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Appetite 180 (2023) 106346 Contents lists available at ScienceDirect...

Appetite 180 (2023) 106346 Contents lists available at ScienceDirect Appetite journal homepage: www.elsevier.com/locate/appet Beliefs underlying older adults’ intention to consume plant-based protein foods: A qualitative study Virginie Drolet-Labelle a, b, c, e, g, Danielle Laurin a, c, f, g, Alexandra Bédard a, b, Vicky Drapeau a, b, d, Sophie Desroches a, b, e, * a Institut sur la nutrition et les aliments fonctionnels (INAF), Université Laval, Québec, QC, G1V 0A6, Canada b Centre Nutrition, santé et société (NUTRISS), Université Laval, Québec, QC, G1V 0A6, Canada c Centre d’excellence sur le vieillissement de Québec, Centre de recherche du CHU de Québec – Université Laval and VITAM-Centre de recherche en santé durable, CIUSSS-CN, Québec, QC, G1S 4L8, Canada d Département d’éducation physique, Université Laval, Québec, QC, G1V 0A6, Canada e École de nutrition, Université Laval, Québec, QC, G1V 0A6, Canada f Faculté de pharmacie, Université Laval, Québec, QC, G1V 0A6, Canada g Institut sur le vieillissement et la participation sociale des aînés - Université Laval, Québec, QC, G1S 4L8, Canada A R T I C L E I N F O A B S T R A C T Keywords: The revised Canada’s food guide released in 2019 promotes the consumption of plant-based protein foods (PBP). Plant-based protein Yet, older adults consume little of them. This qualitative study aimed to identify older adults’ beliefs about Beliefs consuming PBP and to assess differences in beliefs by gender and baseline PBP consumption. Recruitment was Theory of planned behavior done to obtain an equal number of men and women, 20 PBP-consumers and 40 non-consumers. Each participant Older adults Canada’s food guide completed an online questionnaire collecting sociodemographic data and took part in an individual semi- Perceptions structured interview based on the Theory of Planned Behavior. A thematic analysis was performed using the Nvivo software. Health benefits, good taste and protecting the environment were perceived as advantages of consuming PBP, whereas difficulty digesting and not liking the taste were reported as disadvantages. Family members were frequently named as people who would approve and/or disapprove the consumption of PBP. Having more knowledge about PBP would facilitate consumption, while lack of motivation to change eating habits and lack of knowledge on how to prepare PBP meals were perceived barriers. Several differences in beliefs by gender and baseline PBP consumption were observed. Future interventions should focus on the beliefs that were identified as important to older adults (i.e., health benefits and food preparation skills), and should be tailored to their gender and PBP consumption. 1. Introduction Brassard et al., 2022). Thus, in order for this new recommendation to be met, a shift must be made from AP to PBP. However, studies have yet to The latest version of Canada’s food guide recommends choosing identify the psychosocial determinants underlying older adults’ inten­ more often plant-based protein foods (PBP), such as legumes, soy tion to properly substitute AP in their diet. A previous study showed that products, nuts and seeds (Health Canada, 2022). PBP consumption is Canadian older adults who consume half or more of their protein from associated with several benefits including reduced risks of all-cause plants have higher risk of inadequate protein intake compared to those mortality and better cognitive and cardiovascular health (Aune et al., who consume less, mainly because AP are frequently replaced by grain 2016; Blanco Mejia et al., 2019; Chen et al., 2021; Li et al., 2017a; Li products and very little by legumes, soy product or nuts (Fabek et al., et al., 2017b). Also, PBP are more sustainable than animal protein (AP) 2021; Kemper, 2020). since their production is less polluting and energy-consuming (Poore & An adequate protein intake is essential for healthy aging. In Canada, Nemecek, 2018). Yet, based on the Healthy Eating Food Index, Cana­ the protein recommendation is the same for all adults 18 years and dians of all ages show little adherence to this recommendation, mostly older, i.e., 0.8 g/kg/day (Government of Canada, 2006) but according to because AP are still predominant in the diet (Auclair & Burgos, 2020; The European Society for Clinical Nutrition and Metabolism (ESPEN), * Corresponding author. Institut sur la nutrition et les aliments fonctionnels (INAF), Université Laval, Québec, QC, G1V 0A6, Canada. E-mail address: [email protected] (S. Desroches). https://doi.org/10.1016/j.appet.2022.106346 Received 18 August 2022; Received in revised form 11 October 2022; Accepted 12 October 2022 Available online 17 October 2022 0195-6663/© 2022 Elsevier Ltd. All rights reserved. V. Drolet-Labelle et al. Appetite 180 (2023) 106346 intakes of 1–1.2 g/kg/day might be more appropriate for older adults to was determined based on the responses of the first 10 participants. maintain good muscle health (Deutz et al., 2014). However, with aging, Recruitment proceeded until 40 non-consumers and 20 consumers were a decrease in protein intake is often observed (Auclair & Burgos, 2020) included, with equal numbers of men and women in each group. One due to a number of reasons, including physiological changes, health and participant withdrew after recruitment because she lacked time and was economic status, and physical limitations (Deutz et al., 2014). Also, replaced by another participant with similar characteristics, i.e., the meat and poultry, the main source of protein for adults (Auclair & same gender and PBP consumption. The sample size for elicitation study Burgos, 2020; Pasiakos et al., 2015), may be less consumed (Daniel using the TPB has been estimated to be between 15 and 25 (Fishbein & et al., 2011) in relation with chewing problems (Sheiham & Steele, Ajzen, 2011; Godin & Kok, 1996). However, to adequately explore the 2001), increased meat prices (Charlebois et al., 2016) or decreased beliefs underlying the consumption of PBP, which is still an unchartered pleasure associated with meat consumption (Kemper, 2020). In order to area of research among older adults, we adjusted the sample size up­ help older adults, who represent a growing segment of the population wards to allow the saturation of data for the different subsets (i.e. gender (Statistics Canada, 2020), adequately substitute AP and enjoy the ben­ and baseline PBP consumption) (Francis et al., 2004). efits of PBP, it is important to better understand their perception and beliefs about PBP. 2.2. Data collection 1.1. Conceptual framework Participants were asked to complete a self-administered online questionnaire to collect data on sociodemographic characteristics on the The Theory of Planned Behavior (TPB) developed by Ajzen (Ajzen, Institute of Nutrition and Functional Foods secured web portal (http 1985) is used to predict the intention to perform a behavior. It is based s://inaf.fsaa.ulaval.ca/fani/). Then, they each took part in a semi- on three constructs and their respective underlying beliefs: attitude structured individual interview on the Zoom Platform, lasting approxi­ (behavioral beliefs), social norms (normative beliefs), and perceived mately 1h, and facilitated by a female graduate student and registered behavioral control (control beliefs). Attitude corresponds to the positive dietitian (VDL) who was trained by research professional with previous or negative repercussions associated with performing the behavior. So­ experiences in qualitative research. The interview guide was developed cial norms correspond to the importance that the individual attaches to based on the TBP constructs, as recommended by Fishbein & Azjen the opinions of others and to the perception that there is a social pressure (Fishbein & Ajzen, 2011). It was pretested with two individuals from the to adopt or not a behavior. Finally, perceived behavioral control tells us target population, which resulted in no changes being made as the what factors might facilitate or hinder the adoption of the behavior. The questions were found to be comprehensive. The interview guide allowed ability of the TBP to predict behavioral intention has been documented for an in-depth exploration of the TPB constructs i.e., attitude (what are (Armitage & Conner, 2001), and it has already been used to understand the advantages/disadvantages of consuming PBP in the next 6 months?), the eating behaviors of older adults, such as their consumption of whole social norms (who are the important people for you who would appro­ grains (Jung et al., 2022), fruits and vegetables (Jung et al., 2017; Sjo­ ve/disapprove of your consumption of PBP in the next 6 months?) and berg et al., 2004) and dairy products (Kim et al., 2003). Women were, perceived behavioral control (what would make it easier/what are the however, overrepresented in these studies, and none of them focused on barriers for you to consume PBP in the next 6 months?). Probing questions PBP intake. Some studies have also used the TPB to predict meat were asked to facilitate the discussion and clarify the responses. The reduction (Carfora et al., 2017; de Gavelle et al., 2019; Zur & A. project’s aims, as well as a definition of PBP’s were presented at the Klöckner, 2014), or PBP consumption (Wyker & Davison, 2010), but beginning of the interview. The interviews were video recorded. The these have focused on adults under the age of 65. The lack of studies on study was conducted entirely online due to the COVID-19 pandemic. The older adults’ perceptions and beliefs toward the consumption of PBP facilitator had no contact with participants other than during screening limits the development of interventions tailored to their reality and prior to the interviews. The project was approved by the ethics com­ needs. Therefore, this study aimed to identify the salient beliefs under­ mittee of Université Laval (#2020-153). Each participant provided lying older adults’ intention to consume PBP in view of planning dietary informed consent for audio and video recording of the interview prior to interventions that would facilitate their consumption. We also aimed to completing the online questionnaire. They did not receive any examine the effect of gender and current PBP consumption on PBP compensation for their participation. beliefs. 2.3. Data analysis 2. Methods Socio-demographic data was analyzed quantitatively with the R 2.1. Recruitment Commander software. Means, standard deviations, and differences with an alpha level of 0.05 between groups were calculated. Student’s t-tests Participants were recruited between May and August 2021. News­ or Wilcoxon bivariate tests were performed depending on the normality letters featuring the project recruitment ads were sent to several orga­ of the distribution. A thematic qualitative deductive and inductive nizations and associations for older adults and retirees in the Province of analysis of the transcribed verbatims was performed using the NVivo Quebec, Canada. Inclusion criteria were verified during the initial software (Nvivo 12, QSR International). First, emerging themes from the recruitment call with yes or no questions: 1) be 65 years of age or older, interviews were identified and classified under the three TPB constructs 2) understand, read, and speak French, 3) be responsible for at least 50% by the author conducting the interviews (VDL) and sub-themes were of meal planning and/or preparation, 4) have access to the Internet, 5) added for greater precision. Thereafter, double coding was performed feel at ease answering an online questionnaire and participating in a independently by two co-authors (VDL and AB) for the first 5 interviews video-conference interview. Previous studies showed that eating habits that were randomly selected from each of our subgroups. Some wording and gender influence beliefs about diets, e.g. vegetarian or reduced in and grouping of themes and sub-themes were modified to reach a meat (de Gavelle et al., 2019; Mullee et al., 2017), thus, we recruited consensus among coders. Finally, the 55 remaining interviews were according to gender and baseline PBP consumption. To do so, we asked coded by one co-author (VDL) and reviewed by a second co-author (AB). participants about their weekly consumption frequency of meals con­ If there was disagreement, a third co-author (SD) was asked to be taining PBP during recruitment. Those who consumed PBP at main involved. Attribute analysis was used to assess differences between meals less than twice a week were considered non or low consumers genders and the two consumption groups. The interviews and analysis (NC-group) while those who consumed PBP twice a week or more were were conducted in French and recording transcriptions were translated consumers (C-group). As there is no consensus to set a cut-off point, it for this publication. 2 V. Drolet-Labelle et al. Appetite 180 (2023) 106346 3. Results Table 2 Main advantages associated with PBP consumption. 3.1. Quantitative analysis of the questionnaires Frequency (%) Total Women Men NC- C-group Sociodemographic characteristics are presented in Table 1. The (n = (n = 30) (n = group (n (n = 20) mean age of the study sample was 71.1 (SD: 4.8) years; and men were 60) 30) = 40) older than women (72.5 versus 69.7 years). The majority had a uni­ Health 88 97 80 83 100 versity degree (87%) and a household income over CAD 60 000 (55%). Easily digested/ 47 50 43 48 45 Approximately two-thirds of the participants (63%) were living with a Improve intestinal partner. The mean BMI was 26.15 (SD: 5.4) kg/m2, the NC-group having transit Good nutritional 40 57 30 43 45 a significantly higher mean BMI than the C-group (27,4 versus 24 kg/ composition, other m2). than fat Good fat quality and 30 33 27 25 40 quantity 3.2. Descriptive analysis of the transcripts Cardiovascular health 30 37 23 23 45 and cholesterol Good for overall 20 17 23 15 30 3.2.1. Attitudes health Attitudes are presented in Tables 2 and 3. Advantages that were the Weight management 10 17 3 8 15 most frequently mentioned, were related to health benefits, with a Good taste and 62 63 60 60 65 higher proportion of women and C-group participants reporting these texture advantages (Table 2). For example, participants reported that PBP are Environment 60 53 67 53 75 Less resources needed 37 30 43 35 40 easily digested, and that they feel lighter after eating PBP compared to Less pollution 17 17 17 18 15 meat: « [If I eat] meat that is a little bit more fatty, [ …] I’m going to feel Good for the 17 17 17 8 35 heavy [ …] it seems like all my energy is focused on digestion. Whereas, if I environment in have a legume-based meal, [ …] I feel better […] the process is less general Less expensive 37 43 30 38 35 demanding on my body, my energy» (W, NC, #35). Others have also Variety and balance 33 43 23 38 25 mentioned that PBP promote good intestinal transit: “[…] it makes a Animal ethics 28 27 30 25 35 difference when you eat more legumes, [ …], I feel that it improves the Accessibility of 27 30 23 20 40 transit” (W, NC, #20). Good nutrient composition of PBP, namely good recipes and fats, proteins, dietary fiber and vitamins, as well as cardiovascular products Simple and quick to 25 27 23 13 50 health and weight management were also identified as health benefits. prepare The good taste of PBP, mainly legumes, was mentioned several times, for Easy to store 12 13 10 13 10 example, « I have eaten [PBP meals] a few times and they were good, so it’s NC-group: non-consumers of plant-based protein foods; C-group: consumers of encouraging to continue the experience » (W, NC, #1). Participants in the plant-based protein foods. C-group perceived more environmental benefits compared with the NC- group, and PBP were often compared with AP which production was associated with increased use of resources (water and land) and Table 3 Main disadvantages of consuming PBP. Table 1 Sociodemographic characteristics of participants. Frequency (%) Total (n Women Men NC- C-group Total (n Women (n Men (n NC-group C-group = 60) (n = 30) (n = group (n (n = 20) = 60) = 30) = 30) (n = 40) (n = 20) 30) = 40) Health 52 60 43 60 35 Intestinal 33 42 23 43 15 Age (mean ± SD, 71.1 ± 69.7 ± 72.5 71.9 ± 69.7 ± discomfort years) 4.8 4.3 ± 4.9* 5.05 3.8 Lack of some 25 27 23 25 25 BMI (Mean ± SD; 26.15 25.7 ± 26.6 27.4 ± 24.0 ± nutrients kg/m2)a ± 5.4 7.6 ± 4.6 5.5 4.3* Complexity of 37 47 27 38 35 Education preparation (Frequency %) Do not taste good 37 37 37 33 45 High school or less 5 3 7 8 – Social 25 33 17 8 60 College (CEGEP) 8 3 13 10 5 disadvantages University 87 93 80 83 95 Difficult to host 20 30 10 5 50 Household status with PBP (Frequency %) Judgment of 10 13 7 3 25 Living alone 35 33 37 33 40 others Living with a 63 63 63 65 60 Bad for the 20 17 23 20 20 partner environment Other 2 3 – 3 – Lack of 18 27 10 20 15 Annual household availability income At the grocery 17 23 10 20 10 (Frequency %) store 80 000 $ 25 30 20 30 15 know Prefer not to answer 13 13 13 10 20 PBP: Plant-based protein foods; NC-group: non-consumers of plant-based protein *p < 0.05; NC-group: non-consumers of plant-based protein foods; C-group: foods; C-group: consumers of plant-based protein foods. consumers of plant-based protein foods. a Due to missing data on self-reported height and weight of 2 participants, BMI was calculated for 58 participants. 3 V. Drolet-Labelle et al. Appetite 180 (2023) 106346 pollution (water, land, air). The low price, especially when comparing Table 5 PBP with meat, the additional variety that eating PBP brings to the diet People who would disapprove of consuming PBP. (especially for women), animal ethics and the fact that PBP are easy to Frequency (%) store were also mentioned as advantages. The products and recipe Total Women Men NC- C-group availability and the ease of preparing PBP were perceived as advantages, (n = (n = 30) (n = group (n = 20) but mainly by the C-group: « it’s not complicated to take a can of legumes 60) 30) (n = 40) with vegetables, and then I get a complete meal » (W, C, #6). Family member 47 60 33 48 45 Several participants, especially women and those from the NC-group, Spouse 20 23 17 23 15 mentioned health-related disadvantages to consume PBP, i.e., intestinal Daughter-in-law/and 12 20 3 8 20 discomfort (gas and bloating) associated mainly with legumes, as well as son-in-law Children, 10 13 6 13 5 the lack of some nutrients (Table 3). Indeed, some considered that grandchildren higher consumption of PBP could lead to insufficient protein, mineral Brother, sister 7 7 7 5 10 (iron, calcium) or vitamin (B12) intake. Difficulty cooking PBP and the Other family member 12 20 3 13 10 perception that recipes take longer to prepare and contain unknown or Friends 12 23 - 8 20 uncommon ingredients compared with recipes containing AP were also Another person (e.g., 5 3 7 5 5 social group perceived as disadvantages, especially among women. For example, one member, spouse of participant said that « […] if I make a stir-fry with chicken and vegetables, it a friend) doesn’t even take me 5 min. Now I’m looking at the tofu, I’m analyzing it No one would 38 23 53 38 40 every time (laughs), should I have soaked it […] before ? » (W, NC, #12). disagree, don’t know Taste was also identified as a disadvantage by participants and included lack of satisfaction while consuming PBP or simply not liking the taste of NC-group: non-consumers of plant-based protein foods; C-group: consumers of PBP in general or of specific foods such as tofu or processed products. plant-based protein foods. Social disadvantages were very strong in the C-group. Participants in this group considered that having guests over for dinner with PBP was example: « It was really my granddaughter who changed things in my diet challenging, and that often, they must prepare an alternative menu to because she often talked to me about her vegetarian diet [ …] she invited me accommodate everyone. Others felt judged by those around them con­ to her house with a tofu dish to show me what it tastes like [ …] and she gave cerning their PBP consumption. For example, one participant mentioned me the recipe» (W, NC, #7). Individuals referred to as approvers were that « It’s always stigmatized» and that « it’s still there in the mentality, mostly women. Furthermore, approval seemed to be particularly maybe for older people [to be perceived as] granola people, seed eaters» (M, important to the participants when it came from the spouse, whereas the C, #55). For some, and more frequently mentioned by women, the lack approval of other people did not seem to be a determining factor. For or limited availability at the grocery store, as well as the limited variety example: «if [my spouse] really didn’t like it, I would find it annoying to have of PBP dishes offered at the restaurant were considered as disadvan­ to make two meals, and I wouldn’t do it. So, I’m glad he thinks it’s okay that tages. The environmental detrimental effect refers mainly to the I’m cooking [with PBP] » (W, C, #48). perception that overproduction of certain PBP requires the use of pes­ More women mentioned at least one person who would disagree and ticides and insecticides. Also, those who considered PBP to be more the vast majority of those identified as disapprovers were men. Family expensive were mostly referring to nuts and processed products. members were the most frequently mentioned, mainly spouses, followed by friends. Disagreement was expressed by refusing to eat PBP or by 3.2.2. Social norms making negative comments about it. Nonetheless, many of the partici­ Social norms are detailed in Tables 4 and 5. Most participants pants mentioned that they were not influenced by the negative opinions mentioned that at least one person would approve of their consumption of others. For example, one C-group participant mentioned: « [according of PBP (Table 4). A family member, especially children/grandchildren to my friend], I don’t eat well, I don’t get enough protein. It’s all negative », and spouse, were most often named, followed by friends. Approval may but also that « I don’t care, I am not negatively influenced » (W, C, #3). be shown through support (e.g., sharing recipes, advice, learning about new products), encouragement, or by simply enjoying PBP meals. For 3.2.3. Perceived behavioral control Perceived behavioral control is presented in Tables 6 and 7. Most participants felt that knowing how to prepare PBP, i.e., having recipes Table 4 that are simple, quick, tasty and with few ingredients, could facilitate People who would approve of consuming PBP. the consumption of PBP (Table 6). Some also considered that being more Frequency (%) informed about PBP, for example, to know the range of products, where Total Women Men NC- C-group to buy them, what are the benefits associated with their consumption (n = (n = 30) (n = group (n = 20) and how to avoid digestive side effects, could help them: “[ …] if 60) 30) (n = 40) someone could tell me about the benefits of this recipe for me, for my health, Family member 85 93 77 85 85 for the environment, that would help me” (W, NC, #7). Participants would Children, grandchildren 63 73 53 60 70 like to receive such information mainly through a variety of media, i.e., Spouse 45 40 50 45 45 television, websites, and cookbooks. Tasting products and taking part in Brother, sister 22 33 10 23 20 Daughter-in-law and 8 7 10 10 5 cooking workshops would also help increase knowledge, especially son-in-law among men. In addition, participants, mainly those in the C-group and Other family member 10 17 3 10 10 those reporting living in rural areas, would like to have better access to Friends 30 33 27 35 20 PBP, in groceries and restaurants. Some would also like to see new Another person (e.g., 10 10 10 10 10 products on the market, both processed and unprocessed and mentioned social group member, health care that they like trying new products: “As soon as there are [new] products, of professional) [PBP], I will try them. I try everything. And so, to the extent that it’s good, I’ll No one would agree, 5 - 10 5 5 adopt it” (M, NC, #56). Better promotion and valorization of PBP was don’t know also mentioned. The societal dimension refers to advertising and food NC-group: non-consumers of plant-based protein foods; C-group: consumers of marketing that could be more focused on PBP, but also to the promotion plant-based protein foods. of PBP at the grocery store (i.e display of PBP, tastings, recipe cards). 4 V. Drolet-Labelle et al. Appetite 180 (2023) 106346 Table 6 Many have mentioned that AP are taking up too much space in society. Main factors that would facilitate the consumption of PBP. For example, one participant said: “When you want to sell a product, you Frequency (%) have to show it, you have to sell your product, you have to make it known, I think [PBP] are not publicized enough” (M, NC, #24). Another said that “In Total Women Men NC- C-group (n = (n = 30) (n = group (n (n = 20) the first pages of the [grocery] flyers, it’s often not the plant-based products 60) 30) = 40) that are promoted. It’s still meat.” (M, NC, #30). For the individual To have better 95 100 90 95 95 dimension, participants mentioned that placing food differently in their knowledge food pantry to make PBP more visible as well as receiving reminders to Learn how to cook 90 97 83 88 95 consume PBP, could help them. Examples of these reminders identified PBP by participants included weekly newsletters containing recipes or Learn about PBP 63 63 63 65 60 cooking tips. Some also said that scheduling a meatless day per week in More availability 45 47 43 40 55 and accessibility their food habits (e.g., Meatless Monday) could remind them to consume New products 23 23 23 20 30 PBP and would be a way to highlight PBP in their daily lives. Finally, the In restaurants 20 17 23 18 25 social aspect came up. Sharing tips, recipes and advice with others may In the grocery store 13 20 7 13 15 facilitate the consumption of PBP. For some, the simple fact of discussing Promotion and 42 40 43 43 40 recall and taking part in a one-on-one interview gave a certain value to PBP Societal level 28 20 37 30 25 which in turn could lead to a change in their eating habits: « My Individual level 22 27 17 20 25 participation in this research [ …] I think that it will be [ …] an element that Social facilitating 33 33 33 38 25 will ensure that when we prepare our weekly meal plans, [ …] we will add a factors meal [of PBP]. That’s for sure that participation in the research will be an Sharing with others 25 23 27 25 25 To have someone 7 7 7 8 5 element of motivation [ …]”(W, NC, #19). else prepare PBP The main barrier was related to the lack of motivation to change for you eating habits, with a higher proportion of men and those from the NC- Getting others to 5 10 - 8 - group reporting this barrier (Table 7). Laziness, inertia and unwilling­ enjoy PBP Knowledge 65 67 63 60 75 ness to put effort into changing habits were mentioned. The fact that translation some people considered themselves to be in good health at the moment strategies may accentuate this inertia: “I know it’s better for my health and all that, By media 57 60 53 53 65 we talked about it earlier, but I say to myself, well, I’m already healthy, so it’s Workshops and 22 17 27 25 15 not necessary to make the effort” (M, NC, #38). Lack of knowledge about tasting how to prepare PBP, not liking cooking meals anymore or finding it PBP: Plant-based protein foods; NC-group: non-consumers of plant-based protein more difficult to cook as they get older are also barriers to PBP con­ foods; C-group: consumers of plant-based protein foods. sumption, mainly for the NC-group. Some participants perceived a social barrier, mainly when a family member, especially spouses, didn’t like PBP: “My spouse [ …] he’s a carnivore, [ …] it’s hard to get plant protein in Table 7 Main barriers to PBP consumption. [our habits]. It influences me in the sense that I cook less [PBP]” (W, NC, #13). Living alone can also lead to a certain lack of motivation to cook Frequency (%) PBP and to change one’s habits. Then, some participants, mostly men, Total Women Men NC- C-group simply did not have the reflex to eat PBP. Because the habits of (n = (n = 30) (n = group (n (n = 20) consuming AP are very strong, they do not think of consuming anything 60) 30) = 40) else: « We’re not used to it. We don’t have the reflex to grab [and eat PBP]. Lack of motivation 37 30 43 48 15 That’s what it comes down to […]. We don’t have the reflex to do that, we Cooking barriers 27 23 30 33 15 don’t have it yet » (M, NC, #38). Some justified this with the diet they Lack of technique 23 17 30 30 10 and knowledge grew up with, which was often animal-based: “it’s things we didn’t grow Don’t like to cook/no 8 13 3 10 5 up with, my parents didn’t know that, they didn’t cook that, we repeat a little longer cook bit what we know too” (W, NC, #13). When digestive problems were Social barriers 27 23 30 28 25 mentioned as a barrier to PBP consumption by the participants, these Family member who 17 13 20 18 15 does not eat much/ problems were described as very severe and could resemble an allergic no PBP reaction. Taste dislike was a barrier to introduce PBP, mainly in the NC- Living alone 10 10 10 10 10 group. The overpowering taste of processed products, and the lack of Not being used to 23 10 37 23 25 taste of tofu were often mentioned as elements that hinders consump­ consume PBP tion. The products listed in this barrier could also never have been Taste dislike 13 10 17 15 10 Digestive problems 10 10 10 13 5 tasted. Finally, the unattractive nutritional composition, but only for Lack of 10 13 7 10 10 processed products, was a barrier for some participants, especially accessibility regarding the amount of salt and additives. At the grocery store 5 3 7 8 – At the restaurant 8 13 3 8 10 Barriers related 30 33 27 25 40 4. Discussion only to processed products This is the first qualitative study to assess older adults’ beliefs about Suboptimal 25 27 23 20 35 PBP consumption. The interviews provided an opportunity to explore nutritional composition the constructs of the TPB. Several differences have been highlighted Too much similarity 10 17 3 8 15 between men and women and the C-group and NC-group. In general, with meat women perceived more health benefits than men, but they experienced PBP: Plant-based protein foods; NC-group: non-consumers of plant-based protein more digestive problems and considered the preparation of PBP as more foods; C-group: consumers of plant-based protein foods. complex. Men perceived more barriers associated with lack of motiva­ tion and habit to consume PBP. C-group participants perceived more health and environmental benefits and fewer digestive issues, but more 5 V. Drolet-Labelle et al. Appetite 180 (2023) 106346 social disadvantages, while NC-group participants perceived more bar­ men are spending more and more time preparing meals, women are still riers in terms of lack of motivation and difficulty in preparation. primarily responsible for this daily task (Moyser & Burlock, 2018). Even Participants of the C-group had a lower mean BMI than those of the though one of our inclusion criteria was to be responsible for at least half NC-group, which was expected (Clarys et al., 2014). Health benefits of of the meal planning and preparation, it cannot be excluded that men consuming PBP, such as better cardiovascular and digestive health and participants in our study may have been less involved in the kitchen than good nutrient composition, were frequently mentioned by our partici­ women participants, which may explain why they reported fewer pants, especially by women, which is similar to other studies conducted disadvantages. with younger samples of participants (Figueira et al., 2019; IPSOS, Family members, mainly spouse, children, and grandchildren, were 2010). However, the easier and lighter digestion of PBP, often opposed frequently mentioned as people who would approve the consumption of to the heavier digestion of AP, contrasts with a study including 632 men PBP. Indeed, the influence of the spouse is important for older adults and and women aged 50 and over where the digestibility of meat did not can influence dietary quality and habits. For example, the meal choice of seem to be an issue (Schmid et al., 2017). Good taste was also an older women in one previous study depended on the dietary preferences advantage, as raised by other authors (IPSOS, 2010; Schyver & Smith, of their husband (Bloom et al., 2017). Also, grandchildren can have a 2005). Considering how health and taste are determining elements that positive influence on their grandparents’ eating behaviors (Matos & influence older adults’ food choices (Kamphuis et al., 2015), it would be Neves, 2012). Thus, the spouse’s approval and the support of the relevant to promote those in future interventions aimed at increasing grandchildren may be important elements that increases the partici­ intention to consume PBP. Framing public health messages around the pant’s intention to consume PBP. More women were mentioned as easy-to-digest characteristic of protein alternative to meat could be people who would approve the behavior, which is consistent with explored, given that some older adults reduced their meat consumption studies that found that women generally have a more positive attitude in relation to its difficult digestion. Also, increased variety was a toward PBP and vegetarianism (Mullee et al., 2017; Wyker & Davison, perceived advantage of consuming PBP which is a particularly valuable 2010). advantage for older adults since appetite tends to decrease with age On the other hand, several participants mentioned that no one would (Fávaro-Moreira et al., 2016) and that eating a diverse diet can help disapprove the consumption of PBP and overall, participants did not maintain appetite (Vesnaver et al., 2012). value the agreement or disagreement of others, except when it came The environment benefit of PBP was brought up by a high proportion from their spouse. Some mentioned that as they get older, they no longer of participants. Surprisingly almost half of those included in the NC- care about what others think and are more independent, which may group were aware of the environmental benefits, yet their consump­ explain their indifference. These results are in line with those of previous tion remained low. This can be explained by the fact that the environ­ studies, which reported that older adults often believe that no one would ment argument might be insufficient to increase intention and to disapprove of the behavior (Jung et al., 2017, 2022) and that the social generate behavioral change, according to a recent Canadian survey on norm is not as predictive of behavior as the other two constructs of the legume consumption (IPSOS, 2010). The financial advantage of TPB, both in older adults (Kim et al., 2003; Sjoberg et al., 2004) and in consuming PBP was also mentioned and is particularly important the general population (Armitage & Conner, 2001). Also, the majority of considering the current high inflation for meat (Statistics Canada, those identified as disapprovers were men. Indeed, evidence suggests 2022b). Overall, participants in the C-group mentioned more advan­ that more men believe that humans are meant to eat meat, and that a tages, especially in terms of health, environment, ethics, accessibility of meal without meat is incomplete, which may explain the stronger products, and ease of preparation. This is consistent with the study of disapproval (Mullee et al., 2017; Neff et al., 2018). Given their greater Povey et al. which concluded that our attitude toward our diet is more resistance, messages aimed at men must be aligned with their beliefs positive than our attitude toward other diets (Povey et al., 2001). This about PBP, but also those related to meat. highlights the importance of building future interventions around the According to our interviews, increasing knowledge could facilitate target audience’s meat and PBP baseline consumption. PBP consumption, especially by providing information on how to pre­ Several participants, mainly women and those in the NC-group, pare PBP, through media and workshops. On the other hand, lack of associated PBP with intestinal discomfort, i.e. bloating and gas, which knowledge and skills to prepare PBP meals were perceived barriers, is in line with other studies (Figueira et al., 2019; IPSOS, 2010; Lea et al., which has also been raised frequently in the literature (Collier et al., 2006b). Also, our participants pointed out the lack of nutrients in PBP, 2021; Figueira et al., 2019; IPSOS, 2010; Melendrez-Ruiz et al., 2019; mainly protein and iron. Indeed, PBP generally have less protein than Mullee et al., 2017; Schyver & Smith, 2005; Wenrich & Cason, 2004). AP, and the non-heme iron in PBP is less absorbed than the heme iron in Some authors have already studied the effectiveness of cooking work­ meat (Hurrell & Egli, 2010). However, there are ways to increase the shops with older adults. For example, a study analyzing the impact of an absorption of iron from plants (Collings et al., 2013), and the protein 8-month cooking intervention in men aged 65 and over suggested that intake of those who reduce their meat consumption can be adequate and cooking lessons could improve cooking skills and increase the use of new similar to that of omnivores (Clarys et al., 2014). It would therefore be products. These workshops were also beneficial to counter social isola­ important to inform older adults who increase their PBP intake about tion of older adults (Keller et al., 2004). Another similar 8-week inter­ strategies to limit intestinal discomfort, but also to teach them about the vention study found that workshops combining information and nutritional value of PBP in order to address the perceived disadvantages. culinary skills improved older adults’ nutrition knowledge, eating Surprisingly, similar proportions of participants in both C-group and habits, and confidence in eating healthy meals that meet their re­ NC-group mentioned the complexity of cooking PBP as a disadvantage, quirements. Tasting new foods and recipes helped to overcome pre­ and more participants in the C-group mentioned not liking the taste as a conceived notions about these foods and encouraged greater variety disadvantage. Taste is indeed often mentioned as a disadvantage in the (Moreau et al., 2015). Regarding the taste barrier, some of our partici­ literature (Figueira et al., 2019; Schyver & Smith, 2005) but usually, pants had never or hardly ever tasted the food identified, which could those who consume more PBP find their preparation easier (de Gavelle indicate neophobia. Indeed, food fussiness has been associated with a et al., 2019; Schyver & Smith, 2005). This shows that even those who lower likelihood of consuming PBP as an alternative sustainable source have already introduced some PBP into their diet could benefit from of protein (Grasso et al., 2019). In this regard, one previous study raised increasing their cooking skills for preparing PBP which may contribute taste as a barrier to consume legumes and tofu, but it could be overcome to an enhanced taste appreciation. with a better knowledge of cooking techniques (Lea et al., 2005). This In general, women mentioned more disadvantages related to food highlights that cooking classes for older adults may be an effective preparation, in terms of difficulty when hosting with PBP, lack of strategy address some of the barriers to the consumption of PBP iden­ availability at the grocery store, and complexity in cooking. Although tified on the present study. 6 V. Drolet-Labelle et al. Appetite 180 (2023) 106346 Some mentioned that better PBP accessibility would be helpful, referring to the lack of social contacts, so answers related to the social especially those who reported living in rural areas where the nearest norms could have been influenced by this unusual context. Third, par­ grocery store didn’t offer a wide variety of PBP and where the choice of ticipants were categorized into consumer groups based on a single PBP-based meals in restaurants was very limited. Better availability in question in which the number of meals per week containing PBP was grocery stores and restaurants has already been identified in previous self-reported and not assessed with a validated frequency questionnaire, studies as a factor that would facilitate the consumption of soy products so there may have been some misclassification. Finally, despite having (Schyver & Smith, 2005; Weinrich, 2018). Encouraging grocery stores established what are PBP, both in the questionnaire and during the and restaurants in rural areas to increase the availability of PBP could interview, some participants still seemed to confuse PBP with other therefore address this facilitator (Kamphuis et al., 2015). In addition, plant-based foods (vegetables and fruits). When this confusion was promoting products in society was mentioned as a facilitating factor by obvious, a note was taken to this effect and the quote was excluded from participants, in relation to grocery stores and marketing in general. analyses, but it is still possible that other passages were coded when we Indeed, a Canadian study who found that AP take up more than 4 times thought the participant was talking about PBP, resulting in a misclas­ the shelf space of PBP in supermarkets. Also, the consumers interviewed sification of the information. A written and pictorial guide could have considered that PBP were less promoted than AP. Similar to the partic­ been provided to avoid this misunderstanding. To support the general­ ipants in our study, they mentioned that having recipe cards and tastings ization of our study, a quantitative study using a survey questionnaire at the grocery store would facilitate their consumption of PBP (Gravely developed using the salient beliefs identified in the present study could & Fraser, 2018). On a more individual level, some mentioned that be conducted with a larger sample size. Nevertheless, our participants’ adopting a meatless day per week or that receiving newsletters could be distribution was well-balanced across genders and PBP consumption good ways to promote PBP in their daily lives and could serve as re­ levels, which allowed us to observe differences between these groups. minders. Indeed receiving reminders could help achieving behavior Our study is also innovative, as despite the increasing popularity of PBP, change goals (Pirolli et al., 2017). Thus, sending encouraging messages, they remain understudied among older adults. objectives reminders, recipes, and cooking tips to older adults, could potentially increase intention to consume PBP. Email and text messages, 5. Conclusion two means of communication that are increasingly used by older adults (Bourget et al., 2020) appear to be effective methods for inducing a While choosing to consume PBP more often is recommended by the dietary change (Carfora et al., 2017; Lutz et al., 1999). Also, according to 2019 Canada’s food guide, little is known about older adults’ percep­ de Boer et al. (de Boer et al., 2014), meatless days are well received by tions and beliefs towards these foods. Our study fills a gap in the liter­ those who already have an interest in PBP. However, framing the mes­ ature by highlighting beliefs that have the potential to facilitate or sage to promote PBP-days and not meat-free days would be preferable to hinder PBP consumption by older adults. These beliefs could serve as a make it clear that meat has to be replaced by something else, not just knowledge base for the development of future interventions tailored to taken away. In other words, if PBP were more visible in the daily life of older adults, their baseline PBP intake and their gender. older adults might think more about eating them, which would facilitate consumption. Author contributions Lack of motivation and not being used to consume PBP were raised as barriers, especially by men. Growing up with a meat-based diet made it DL, VD and SD designed research; VDL conducted research; VDL and difficult to reduce meat and to change one’s diet routine, which is in line AB analyzed data. VDL wrote the paper. All authors read and approved with other studies (Collier et al., 2021; Lea et al., 2006a; McBey et al., the final manuscript. 2019). Lack of motivation is indeed an important element that must be addressed in the behavior change process, as is the balance of pros and Funding cons (Prochaska & Velicer, 1997). Educating older adults about the benefits of consuming PBP and helping them develop PBP cooking skills This research was supported by Institut sur la nutrition et les ali­ could eventually increase their intention to consume PBP. It should be ments fonctionnels (INAF). VDL has also received scholarships from noted that increasing PBP cooking skills seems particularly important Centre Nutrition, santé et société (NUTRISS), and Centre d’excellence en according to the literature (Schyver & Smith, 2005; Wenrich & Cason, vieillissement de Québec (CEVQ). 2004), and that awareness of the benefits alone is often not enough to change habits (Melendrez-Ruiz et al., 2019). Based on our results, men and participants in the NC-group, perceived more barriers. It has indeed Declaration of competing interest been shown in the literature that the perceived barriers to vegetarianism and PBP consumption depend on gender and diet (de Gavelle et al., The authors declare that they have no known competing financial 2019; IPSOS, 2010; Mullee et al., 2017; Pohjolainen et al., 2015) which interests or personal relationships that could have appeared to influence demonstrates once again the importance of developing interventions the work reported in this paper. adapted to PBP intake as well as to gender. A few limitations can be pointed out. First, our participants had Data availability higher incomes and education levels than the average in the Province of Quebec (Revenu Québec, 2019; Statistics Canada, 2022a) and infor­ Data will be made available on request. mation on their ethnicity was not collected, which can limit the gener­ alization of some of the results (Fishbein & Ajzen, 2011). 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