Rating One’s Diet Quality: Qualitative Study Results

Abstract

American adults struggle with accurately assessing the quality of their diet, with the majority overrating their diet quality. Thus, the objective of the study was to explore what individuals think about when asked to rate their diet quality. Virtual focus groups were conducted from October 2023 to April 2024, using a semi-structured interview with open-ended questions. Convenience samples of small-scale farmers, school food service directors, health clinic patients, and university students and staff in Mississippi and Arkansas participated (N = 27). Themes and subthemes from NVivo-transcribed discussions were identified and coded inductively. Four subthemes emerged for description of diet: balance, consideration for others, convenience, and location. Four subthemes emerged for quality of diet: availability/access, culture/tradition, health considerations, and making better choices. Three subthemes emerged for healthy food: composition/preparation, nourishing benefits, and taste/flavor. Three subthemes emerged for unhealthy food: addicting/overconsumption, composition/preparation, and undesirable effects. Three subthemes emerged for nutrition knowledge: audience specific, general knowledge, and ambivalence. Three subthemes emerged for food shopping: food types, family influence/preference, and planning. Factors shaping how individuals perceive their diet quality are complex with intertwining components. Understanding the complexity involved in self-perceptions of diet quality will help us better quantify perceptions and link them to measurable outcomes.

1. Introduction

Diet and disease are irrefutably linked with approximately 90% of the USD 4.3 trillion annual cost of health care in the United States (US) spent on medical care for chronic disease [1]. Yet diet quality remains low among US adults [2]. Barriers, such as food and nutrition insecurity, food marketing and advertising, access to and affordability of healthy food, and behavioral challenges (e.g., immediate versus delayed gratification), hinder the adoption of more healthful dietary patterns for many individuals [1]. Additionally, US adults, in general, are not adept at accurately assessing the quality of their diet, with the majority overrating their diet quality [3]. This is concerning as individuals who overrate their diet quality may not be aware of the need to make more healthy food and beverage choices.

The disconnect between self-perception of diet quality and actual dietary intake is puzzling and may be partly due to inaccuracy or bias in recalling food and beverages consumed. A study conducted by the Center for Nutrition Policy and Promotion found that adults underestimated consumption of grains, fats, oils, and sweets, and overestimated consumption of fruit, milk products, meats, beans, eggs, and nuts [4]. Another possible cause for the cognitive disconnect may be the idea that one’s diet, while not being exactly healthy, is healthy enough if one feels good [5]. In fact, individuals tend to assign a diverse range of meanings to healthy eating. Based on a qualitative review of healthy eating interpretations, individuals consider aspects such as types of food (e.g., fruits, vegetables), nutrients, additives and processing, and ways of eating (e.g., variety, moderation) when thinking about healthy eating [6]. These aspects of healthy eating are covered in the Dietary Guidelines for Americans (DGA) [7] and can be captured with diet quality measures such as the Healthy Eating Index (HEI) [2]. However, Bisogni et al. found that individuals consider other aspects of healthy eating not typically captured with diet quality indices such as physical consequences (e.g., body weight, disease prevention/management), psychosocial and spiritual well-being, and moral aspects (e.g., attending to others’ nutritional needs) [6]. While these studies explored individual’s perceptions of and beliefs about healthy eating, they did not specifically investigate individuals’ thoughts about rating the quality (healthfulness) of their own diet. Therefore, to address this research gap, the purpose of this study was to qualitatively explore what individuals think about when asked to describe and rate the quality of their diet. Secondary objectives included exploring definitions of healthy and unhealthy food and level of nutritional knowledge.

2. Materials and Methods

We recruited focus group participants from pools of small-scale farmers and K-12 public school food service directors (SFSDs) in Mississippi using contact lists. We chose these individuals because they are key stakeholders of the nutrition and economic well-being of their communities. Additionally, we recruited patients from a Mississippi rural health clinic and students and staff from an Arkansas university to achieve more diversity in the sample by including racial/ethnic minorities (Black, Hispanic, and Asian). Thus, focus group members represented convenience samples from populations of interest to us. We recruited small-scale farmers and SFSDs by phone and email and health clinic patients and university students and staff using flyers, on site/email, and by word of mouth (i.e., snowball sampling). Study eligibility criteria included aged ≥18 years and willing to participate in a virtual focus group. We explained the purpose of the focus groups during recruitment. All participants provided electronic informed consent. The consent form was created using Snap Desktop software (version 12.06, Snap Surveys Ltd., Portsmouth, NH, USA) and information was collected using Snap Online (Snap Surveys Ltd., Portsmouth, NH, USA). The form included the purpose of the study, voluntary participation, time involved and compensation, benefits/risks, confidentiality, and contact information. Eligibility criteria were affirmed with electronic signing of the consent form. All participants received a USD 25 e-gift card for their time. The study was reviewed and approved by the Institutional Review Board of Delta State University (protocol 2024-013).

This was a qualitative study conducted using focus group discussions and guided by the standards for reporting qualitative research [8]. We conducted focus groups from October 2023 to April 2024 with 4–6 participants recruited for each group [9]. Discussions lasted approximately 1 h and were conducted and video-recorded via Zoom. We developed a semi-structured interview guide using open-ended questions to explore participants’ thoughts about the quality (healthfulness) of their diet and factors they considered when asked to rate the quality of their diet. Because there is a paucity of information regarding what individuals think about when rating the quality of their diet, we developed the interview guide based on subject matter experts’ recommendations as well as concepts from the consumer behavior and food choice model [10]. The model posits that food choices are made on the basis of taste, cost, and convenience with health playing a less important role [10]. We reviewed the initial guide, asked for feedback from graduate research assistants and community members not involved with the project, incorporated the suggested revisions, and agreed on the final version. We made minor modifications to the interview guide after conducting the first focus group. The focus group topics and final interview questions can be found in

Table 1. Focus group topics and questions.

Topic	Question
Description of diet	How would you describe your typical diet?
	Probe: How many meals do you eat per day?
	Probe: How often do you eat the first meal of the day?
	Probe: When is your last meal of the day?
	Probe: How often do you cook at home?
	Probe: How often do you eat out?
Quality of diet	In general, do you think your diet is healthy? Why or why not?
	Probe: How would you describe the quality of your diet?
	Probe: When asked to rate your diet, what word or words would you use?
	Probe: If you gave your diet a number or grade, what would it be?
	Probe: What things did you think about when rating the quality of your
	diet or deciding if your diet is healthy?
	Probe: Others have mentioned that they consider their weight, body size,
	and other health factors. What specifically did you consider?
	Probe: How does your daily routine influence your diet quality?
Healthy foods	What do you think makes food healthy?
	Probe: Do you consider the type of food, how food is prepared, how it is
	eaten, or what you serve with the food?
Unhealthy foods	What do you think makes food unhealthy or bad for you?
Nutrition knowledge	Are you comfortable giving others advice about nutrition? Why or why not?
Food shopping	How would you describe the items you purchase during a routine trip to
	get food for your home?

.

One research staff (PhD level), trained and experienced in focus group methodology, moderated the virtual focus groups. All focus groups were conducted in English, except for one group that was conducted in both English and Vietnamese using another trained moderator (registered dietitian) fluent in both English and Vietnamese (native language). Audio recordings of focus group discussions were transcribed by a trained researcher using NVivo software (version 12; Lumivero, Denver, CO, USA). The same researcher then checked the transcriptions for accuracy, making any necessary corrections. The one exception was the discussion conducted in Vietnamese, which was transcribed and checked for accuracy by the dual language moderator.

Using the first focus group, we developed a hierarchical coding system using an inductive coding approach. We used the topics of the interview questions as the overarching themes (Table 1). Each focus group discussion was independently coded for subthemes within the overarching themes by 4 members of the research team (2 senior researchers, a post doc researcher, and a research assistant). Subsequently, one team member combined the subtheme coding from all the discussions for subtheme analysis, which was conducted by the same 4 research members. Differences in subthemes were discussed with the final coding schema agreed upon by all team members. Finally, we identified quotes to illustrate concepts of the themes and subthemes. Thematic data saturation was evaluated iteratively starting with the third focus group and reached by the eighth focus group. Our thematic analysis aligned with the 6 steps of Braun and Clarke’s method [11].

3. Results

The 8 focus groups consisted of 2–5 participants each for a total of 27 participants. Participants represented a mix of men and women of various races/ethnicities including Asian, Black, Hispanic, and White. The list of themes, subthemes, and illustrative quotes are presented in

Table 2. Main themes, subthemes, and illustrative quotes from focus group discussions.

Main Theme	Subthemes	Illustrative Quotes
Description of diet	Balance	“I try to get at least one balanced meal, a complete meal a day with vegetables and the whole ball of wax …salad, green vegetables, and a meat.” [FG1-102]
		“I see a balanced meal with the starch, the vegetables, and the meat portion.” [FG5-101]
	Consideration for others	“I have two little kiddos. And so, I would definitely say that impacts my diet. …I do really well with eating choices until we get to dinner and then we’re all trying to eat together, and everybody’s got different tastes.” [FG3-101]
		“Usually it’s something fried because that’s what my sister prefer. And I cook for both of us, but I prefer baked, like baked chicken…” [FG5-101]
	Convenience	“But I won’t lie that sometimes the convenience of it is a lot easier. …when you can just go to the student center instead of…take the time to go shopping and then prepping the food…” [FG4-102]
		“On busy days, like when I have to study, I often order pizza or fried chicken for the family.” [FG6-104]
	Location	“It just depends on where I am and what I get to get access to eat in a healthy way.” [FG2-101]
		“…when I’m at work, I only drink water… When I get home I don’t drink water, I drink tea and punch. …I don’t bring my lunch, I eat in the cafeteria and we tend to serve things that students would like as opposed to what adults would like.” [FG2-104]
Quality of diet	Affordability	“…Black people in not just Mississippi, but in America, in food deserts and in small towns and don’t have major grocery stores and have limited income that your diet is dictated by.” [FG2-101]
		“Money is definitely an issue. It does cost more for fresh vegetables versus canned vegetables or frozen vegetables.” [FG3-103]
	Availability and access	“This is all you have. You have to eat. So really, what choice do you have or what choice is there? Unless, you’re going to drive a half hour, one way to get something, it’s no guarantee it’s going to be something healthy there either.” [FG2-101]
		“So a lot of times your diet depends on where you live, what you have access to. And what you consider healthy depends on where you live and how you grew up.” [FG3-103]
	Culture and tradition	“Our culture pieces still kicks in because we grew up on grits [type of porridge made from coarse ground dried corn] and eggs and bacon and think that’s what breakfast should be. …Until I knew better, I would just do like my mom and my grandmother did. Everything was cooked to death now it’s cooked or sauté not boiled to death. …I think that too has changed a lot for me in changing that culture piece of how it was done in the past and what I’m doing with it now.” [FG2-101]
		“I feel that my meals fulfill all the nutritional groups for the family. However, I haven’t been able to get my [Vietnamese] children accustomed to the American diet yet, for example, dairy products and good-fat foods.” [FG6-105]
	Health considerations	“Because I’m type 2 diabetic, also we supposed to limit the starches, the carbs, and especially the sweets, but I am a sweet nut.” [FG5-101]
		“…I also feel like what factored into my score was I am slightly overweight.” [FG8-105]
	Making better choices	“I need to do more than just get a partially balanced diet… A lot of times I just don’t have time. …whatever is the quickest…unhealthy and it’s because of the choices that I make. I know what to do, but I choose to do something different.” [FG1-104]
		“…if I have to rate my diet, I would only rate 5 out of 10 because I know I can do a lot better. But with my busy schedule which I have to commute almost 2 h to work, it is impossible for me to actually prepare meals. …I know it’s bad but then I feel like I need to eat to have the energy to function. Looking at all of the nutrition details, I didn’t really meet the standard.” [FG6-101]
Healthy food	Composition and preparation	“But for the biggest part, is how are we preparing the food? Are we still putting all the butter? Are we still putting all the salt? How we preparing this cabbage that we love to eat? Are we putting that fat back in there?” [FG2-101]
		“…I also think that what makes a food healthy is just how nutrient dense it is. …if it provides any nutritional value or if there’s like it gives you any vitamins or minerals.” [FG8-105]
	Nourishing benefits	“I think what makes it healthy is the value that you get from it. How does it benefit my body by eating it? Does it benefit my mind? Does it strengthen my muscles? What does it actually do or not do?” [FG2-103]
		“…if a food is healthy, like it’ll make me feel good. …I just feel like I have to do like a little dance like when I eat it because I’m like this is so good.” [FG8-101]
	Taste and flavor	“…help our cafeteria food not to be bland is we spice it up with seasonings, with vegetables. Cooking it a little different way and just seasoning it with more, a little more onion to give a little more flavor, a little more garlic to give it a little more flavor.” [FG2-103]
		“…it’s plain. It don’t taste good because I can’t use the butter. …You got to find a season that don’t have a lot of sodium. So you eating all of this really bland food.” [FG3-102]
Unhealthy food	Addicting and overconsumption	“To me, I was thinking, if it’s easy to become addictive. To me, that’s unhealthy. So like foods that are addictive like sugar…even ketchup and sugar. …a lot of things become unhealthy if you do too much of it… ” [FG8-103]
		“We have a whole lot of sugar. So I tracked my food for a while. …sugar and salt were always my problems. And that’s probably one of the things I would say, like adding too much of something.” [FG7-104]
	Composition and preparation	“A lot of fried food is not healthy because you getting grease and that’s cholesterol. And it’s really in the preparation, if it’s packaged.” [FG5-101]
		“To me, foods that are deep fried in too much oil are unhealthy. Secondly, foods that are too sweet or contain too much sugar. …here, frozen foods are common unlike the fresh ones in Vietnam. Foods that have been frozen for months and then defrosted in a microwave are also not healthy for you.” [FG6-105]
	Undesirable effects	“…having…that…healthy relationship where you’re just like avoiding it because you don’t feel good about eating the food… …in terms of…what is unhealthy…I think I’ll always just go back to the way the food makes me feel.” [FG8-101]
		“…I also avoid eating meals that are unbalanced, like too much meat or carbs, cause I just don’t feel good after that.” [FG6-102]
Nutrition knowledge	Audience specific	“…I would when it comes to diabetes. I will be comfortable sharing what I’ve learned through trial and error. …But going into details like a [nutritionist] would be, no.” [FG5-101]
		“…teaching …it just depends on the population who I’m talking to.” [FG8-105]
	General knowledge	“Probably just general recommendations that a lot of folks probably know. But I also feel like my diet is not five star. So I also will probably not feel like I was the best person to give advice to someone else.” [FG3-101]
		“So, I think I know enough nutrition just for myself and for my family.” [FG6-101]
	Ambivalence	“I’m aware of a healthy diet but I don’t eat thinking about it. I eat because I’m hungry, and it tastes good.” [FG1-102]
		“My knowledge about nutrition is I know what you [are] supposed to eat and what you are not supposed to eat, but I don’t follow it because it’s not convenient to me.” [FG7-102]
Food shopping	Food types	“I always get bananas, apples, cucumbers, ham, because I like sandwich ham, and chicken for my sandwich… I like to fry a lot, so I always have oil and chicken, chicken wings. So always going to Sam’s and get 25 pounds of rice, 25 of sugar…” [FG4-102]
		“…American supermarket called HEB. I usually buy chicken and fruits like tangerines, bananas, and apples, milk and avocados at Costco. And I go to an Asian market maybe every 2 weeks to buy pork. I go to HEB every week and Costco every 2 weeks.” [FG6-103]
	Family influence and preference	“…I get like my husband, like pecan and nuts and stuff like that… my grandson, who lives with us, cookies, chips, Jolly Ranchers. Him and my husband just sit there and eat Jolly Ranchers all night long.” [FG7-101]
		“…sometimes I don’t like what they like, but I still cook what they like so they can eat. I don’t like spaghetti as much and my husband doesn’t like [it] either, but my little kids like [it].” [FG4-102]
	Planning	“So I rely a lot on delivery service. …Since I have a busy schedule, it’s really hard for me to actually go and spend time at the supermarket. I will choose whichever supermarkets that offer the delivery service.” [FG6-101]
		“I can kind of think ahead and I don’t impulse buy. You don’t grab that bag of chips because you don’t see them…I can only get the items that I really need. Out of sight, out of mind kind of thing.” [FG3-103]

. Despite the varied positions of the focus group members (e.g., school food staff, small-scale farmer, university student), the results were relatively consistent across the eight focus groups, with some racial/ethnic and/or cultural differences observed.

3.1. Theme 1: Description of Diet

Within Theme 1, description of diet, four subthemes were identified: balance, consideration for others, convenience, and location. Participants often mentioned trying to eat “balanced” or “complete” meals. They also indicated the types of food or food groups (e.g., vegetables, meat) they believed constituted a balanced meal. Consideration for others when purchasing or cooking food was frequently mentioned during the discussions. Some participants mentioned cooking food preferred by other adult household members (e.g., sister), but the majority indicated that children in the household affected meal choices because of “different tastes.” Convenience was mentioned in all the focus group discussions. Some participants expressed that they often ate out or ordered meals for delivery because of busy schedules or lack of time to cook. This was particularly true when children were present in the household or participants confessed that they lacked the skills or desire to cook. Location was a topic often mentioned in combination with convenience, with many participants indicating they ate differently at work than at home.

“But I won’t lie that sometimes the convenience of it is a lot easier. …when you can just go to the student center instead of…[taking] the time to go shopping and then prepping the food…”

[ID FG8-101, university student]

3.2. Theme 2: Quality of Diet

Within Theme 2, quality of diet, five subthemes were identified: affordability, availability and access, culture and tradition, health considerations, and making better choices. Participants expressed that purchasing healthy food was expensive, sometimes in relation to less healthy food (e.g., fresh vs. canned vegetables), and that their diet quality was dependent on their food environment. The term “food desert” was used and environments were described as lacking in availability of and access to healthy food options. Affordability, availability, and access were intertwined in the discussions.

“Black people in not just Mississippi, but in America, in food deserts and in small towns and don’t have major grocery stores and have limited income that your diet is dictated by.”

[ID FG2-101, small-scale farmer]

Cultural and traditional food/cooking were at times discussed negatively (e.g., “cooked to death”) and other times they were discussed more positively (e.g., eat at home). Interestingly, a Vietnamese participant mentioned that their children were unaccustomed to the American diet, and this was not optimal in terms of diet quality. Some participants expressed that they ate more healthfully because of an adverse health diagnosis or chronic illness, while others indicated that they should eat more healthfully but found it hard to do so. Many participants felt that there was room for improvement in their diets but found that making more nutritious choices difficult because of inconvenience and/or lack of time to choose and/or prepare healthier food. Several participants opinioned that unhealthy food tastes better and healthy food is “bland” or “boring.” When asked to rate the quality of their diet, participants provided descriptive terms (e.g., healthy, unhealthy, good, fair, poor, bad), letter grades (i.e., A, B, C, D), and/or numeric values (i.e., 4 to 9 on a scale of 1–10). One participant (small-scale farmer) described their diet as a “roller coaster, sometimes good and sometimes bad.”

3.3. Theme 3: Healthy Food

Within Theme 3, healthy food, three subthemes were identified: composition and preparation, nourishing benefits, and taste and flavor. Most participants defined healthy food in terms of composition (e.g., vitamins, nutrients, organically grown) and preparation (e.g., cooking from scratch and using less oils, fats, or salt). Several participants defined healthy food as having nourishing benefits, either on the body or the mind. Nourishing effects on the body included providing energy and building muscle while effects on the mind included making one “feel good.” Participants also expressed negative thoughts about healthy food as being “bland” or not tasting good due to lack of ingredients such as butter and salt. They needed to remind themselves that eating the “bland food” was good for their health. Other participants expressed more positive thoughts, indicating that they would add spices and seasonings to healthy food to make it more palatable and attractive.

3.4. Theme 4: Unhealthy Food

Within Theme 4, unhealthy food, three subthemes were identified: addicting and overconsumption, composition and preparation, and undesirable effects. Several participants opinioned that unhealthy food is “addictive” and can lead to overconsumption. The idea that “too much of anything is bad” was voiced. Similarly to the healthy food theme, participants defined unhealthy food in terms of dietary components (e.g., oils, salt, sugar) and preparation (e.g., freezing and then microwaving). Frying or fried food were most often given as examples of unhealthy food. In contrast to the healthy food theme of nourishing benefits, participants described unhealthy food as having undesirable effects such as resulting in poor health and disease diagnoses. Others voiced the opinion that unhealthy food did not make them “feel good” after consuming it.

3.5. Theme 5: Nutrition Knowledge

Within Theme 5, nutrition knowledge, three subthemes were identified: audience specific, general knowledge, and ambivalence. Participants expressed that whether they felt comfortable giving advice to others was dependent on whom they were advising (e.g., more or less knowledgeable than themselves). Other participants expressed their ability to give advice in terms of general nutrition knowledge sufficient for themselves and their family or in terms of general dietary recommendations. Participants also voiced the opinion that because their diets were subpar, they may not be the “best person” to offer advice to others. Several participants indicated that they were aware of dietary recommendations for a healthy diet but chose not to follow them for various reasons including food preference and convenience. Feelings of guilt also were expressed when participants chose not to eat healthfully.

“My knowledge about nutrition is I know what you [are] supposed to eat and what you are not supposed to eat, but I don’t follow it because it’s not convenient to me.”

[ID FG7-102, health clinic patient]

3.6. Theme 6: Food Shopping

Within Theme 6, food shopping, three subthemes were identified: food types, family influence and preference, and planning. Participants described the types of food they typically purchased when food shopping (e.g., meat, fruits, vegetables, dairy, grains) as well as where they shopped. While most participants indicated that they shopped at big box stores (e.g., Walmart) or membership warehouses (e.g., Costco), some also mentioned shopping at specialty stores, particularly the Hispanic and Vietnamese participants. Several participants discussed purchasing food for other household members, such as husbands, children, and grandchildren, and that these items were not food they typically preferred themselves. Participants also discussed planning ahead for food shopping and meal preparation. Several participants mentioned the convenience and time-saving benefits of food shopping with a mobile app and that they “shopped better” using an app than by going to the store. Others mentioned that they purposefully shopped on the “perimeter” of grocery stores, thereby avoiding aisles with unhealthy food.

4. Discussion

In this qualitative study, we explored what individuals think about when asked to describe and rate the quality of their diet. We discussed the description of diet and quality of diet themes together because ideas and opinions expressed were similar and overlapping. Several subthemes aligned with the Consumer Food Choice Model proposed by Drewnowski [10], suggesting that when individuals are asked to describe and rate their diet quality, they do consider aspects of food choice, such as convenience, cost, and well-being (e.g., health considerations). A common subtheme was the concept of obtaining balance in one’s dietary choices. Balance is often used in reference to healthy eating, both in terms of food groups and nutrients [6], and it is how the term was used in the current study. An interesting finding was the disconnect between knowing what or how to eat healthfully and actual dietary consumption, a result which has been previously reported. One suggested reason for the gap between ideal and actual dietary behavior is social relationships, which may be particularly important when a family member is diagnosed with a disease [6]. This proposed reason aligns with the consideration of other subthemes identified in the current study, including the need to prepare special meals for household members with disease diagnoses. Other suggested reasons for the gap between ideal and actual dietary behavior include resources (e.g., financial) and the environment (e.g., widespread availability of unhealthy food) [6]. These components are similar to the external factors of location (e.g., work vs. home), affordability, availability, and access that participants discussed in the current study, suggesting that how individuals think about their diet quality is intertwined with how they interpret healthy eating. Except for the Vietnamese participants, culture and tradition often were portrayed as negatively affecting diet quality, particularly for the Black participants. For Black individuals, “soul food” can be an important part of their cultural diet although it has changed from traditional, healthful components like collard greens, okra, beans, and grits, to include less healthful food like fried chicken and fish, baked macaroni and cheese, and sweet tea [12]. Thus, individuals’ cultural identity may have substantial effects on how they perceive their diet quality.

We also discussed the healthy food and unhealthy food themes together because the opinions and thoughts expressed were similar, particularly regarding composition and preparation. While some participants described healthy food as freshly prepared and containing nutrients, the majority were more likely to describe what healthy food was not (e.g., not fried, not containing too much sugar and salt). This was somewhat surprising and suggested to us that some individuals know what components should not be in healthy food but are not as knowledgeable about or comfortable identifying what composes healthy food. Somewhat aligned with our findings, fat, sugar, and salt were the most frequently mentioned food components to avoid for a healthy diet in a review about perceptions of healthy eating [13]. Thus, it appears that public health recommendations regarding reducing or avoiding dietary fat, sugar, and salt have been assimilated by the general population. Healthy food was also described as providing nourishing benefits to both the body and mind (e.g., makes one feel good) while unhealthy food was described as having undesirable effects on health and how one feels. These findings are supported by results from a systematic review of interpretations of healthy eating for which participants related healthy eating to well-being or feeling good about oneself [6]. The current study’s findings also align with another qualitative study that found individuals evaluated the healthfulness of their diet based on their nutritional knowledge and considerations about healthy eating practices [5]. However, these considerations were overruled when individuals believed their diets were not exactly healthy, but healthy enough so long as they were feeling good [5]. Participants in the current study also described healthy food as not tasting good (e.g., plain or bland), opinions that also align with the review’s finding that healthy eating was commonly described as boring, not tasty, and not satisfying [6]. Participants in the current study also described unhealthy food as addictive or resulting in overconsumption. The addictive view is interesting and supported by studies showing that the brain regulates dietary behavior. Foods containing sugar and fat tend to be both energy dense and highly preferred [14], and sustained consumption of them can lead to changes in brain sites involved in feeding and reward [15]. Thus, there is a biologically plausible explanation for the addictive properties of palatable food high in sugar and fat. Finally, while others have reported that individuals view healthy food as expensive [6], this did not emerge as a subtheme within the healthy food theme in the current study, although it was a subtheme within the quality of diet theme. It is possible that because the perceived high cost of healthy food was expressed in earlier discussions about diet quality, participants did not feel it necessary to mention cost again in later discussions about healthy food definitions.

Curiously, the ambivalence subtheme for nutrition knowledge was surprisingly similar to the make better choices subtheme within the quality of diet theme. The idea that participants were aware of what constituents a healthful diet but chose not to eat in alignment with that knowledge was commonly expressed. Reasons for misalignment between ideal and actual diets often included convenience and taste preference. These results are supported by research regarding consumer behavior and food choices. Marketing studies have suggested that food choices are made based on taste, cost, and convenience, with health playing a lesser role [16]. Thus, ambivalence in nutrition knowledge coupled with the view that healthy food makes you feel good may at least partially explain why individuals are unable to accurately assess their diet quality.

Similarly to the consideration for others subtheme within the description of diet theme, family influence and preference emerged as a subtheme within food shopping. In a study exploring perceptions of and barriers to healthful shopping, participants expressed that demands from multiple family members made healthful shopping more difficult, while others were reluctant to impose healthful eating on family members [17]. Results from a nationwide online survey found that parents and spouses were most influential on shoppers’ impulse purchases, although children also had an influential effect [18]. The planning subtheme was quite intriguing, particularly the discussions about food shopping with a mobile app to save time and avoid purchasing unhealthy food. Evidence from a review of online grocery shopping supports the current findings that individuals are motivated to grocery shop online because of convenience and ability to save time [19]. The review also found that online grocery shopping may support healthier food and beverage choices (e.g., fewer impulse buys), but also that consumers may be less likely to use online grocery shopping to buy perishable food (e.g., fresh fruits and vegetables) [19]. The concepts of convenience and taking others into account were woven throughout several of the subthemes.

Limitations of this study include the small size for some focus groups. We reminded participants multiple times about their upcoming focus group session, including on the session day. However, cancelations and no shows on the session day resulted in some focus group sizes being smaller than planned. Because study participants represented convenience samples of populations of interest to us, the results may not be generalizable to the populations of interest or the US population overall. Sociodemographic information was not collected from participants to reduce participant burden and for confidentiality purposes.

5. Conclusions

Among the themes identified in this study, overlapping concepts included accessibility, convenience, consideration for others, health consequences, and ambivalence. Factors that shape how individuals perceive their diet are complex with internal and external elements intertwined. Forming a basis of understanding for this complexity will help us better quantify perceptions and perhaps link these perceptions to measurable diet outcomes. Additionally, allowing for personal introspection could help individuals reflect on their eating choices and provide motivation to improve those choices. For public health professionals, this is an important step forward because as we understand more about how people perceive their diet, we can better frame public health initiatives aimed at reducing diet-related diseases and promoting healthy lifestyles in general. Policies that prioritize nutrition education focused on cooking skills and meal planning and that include culturally responsive food options may be particularly effective.