Persons with and at risk of osteoporosis have unique requirements for nutrition education. It is important for these individuals to achieve adequate intake of nutrients that are important for bone health (i.e. calcium, vitamin D, protein) and, where possible, this nutrient intake should be achieved in the context of a healthy dietary pattern that is rich in whole foods. Using focus groups, we identified several barriers to maintaining a bone-healthy diet among individuals with and at risk of osteoporosis, including cooking for one, low motivation to prepare meals, and dietary restrictions. Facilitating factors included meal planning and advance preparation, online grocery shopping, and engaging in regular exercise, which participants noted to be associated with improved appetite and increased motivation to adopt a healthy diet. There was consensus among focus group participants that a bone-focused CM program would be beneficial, with preference for a virtual format. Our findings can be used to inform the development of programs to improve nutrition education and facilitate adherence with dietary recommendations among individuals with and at risk of osteoporosis.
To our knowledge, the present study is the first to evaluate barriers and facilitators to consuming a bone-healthy diet among individuals with and at risk of osteoporosis that is not confined to assessment of intake of a specific nutrient (e.g. calcium) or food group (e.g. dairy). Previous studies have primarily focused on barriers and facilitators to consuming calcium-rich foods in a variety of populations, including women and adolescents. Reported barriers in these studies include lack of time, cost, inconvenience, concerns about waste, cultural practices, not seeing calcium deficiency as a threat, perception that calcium-rich foods do not taste good, real and/or perceived intolerance or allergy to dairy and lactose, belief that all dairy foods are high in calories and fat, and uncertainty about good dietary sources of calcium [15,16,17,18, 31]. Reported facilitators for calcium-rich food intake in prior studies include: perceived benefits such as improved energy levels and osteoporosis prevention, good taste, and educational information from trustworthy sources that was presented in a catchy manner [18, 32]. The present study identified some of the same barriers, specifically lack of time, inconvenience, and dietary intolerances. Needing to cook for one and lack of motivation to cook multiple meals a day were not highlighted as barriers to consumption of calcium-rich foods in prior studies, but may have emerged as principal barriers to maintaining a bone-healthy diet in the present study given the relatively older age of our population (age range 56–87). Accordingly, social isolation, not being married, and lack of interest in life have been identified as risk factors for malnutrition in older populations [33]. In addition, participants in the present study were primarily of White ethnicity and moderate-to-high socioeconomic position, which may respectively explain why cultural practices and cost did not emerge as major barriers.
While our findings indicate that individuals with and at risk of osteoporosis face several barriers to eating well for bone health, they also suggest that a bone-focused CM program, designed with the view of mitigating these barriers, would be well accepted among our target population. CM programs can incorporate strategies such as meal planning, preparation of multiple servings for leftovers and freezing [34, 35], which can ameliorate the challenges associated with cooking for one and lack of motivation to cook multiple meals a day [36]. Additionally, CM provides an optimal environment for education regarding substitutions and modifications to address dietary restrictions, as has been shown in individuals living with chronic kidney disease [37], hypertension [38], cardiovascular disease [39], and cancer [40]. CM also has the potential to promote and encourage the facilitating factors identified in this study, particularly meal planning and advance preparation [34]. Depending on the mode of delivery, CM programs could be leveraged to support patients with online grocery shopping [41], and to encourage exercise [42]. Additionally, CM interventions are often delivered in a group environment, which our focus group participants identified as a potential benefit with a desire for sense of community. Nanduri and colleagues have also demonstrated that participation in organized social support systems can contribute to improvement in physical activity among seniors with osteoporosis [43], and McAlpine et al. found that social engagement was associated with improved quantity and quality of nutrient intake among older adults [44].
In terms of developing a bone-focused CM program, focus group participants indicated that a virtual program would be favored over in-person programming, with some individuals expressing preference for a demonstration format while others preferring a cook-along. Contrary to what has been reported in other populations, lack of cooking skills did not emerge as a common barrier to maintaining a bone healthy diet in our study population, which may explain why participants were more motivated to attend a virtual CM demonstration or cook-along rather than an in-person cooking class. However, given the timing of this study, conducted in 2021, it is possible that the preference for virtual delivery was related to the COVID-19 pandemic rather than other reasons; reassessment of the preferred mode of delivery for bone-specific CM programming may be warranted in the future.
While the results of this study provide a rationale for the development of a CM program tailored towards individuals with and at risk of osteoporosis, our findings also indicate that the nutrition education needs and preferences of this population are varied and highly personal. A one-size-fits-all approach to nutrition education is unlikely to be successful. For example, while several barriers to eating well for bone health were identified in the focus groups, survey responses indicated that almost half of the study participants did not experience any barriers to eating well for bone health, and fewer than 40% indicated a need for further nutrition education beyond what they had already received in the didactic bone health class. Furthermore, some of the barriers reported by survey respondents—including time, money, taste preference, family/friends, knowledge of foods, and culture—were never raised in the focus groups. This may be the result of group dynamics: in the focus group setting, the opinions of one or two individuals has the potential to sway the opinions of the collective group [45]. Additionally, some participants may not share personal sensitive information, such as financial concerns, in a group environment [45]. It is also important to note that almost two thirds of survey participants indicated that they were confident in their ability to prepare meals that aligned with recommendations for bone health, and that they had good knowledge of dietary sources of calcium and protein, whereas just over half of participants reported getting sufficient calcium intake in their diet. This suggests a discrepancy between perceived abilities and implementation when it comes to dietary knowledge and skills. Ultimately, while it is unlikely that CM programming will be necessary or beneficial for every individual with and at risk of osteoporosis, our findings indicate that it may be a helpful adjunct to didactic education for some. Bone-focused CM programs should be designed with flexibility in mind, to accommodate the varied needs of this population and individuals. The development and use of screening tools may help to identify the individuals most likely to benefit from a CM program for bone health.
The results of this study should be interpreted in the context of some limitations. The generalizability of our findings is limited by the modest sample size and relatively homogeneous demographics. For example, the study population was entirely of White ethnicity and therefore not reflective of other ethnicities. The study population was also comprised predominantly of women, and with such a small number of men in our sample, it is difficult to discern whether men experience different barriers and facilitating factors to maintaining a bone-healthy diet than women. Gender-specific expectations and division of household duties must also be considered with respect to meal preparation. Additionally, inclusion criteria for this study included having access to internet and an online device, which may have precluded individuals who experience low socioeconomic standing from participating. This could explain why food access and cost did not emerge as barriers in our cohort. Furthermore, as indicated above, the results of focus group studies can be influenced by group dynamics and therefore may not be fully representative of the thoughts and beliefs of all group members [45].