin Chinese, with data collection carried out by trained researchers (CL and HYZ), both holding Ph.D. degrees in nursing science. One author (CL) acted as the primary interviewer, engaging with participants, while the other author (HYZ) was responsible for recording and managing time.
Prior to the data collection, relevant matters were communicated with the interviewees, ensuring full disclosure of the purpose, content, significance and confidentiality of the interview. Participants were informed that their participation in the study was voluntary, and they were given the option to withdraw at any time. All data underwent anonymisation and were securely stored on password-protected computers, with access restricted solely to the researchers.
During interview sessions, participants may be asked both questions and probes, but not necessarily in a predetermined order. Questions are the main inquiries posed to participants to gather information related to the research topic. Probes, on the other hand, are follow-up or clarifying questions used to delve deeper into a specific aspect of a participant’s response. Each discussion was carried out with some flexibility by adjusting the order of questions depending on the participants’ responses. Changes in expressions, tone and body language were observed. Transcripts were not returned to participants for comment and/or correction. The interviews underwent translation into English for analysis. A professional translator (WLL) was responsible for conducting both the transcription and translations. Following this, the transcripts were thoroughly examined by the first author (CL), who possessed double proficiency in Chinese and English, to ascertain their high standard. Participants were given pseudonyms to preserve their anonymity.
All participants were willing to take part and did not drop out during the study. They were highly interested in the discussions and engaged in them during their free time. There were no people present during the data collection besides participants and researchers. We assessed the appropriateness of the sample size31 through gradual participant recruitment and ongoing data analysis to confirm saturation. Data collection continued until saturation was achieved. Each participant who completed the interview received compensation of 20 RMB (approximately US$3).
Data analysis
Data were transcribed within 24 hours of the discussion and was imported to the NVivo 12.0 Plus software for management and analysis. Two researchers (CL and WLL) with experience in qualitative research independently performed the coding of data initially, followed by comparing and discussing the codes to identify and rectify errors and inconsistencies. The research team of four researchers (CL, WLL, JHZ and MCC) collectively analysed and discussed the findings to refine the themes, ensuring objectivity and avoiding biases. The analysis process followed a six-step approach32 as follows: (1) data familiarisation; (2) code generation; where the researcher categorised and labelled information in the text based on predetermined coding rules aligned with the research objectives and questions; (3) theme development, where the coding results were integrated and summarised to establish a comprehensive coding system; (4) review of candidate themes; (5) theme refinement and (6) writing up the findings.
The study’s trustworthiness was evaluated following the framework outlined by Lincoln and Guba.33 To ensure dependability, an interview script for the FGDs was meticulously developed through an extensive literature review and initial interviews with research participants. This script was then subjected to a rigorous review and revision process by two experienced nursing experts in qualitative research. For enhanced data credibility, the researchers provided feedback and sought confirmation from research participants regarding the interview content, ensuring the accuracy of their perspectives and experiences. To address confirmability, two researchers well versed in qualitative research independently conducted the initial data coding. Subsequently, they engaged in a comprehensive comparative and collaborative process to identify and rectify any errors or inconsistencies. Furthermore, the research team collectively analysed and discussed the findings to enhance the credibility of the subsequent results, refining the emergent themes. To improve the transferability of this study, we included comprehensive background information and detailed descriptions of the research methods and participant characteristics.
Results
Characteristics of participants
A total of 31 eligible adults participated in the FGDs, comprising 18 males and 13 females. Many participants were 56–59 years old (68%), living with family (90.3%), were employed (58%) and had two risk factors of stroke (54.8%). Table 2 illustrates the characteristics of the study participants.
Participants’ characteristics (n=31)
The four central themes that emerged from this study were (1) cognitive understanding of a healthy diet; (2) dietary practices; (3) knowledge acquisition; and (4) barriers to dietary adherence. The themes and subthemes are shown in box 1.
Themes and subthemes
Theme 1: cognitive understanding of a healthy diet
Balancing nutrition
Light diet
Regularity and moderation
Safety
Theme 2: dietary practices
Deep-rooted eating habits
Satisfying an individual’s dietary preference
Disease-driven awareness
Alcohol culture
Theme 3: knowledge acquisition
Random acquisition
The credibility gap
Theme 4: barriers to dietary adherence
Self-restraint
Discrepancies in knowledge and education
Work and social interactions
Influence of family members
Regional disparities
Theme 1: cognitive understanding of a healthy diet
The understanding and awareness of healthy eating among Chinese people are gradually improving. People are increasingly paying attention to a healthy diet and focusing on balancing nutrition, light diet, regularity and moderation, and safety.
Balancing nutrition
The overwhelming consensus among participants was that adjusting the dietary structure is key to a healthy diet. They emphasise the importance of achieving balanced nutrition and diversifying food choices while ensuring reasonable combinations.
A well-balanced diet involves incorporating a variety of vegetables into meals. For example, you can eat one type of vegetable today and another type tomorrow, constantly rotating and replacing them to ensure comprehensive nutrition. Carrots, cauliflower, celery, and chives are commonly consumed vegetables. However, the key is to have variety by consuming different vegetables on different days, which is what we consider a reasonable diet. (FGDs 7: participant 3)
Light diet
Almost all participants believed that a healthy diet should avoid greasy and high-calorie foods and instead choose light, low-salt, low-fat and vegetable-rich options. They also were well aware that low-salt and low-oil foods can help prevent disease, while meats such as red meat with high-fat content can contribute to obesity and other chronic diseases.
A healthy diet is generally described as light, vegetarian, and includes plenty of fruit. (FGDs 6: participant 3)
At our age, various health issues emerge, right? No matter where you go, doctors always advise us to stick to a light diet. Especially for someone like me with excess weight, it’s necessary to lose some weight. So, wherever I go, I prioritise a light diet. It’s better to avoid excessive consumption of fatty meats and focus on eating more vegetables, right? With the prevalence of conditions like hypertension, hyperlipidemia, and hyperglycemia, it’s best to keep the diet light and include more vegetables. (FGDs 5: participant 4)
In comparison to the emphasis on low salt and low oil in a healthy diet, the participants generally considered deep-fried foods and dishes with a large amount of oil to be unhealthy. The greater part of them recognised that consuming excessive amounts of fats and oils can lead to conditions like high blood lipid levels and obesity, which can adversely affect their overall health.
Fried foods, such as deep-fried dumplings, cause an immediate spike in blood sugar levels upon consumption. (FGDs 1: participant 2)
A large portion of participants believed that eating out is unhygienic. They thought that the oil used in restaurant kitchens was likely to be of poor quality, and there may be instances of reusing cooking oil, making the food unhealthy. Additionally, they recognised that barbecue dishes are popular nighttime snacks in China, but they also acknowledged that excessive consumption of such foods is not advisable.
When it comes to deep-frying at home, I don't think it’s too much of a concern. However, I generally avoid buying deep-fried foods outside because they reuse oil, which is not good for our health. We rarely deep-fry food at home as well. (FGDs 6: participant 1)
Regularity and moderation
Participants argued that a healthy diet is characterised by regularity, which means having three meals a day at scheduled times. Eating meals on a regular schedule is important.
A healthy diet involves maintaining regular eating patterns. (FGDs 7: participant 2)
Additionally, some participants believed that meals should be eaten until they felt about 70%–80% full, avoiding overeating. They thought that, as they age, their digestive function declines, and eating too much can lead to discomfort.
Don't eat too much, avoid overeating, and opt for smaller, more frequent meals. This approach is beneficial for managing blood sugar levels. (FGDs 7: participant 5)
Safety
Some participants stated that among the foods they consume daily, they are more inclined to accept seasonal vegetables and fruits, believing that they should follow the natural rhythm of the seasons. They felt that eating seasonal produce was healthier, and they also preferred the taste.
It tastes better when it’s in season. At our age, we feel that seasonal foods are better. They are locally produced and have a better taste. (FGDs 7: participant 2)
Nowadays, people pay more attention to the safety and healthiness of food. The potential risks and harm of processed foods and genetically modified foods are subjects of uncertainty and suspicion. Participants prefer to cook their meals or purchase from reputable supermarkets or food stores to ensure the quality and safety of the food.
Moreover, there is a greater fear of consuming processed foods, especially meats, because of concerns about the selection of processed ingredients whose nature is unknown. Therefore, individuals try to consume more natural and unprocessed foods. There are also considerations regarding meat, eggs, dairy products, vegetables, and crops, as hormones and pesticides used in the production of these food items raise concerns. (FGDs 5: participant 4)
Theme 2: dietary practices
The theme is about the experience of dietary management status, including deep-rooted eating habits, satisfying an individual’s dietary preference, disease-driven awareness and alcohol culture.
Deep-rooted eating habits
Most of the participants stated that their current three meals a day are based on certain dietary patterns, with staple foods occupying an important position in their diet. In the northern region of China, staple foods, particularly wheat-based noodles, hold a deep-rooted historical and cultural significance.
We still follow our daily customs and local traditions in our diet. We have porridge in the morning, noodles for lunch, and porridge again for dinner. This is the usual dietary pattern for us. (FGDs 3: participant 1)
On the other hand, influenced by a diet primarily centred around grains, a significant number of participants continued to express concerns about their relatively inadequate intake of fruit and soy milk, even as their consumption increased.
I don't eat much fruit, basically only about twice a week. (FGDs 2: participant 2)
Fruits, oh well, we just go without eating them and let them go bad; we never seem to remember to eat them. (FGDs 3: participant 1)
I rarely drink milk. Sometimes, when I remember, I'll drink a little. (FGDs 1: participant 2)
Satisfying an individual’s dietary preference
Participants described that with the improvement of living standards, there has been a notable increase in individual daily consumption and changes in purchasing patterns. This largely facilitates the fulfilment of each person’s distinct dietary requirements. This encompasses various factors such as an individual’s preferences, nutritional needs, taste preferences, cultural influences and health conditions. It extends beyond merely supplying sufficient food; it also involves ensuring that the food aligns with an individual’s preferences, adheres to specific dietary requirements and caters to their unique health and lifestyle needs.
Make whatever you feel like eating, for example, if I feel like having noodles today, I’ll make noodles; if I feel like having rice, then I’ll have rice. Sometimes, I also have dumplings. (FGDs 4: participant 1)
While meeting their daily dietary needs, most participants mentioned having meat and eggs almost every day.
Well, when it comes to meat, I make sure to have it at home every day. Additionally, I prefer to consume lean meat for protein. (FGDs 1: participant 3)
Disease-driven awareness
Most participants expressed a greater interest in dietary guidance related to their specific health conditions. They may pay more attention to how to eat to prevent disease and promote overall health.
We have a wide variety of food options, and there’s nothing we won’t try. I particularly like dishes with rich flavours, such as those with ample oil and meat. However, in pursuit of a balanced diet, I make a conscious effort to regulate and minimise my consumption of such items. (FGDs 5: participant 2)
In contrast, participants aged over 50, driven by their specific health requirements, tend to prioritise dietary and health considerations more diligently.
At home, we usually don't make corn porridge because I have high blood sugar, so I can't make it. (FGDs 1: participant 2)
Once I crossed the age of fifty, I started feeling that my health was gradually declining, and I realized that it was time to pay more attention to my diet and well-being. (FGDs 6: participant 4)
Alcohol culture
In Chinese culinary culture, drinking alcohol is often closely associated with socialising and interpersonal interactions. Drinking alcohol is seen as a means to bring people closer and a symbol of respect and friendliness. When people go out for meals, especially adult males, it is common for them to consume alcohol during the gathering. Although many male participants acknowledge the adverse effects of alcohol consumption and understand the importance of moderation, they find themselves compelled to partake in drinking during work and social events.
In fact, in the past, I didn’t pay much attention to it. But now, I prefer eating at home and don’t want to drink when going out. It’s just that in social situations, not drinking is not acceptable. (FGDs 1: participant 4)
Theme 3: knowledge acquisition
The theme is about the experience of acquiring knowledge on the topic, which appears to revolve around randomness and differences in credibility.
Randomness
Regarding how they got to know about diet and health, participants admitted that they usually do not have a fixed channel to learn about the topic. They acquire information intermittently from various sources, without continuity.
We gather information from hospitals, television, sometimes on our phones, and occasionally from friends, and there is not much discussion in the community. It mainly accumulates from daily life. If you ask where we acquire most information nowadays, sometimes we read books, but there is no specific and consistent source for obtaining information. (FGDs 7: participant 2)
The credibility gap
Some participants mentioned that they often encounter inconsistent facts and figures on diet and health, which creates confusion about which information to trust. As a result, they choose to no longer pay attention to such information, believing that, ultimately, it does not benefit them.
You see, sometimes experts say different things. Some doctors say we should drink more milk, but other experts say milk is not good for us. I feel that even the experts’ opinions are inconsistent. Since we can’t rely on what the experts say, I think these pieces of information are not helpful. So, when it comes to diet, I prefer to stick to my usual eating habits. (FGDs 7: participant 1)
Theme 4: barriers to dietary adherence
This theme primarily addresses six aspects of dietary impediments.
Self-restraint
Individual preferences and taste preferences for different foods can influence dietary management. Some individuals may prefer high-sugar, high-fat or high-salt foods, while others may lean towards healthier and more balanced food choices.
In my opinion, I know in my mind that I should eat less, but I can’t control myself. I have that awareness. For my current physical condition, it would be better for me to eat more whole grains. However, when I eat them, I feel like they have no taste, and I don’t want to eat them. (FGDs 7: participant 5)
A weaker sense of self-restraint may also be related to health status. A substantial proportion of participants under 50 often have a somewhat relaxed attitude towards dietary and health concerns.
In my current routine, I just eat whatever I feel like in a normal manner, without any strict dietary restrictions. To be honest, at my age, in my forties, but not yet fifty, I don’t have any noticeable health issues, so I don’t think about how to maintain my health at this point. (FGDs 5: participant 3)
Discrepancies in knowledge and education
Individuals’ dietary knowledge and educational levels can also affect their ability to manage their diet. Participants with higher levels of education are more likely to have a deeper understanding of nutritional needs and a more conscious approach to dietary management. On the other hand, individuals with lower levels of knowledge and education may only be familiar with certain local ingredients and cooking techniques, incorporating them into their daily meals.
Speaking for myself, I don’t eat very healthy food. It’s not very nutritious. You see, I don’t know how to cook, so I don’t cook shrimp and fish. Aren’t fish and other seafood considered healthy? I don’t know how to prepare them, so I don’t eat them. If you don’t pay much attention to it, you just have simple meals to fill your stomach. (FGDs 3: participant 4)
Work and social interactions
In the workplace and interpersonal interactions, middle-aged individuals often need to participate in gatherings and banquets for socialising and leisure. Additionally, busy lives and work pressures can present challenges in terms of dietary management. Lack of time, insufficient cooking skills and the temptation of convenient foods can all lead to unbalanced and unhealthy food choices.
Sometimes it’s due to work-related relationships or the need to relieve stress. Sometimes it’s simply a matter of socialising with friends over a meal. (FGDs 2: participant 3)
Influence of family members
In a shared living environment, family members can mutually influence each other’s dietary choices and behaviours. When cooking, one member of the family selects ingredients and dishes very often of their preference, which significantly impacts the dietary choices of other family members who share the meal. If the family cook prioritises healthy eating and chooses fresh vegetables, lean meats and whole grains, other members are also more likely to consume more nutritious and healthy foods.
I’m interested in it, but I can hardly achieve it. I attended a lecture on diet and health before, but I couldn’t follow through. My wife cooks at home, but she also can’t do it, so in this aspect, I think about eating low-sugar foods, but the meals at home are limited to a few types and not well-prepared. (FGDs 7: participant 5)
Regional disparities
Environmental conditions have an impact on dietary management. Participants living in rural areas mentioned that food resources are relatively limited, which may restrict individual dietary choices and management.
Discussion
The study aimed to explore the perceptions and self-management practices regarding a healthy diet among middle-aged adults at risk of stroke in North China. Specifically, we examined participants’ awareness of dietary knowledge, their practices in managing their diet, the extent they received guidance on their dietary choices and the sources of that information. Our findings indicate that the majority of participants possess a certain level of awareness regarding healthy eating. Regarding the understanding of healthy eating, most participants in this study correctly identified that a healthy diet should be light, low in salt, oil and fat and that it should incorporate a diverse range of vegetables and fruits. Some participants also highlighted the significance of maintaining a balanced diet, avoiding monotonous food choices, adhering to regular eating habits and limiting alcohol consumption. They also believed that the freshness of food can be assessed by its appearance. However, some participants face challenges in implementing healthy eating habits. Among these challenges are unhealthy dietary practices, including prioritising personal taste preferences over nutritional considerations, frequenting restaurants, or consuming excessive amounts of alcohol. These findings highlight the necessity of targeted educational interventions aimed at middle-aged adults at risk of stroke, to enhance their knowledge and awareness of healthy dietary practices.
We speculate that the gap between middle-aged adults’ awareness and practice of healthy eating may be influenced by various factors.34 Individual consciousness35 is one significant influence, including participants’ health awareness, level of knowledge, attitude concerning the subject and behavioural habits. The participants in this study generally regarded self-discipline as the most important factor in managing their diet. They believed that change can only occur when individuals become conscious of the importance of diet and actively try to follow advice. However, not all participants exhibit the same level of awareness or consistency in managing their diet.36 Disparities in participants’ awareness of healthy dietary practices were evident. Some individuals exhibited limited knowledge of basic dietary concepts, expressing the belief during interviews that a healthy diet simply involves consuming three meals a day without much thought. This underscores a deficiency in understanding the significance of dietary choices, suggesting a certain level of confusion surrounding the concept and practice of healthy eating among these participants. Additionally, dietary habits are influenced by family and social environments, as well as work-related pressures and time constraints. This group, predominantly composed of relatively younger individuals, especially those under the age of 50 and still actively employed, often faces social obligations and interactions related to work. Unfortunately, these engagements frequently involve unhealthy eating habits and alcohol consumption. The manifestation of health issues may not yet be apparent in this age group, leading them to perceive these health problems as distant and not personally relevant. However, as physical health issues emerge, individuals tend to become more aware of associated risks, prompting them to pay more attention to adopting a healthy lifestyle and taking medication. To address this issue, it is imperative to bolster preventive awareness and risk perception among individuals, particularly those under the age of 50.
Traditional dietary patterns,37 regional cooking styles and cultural norms surrounding food consumption all influence individuals’ dietary choices and preferences. When it came to managing their diet, many participants showed some variation in their daily eating habits, which were largely shaped by local dietary customs and preferences. This may be related to local dietary customs and the availability of resources that provide relevant information. This corresponds with the research findings of Sorokowska38 and Linda C Tapsell.39 In the context of preserving the traditional dietary culture, there is a need to enhance awareness, intensify promotional efforts and promote a moderate increase in the consumption of traditional dietary components that are currently lacking. Meanwhile, while acknowledging the importance of diet, participants also expressed concerns about food safety. Participants raised questions about the consumption of out-of-season and genetically modified foods, considering seasonal foods to be healthier, and expressed concerns about the lack of hygiene in eating out, the excessive use of cooking oil in food preparation and the unhealthy nature of grilled foods, among other issues.
The situation of dietary guidance is also worthy of attention.40 The qualitative survey conducted among all participants in this study revealed that the guidance on diet and disease they currently receive is inadequate. They only receive partial advice from doctors during medical visits or rely on media such as smartphones, television, informal conversations among friends, and personal experiences for dietary management. Professional dietary guidance is largely absent. When it is available, there is some confusion in understanding the information. Sometimes, even for the same food, different experts provide conflicting recommendations, leaving individuals unsure about how to comply. Based on these current issues, it is necessary to strengthen professional and personalised education through various channels, which is in line with the findings of Katharina.41 In the study, participants also expressed support for mobile interventions. They believed that this approach is convenient and would effectively use the potential of educational applications on a smartphone. In future research, it is necessary to further explore the levels of dietary knowledge, practices in diet management and the effectiveness of dietary guidance among different regions and age groups. Additionally, studying the underlying mechanisms of influencing factors should be conducted in-depth. For the slightly older middle-aged population, emphasis should be placed on acquiring knowledge and providing support within the family and broader social networks. This will help them understand how to better maintain and improve their physical well-being.
Strengths and limitations of the study
Through this study, we aim to gain a deep understanding of the dietary experiences of middle-aged individuals at risk of stroke in northern China. Researchers can better grasp how the cultural and dietary backgrounds of the participants influence their dietary choices. This is crucial for devising dietary intervention measures tailored to the specific cohort of middle-aged individuals at risk of stroke in this study. This will contribute to the development of more personalised and effective dietary intervention strategies, promoting health through diet and the prevention and management of chronic diseases through diet. Although our study has provided valuable insights, there are also some limitations. To begin with, the research used an interpretive descriptive qualitative design accompanied by a comparatively limited sample size; consequently, the findings might not be generalisable to the entire middle-aged population. Second, the exclusive focus of our research was on North China, which might limit its applicability to other regions. Future studies could adopt larger-scale quantitative research designs and consider multiple influencing factors to achieve a more comprehensive understanding of middle-aged adults’ perceptions and practices regarding healthy eating. Additionally, further exploration of interventions such as health education and behavioural interventions may be warranted to assist middle-aged adults in improving dietary habits and reducing the risk of stroke.
Conclusion
Overall, the awareness of dietary knowledge among the middle-aged population at risk of stroke is continuously improving but still faces some challenges. Further strengthening the public promotion and education on dietary knowledge and providing personalised guidance for different populations will help enhance the overall level of dietary awareness, promote healthier dietary behaviours and improve lifestyle choices.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by the Ethics Committee of Xinxiang Medical University (XYLL-20210321). Written informed consent was obtained from all participants and all procedures were conducted in accordance with the Declaration of Helsinki.
Acknowledgments
We extend our gratitude to all the authors who participated in the study's management, and we also wish to thank the participants for their valuable cooperation in this research.
References
Footnotes
Contributors CL made substantial contributions to the design, data collection, data analysis and writing of the manuscript. HYZ made substantial contributions to data collection. WLL made substantial contributions to design, data analysis, reviewing, editing and study supervision. JHZ and MCC made substantial contributions to design, resources, data analysis, reviewing, editing, study supervision and funding acquisition. MCC is responsible for the overall content as the guarantor. All authors read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.