• P10: I looked at myself in the mirror, nothing looked good, even if I wasn´t so fat, but I still felt bad in clothes, in mood. But now I feel more like getting up, going to work. So that change has been good for me.

  Participants mentioned several tools they use to manage eating healthily and making adequate food choices. These tools were classified into three groups: knowledge, resources and skills and motivation.

  Knowledge: Three types of food-related knowledge emerged from the transcripts. The first kind is factual knowledge, concerning different levels of food and nutrition knowledge and facts. On a first level, participants identify the existence of food groups associated to healthy diets, based on features such as origin, quality and nutritional value. These food groups are preferred over others with unhealthy characteristics.

• P8: I know chocolate is not bad, depending on how it is. Chocolate with 70% cocoa is not bad, but those cheap chocolates are sickening.
• P29: Well, for me, healthy things are those that don’t have much sugar [...] For example, vegetables are healthy, unlike pasta. For me that isn’t very healthy, one can eat them occasionally, but not regularly because they provide carbohydrates and that is transformed into sugar.

  On a second level, participants recognized being aware of adequate portions, and the importance of serving sizes according to specific life-stage needs. They also refer concern and knowledge related to proper food preparation and storage processes, which in some cases is mentioned as harmful to health if not followed correctly.

  All these levels of knowledge sum into the understanding of food having an influence on health, acting as protection from certain nutrition-related diseases or as a risk factor to acquire them. This is translated into self-knowledge and awareness of body signals generated throughout the life cycle as a response to eating habits:

• P8: At sixty (that’s my age), one must be smart enough to realize… I know my body and I know what is good or bad for me…

  The second type of food-related knowledge are myths and beliefs, which contrary to factual knowledge, are based on hearsay or participants’ own perceptions. These myths and beliefs comprise ideas such as healthy diets having higher costs or obesity within families being caused by genetic hereditary factors (instead of acquired eating habits). The emerging myths and beliefs that stand out relate to specific negative or positive attributes assigned to food and their effects on health, such as sugar and carbohydrates being “poisonous” and farm/countryside products being wholesome foods. These myths and beliefs are exemplified by the following extracts:

• P8: They say that cow milk is bad ... They say that milk is bad, that Chinese don’t drink milk so they don’t have cancer…
• P14: I know that sugars are bad for the brain, I’ve done some research.
• P14: ...My mother sends eggs [from the south]. Those free-range eggs are healthier.

  Resources and management skills: Two kinds of resources are identified by participants as relevant when dealing with food: time and money. However, participants mention that time and money are rather scarce and regardless they manage to use and distribute them efficiently to have healthy dietary behaviors. Participants recognize that, despite having a busy life, they are able to manage the time to perform healthy food processes, such as cooking; moreover, they do not perceive these practices as time consuming. Additionally, money is recurrently mentioned as a resource taken into consideration when making food choices, and budgets are carefully considered when purchasing food, as mentioned by one of the participants:

• P13: Time [for cooking] ... how long ... an hour, half an hour, I do not know, it's not much. I like cooking... But not cooking dishes that take a lot of time to elaborate; I have a simple and basic cuisine…
• P13: It depends on how much money I have. There are things that sometimes I can’t buy. But if at a given moment I have money and I am going to buy food, meat goes last; I first look for vegetables, I can’t go without bread, [non-caloric] sweetener, fruits, and milk.

  Motivation: Motivation emerges as a necessary tool for conducting healthy eating behaviors. Participants mentioned internal and external incentives for eating healthily. On the one hand, internal motivation refers to the desire to take care of one's own diet for personal purposes, such as wanting to feel healthy, avoid illness and looking good physically:

• P23: At my 46 years of age, fortunately I don’t have hypertension, I don’t have diabetes, I don’t have any chronic illness… I started to take care of myself particularly because I don’t want to depend on medication at some point.

  On the other hand, external motivation refers to the determination to take care of one's own diet to stay healthy because of others, particularly due to the responsibility of rearing children. Participants also refer external motivation when seeking to establish healthy food habits at home in favor of the health and well-being of other family members (children, grandchildren, partners).

  P17: They can prepare a barbecue full of sausages and no thanks, I’ll pass. If I don’t take care of myself, where will I end? I have six grandchildren and four daughters... So, I better [take care of diet], especially since I want to see my grandchildren with my children…

  Participants’ narratives reveal certain mechanisms allowing them to face the daily challenges of eating healthily within obesogenic environments. These mechanisms comprise a deep realization of the importance of food for themselves and their families, identifying eating habits as health promoters, as well as causes of illness. Furthermore, participants mention being aware of the impact of food on their past and current health status, recognizing the link between food and health as the main mechanism that sustains their healthy diets. Specific mechanisms emerged from the interviews: Historic, Preventive, Reactive and Vicarious mechanisms.

  Historic mechanism: Parent-influenced eating: Based on childhood memories and/or constructions generated from stories told by others (i.e. parents, siblings relatives, etc.), participants identified food patterns fostered by their parents as crucial influences on their current diet and health status. Some participants mentioned them as the reason they managed to grow healthily and remain healthful; while others refer to them as the cause of their current illness. Both cases are depicted by the following extracts:

• P17: I think that the food: beans, vegetables ... it was more nutritious, because we were satisfied. Did we get sick? ... We never got sick, we all turned out healthy.
• P18: You see; I feel that somehow the obesity I dragged during that time had something to do with the little [nutrition] education available for people in those days. I remember a chubby kid was considered a healthy kid.

  Preventive mechanism: Conscious eating: Participants express awareness of the risks of unhealthy diets and the benefits of adequate eating habits for current and future health. The importance of this for an adequate ageing process is also taken into account. Such awareness drives them to be healthy eaters in order to avoid future diseases and have a healthier ageing process. A couple of participants illustrate:

• P14: "I know that I just have to eat well for my health, because I am older, so… my husband said " we are reaching the third age". That´s why we have to take care of our health, for our old age".
• P23: "I mean, if I take care the risk decreases… Avoid getting diabetes one day, hypertension, I don’t know if at some point, further down the line, in a few more years. But for now it's what I'm trying to do… avoid.

  Reactive mechanism: Food for healing: In the presence of disease or its possible short term installation, the instrumental use of food as part of a health restoration process emerges as a mechanism. Participants mention how they confront health conditions and pathologies (overweight, fatty liver, hypertriglyceridemia, gastroesophageal reflux, etc.) with a dietary approach:

• P14: Now I am giving it [diet] more importance, because at my age… Before I ate a lot of junk food, not anymore. Now I make time, for example, lots of vegetables, fruits during the day, I try to eat more fish instead of meat, I try to make lots of vegetable tortillas. Since I had surgery a few months ago I'm taking care of my diet, I don’t know why ... maybe to take care of myself so I don’t get a new kidney stone.
• P10: I need surgery for an umbilical hernia that’s bothering me. I looked into it years ago but stopped going to the hospital, I even lost the surgery appointment. Now I picked it up again, three months ago, they told me that if I wanted to get surgery I had to lose weight, and there everything started.

  Vicarious mechanism: All for one and one for all: Caring for children and/or family members’ diet is manifested by participants as an altruistic interest to favor healthy food practices within the household. The family or social group’s heathy diet is identified as a superior incentive that promotes developing and establishing dietary routines to attain and/or maintain good health for the whole group:

• P18: …I try to pass good food practices on to my children. Therefore, in terms of being able to provide a healthy diet and teach them that, I consider myself paid… So when I spend the weekend cooking, I try to make everything balanced, try to give more importance to vegetables, try to add color to meals, try to make them entertaining so it will actually catch the children’s attention. For example, a rich salad of lettuce, but with beans. Mix legumes, colors, vegetables… things that are healthy for them.

  Participants also mention implementing family support systems for members who must face restrictive diets or change their eating habits due to specific health conditions. This special diet is (partially or completely) adopted by other family members even if they do not have the condition themselves, in order to provide a supportive food environment that allows a better adherence to the special diet. This is exemplified by one of the participants:

• P28: My dad has a kidney condition, so I'm super restricted [food wise]. On our refrigerator there is a list [this long] of what you can’t eat, and [this short] of what you can eat. So, we try… my mom cooks almost with no salt and we try to avoid eating things that he can’t eat so he doesn’t see, or else he feels bad.

Discussion and Conclusion

  This study sought to identify mechanisms that enable overcoming obesogenic environments amongst people that manage healthy eating habits, based on the Salutogenesis [8-11] perspective and through qualitative methods.

  The study population was comprised only by people who obtained high scores in the Healthy Eating Index. Even though some of them were overweight, they had recently changed their eating habits and had adopted healthy diets. Most of the participants in this study (14 out of 16) were female, indicating that women are usually healthy eaters rather than men. These results coincide with national data [3]. Studies show that being female is a protective Salutogenic factor regarding food [13] and attribute the tendency of women having healthy diets to their strong beliefs in the importance of eating healthily [26].

  Several resources used to accomplish healthy diets were identified. One of these resources is knowledge, comprised by formal science based nutrition knowledge provided by health professionals, as well as beliefs and myths acquired from popular sources. There is contradictory evidence regarding the impact of nutrition knowledge as an influential factor in healthy dietary behaviors [4,27,28]; however, food and nutrition knowledge is identified as one of the attributes of food literacy [29], thus it is important that health professionals generate nutrition educational measures to diminish the gap of formal knowledge regarding food and nutrition to facilitate patients making informed food decisions.

  Research has identified time [27,30,31] and money [30] as main barriers for healthy eating. However, in the present study, healthy eaters recognized having the ability to optimize time and money to ensure a varied and sufficient diet of nutritional quality, despite acknowledging having limited free time and budgets due to their socioeconomic condition. Skills related to purchasing, preparing and handling food have also been identified as attributes of food literacy [29]. According to the Salutogenic Model, the ability to recognize and use resources (even though they are limited) for health promotion purposes is congruent to elements of Sense of Coherence (SOC) described by Antonovsky [8-10]. Studies have demonstrated an association between a high SOC and healthy dietary decisions [14-16]; therefore, the population interviewed may have this feature since they recognize having the ability to manage and prioritize time and budgets for healthy food despite limited availability of these resources. Having resource-management skills enables them to successfully face the challenge of healthy eating. This is associated to food literacy attributes of self-efficacy and confidence [29].

  In this study, the relationship between food and health emerges as the main mechanism that promotes good dietary behaviors. Maintaining a healthy diet is done to benefit health either in a preventive or curative way, for themselves and their families. Healthy eaters from this study assign food a significant role in wellbeing. It is important for physical health as it is recognized as the source of nutrients and energy needed for everyday life, to prevent illnesses and reach old age in good conditions. At the same time, an emotional role is identified, associating the consumption of healthy foods to positive feelings, and unhealthy foods to negative feelings. Healthy eating interpreted as fundamental to reach a state of health and well-being has also been identified in other populations [28,32-34].

  A food learning process was constructed and conceptualized, based on three correlated stages through which food-related learning takes place and favors performing and adopting healthy eating habits. This Food Learning Triad is a dynamic process that integrates knowledge, contemplation and experience that allow the modification and adoption of food behaviors. From a Salutogenic perspective, the Food Learning Triad is comparable with the three dimensions of SOC [8-10]. Firstly, the Triads’ Cognitive Stage emerged as the moment when nutrition information is incorporated and taken into consideration for coping with food practices and environments. It is comparable to the SOC’s comprehensibility dimension, its cognitive component which refers to the extent to which received information makes sense and the degree to which the challenge of coping with stressors is understood. Secondly, the Reflective Stage of the Triad in which an evaluation process of one’s capability of performing certain behaviors takes place can be associated to the manageability dimension of SOC, its behavioral component referring to the extent to which resources needed to cope with stressors are perceived as accessible. During this stage, the emotional role of food identified in this study is materializes, as positive mood states arise when performed food behaviors and food goals are congruent, reaching feelings of achievement and tranquility; whereas negative feelings like guilt arise when behaviors do not meet established food goals. Finally, the Triad’s Modification in Praxis Stage in which the new behavior is accepted as useful and beneficial for set food goals relates to the meaningfulness dimension, the motivational component of SOC that refers to the degree to which life makes sense and there is a desire to cope with stressors.

  This study was the first of its kind in attempting to unravel the mechanisms by which Chilean adults overcome the obesogenic environment through a Salutogenic perspective and it is not without limitations. Firstly, the study population’s homogeneity, being mostly women given by the sampling strategy used. Through intentional sampling, a greater male participation could have been obtained, gathering relevant data to detect more elements that facilitate healthy eating in men. Secondly, conducting semi-structured interviews in various meetings would allow a better understanding of the topic investigated, as compared to a single semi-structured interview session; since it requires participants to recall life experiences, and reflect on the meaning of food and why it is important to them. Regardless of these limitations it was possible to explore how the value of health is the main drive for healthy food practices among healthy eaters.

Implications for Research and Practice

  Further research exploring the mechanisms that allow successfully coping with nutritionally challenging food environments should focus on different age groups, socioeconomic status and ethnic origin. Additionally, special attention should be payed to healthy eating men, as well as people with NCDs who manage to adequately control their condition to gain greater scope of promoters of healthy food behaviors.

The health-food link identified in this study as the main mechanism that supports healthy eating habits may provide nutritionists and dietitians with a better understanding for approaching food behavior change by dealing with patient’s perception of susceptibility to nutrition related diseases. Additionally, the Food Learning Triad may serve as a useful tool for nutrition education interventions, establishing a closer link between patients’ motivations and interests and the nutritional needs detected.

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