Abstract

Connectedness to nature can boost well-being and lead to healthier and more sustainable food choices. Health professionals have the potential to be key agents in promoting environmental health. A cross-sectional study was conducted with 146 primary healthcare professionals to determine the association betweennature connectedness and food choicemotives considered important for human and environmental health. We used the 14-item Connectedness to Nature Scale (CNS) and the Food Choice Questionnaire (FCQ), consisting of 36 items distributed between nine factors, including “health”, “natural content”, and “ethical concern”. The average CNS score was 53.8 (± 9). The highest scoring factors of the FCQ were sensory appeal and price.Ethical concern was ranked last. There was a significant positive association between degree of nature connectedness and scoring for the factors health (p = 0.031), natural content (p = 0.001), and ethical concern (p <0.001). The results of this unprecedented studyshow that increased connectedness to nature may lead to healthier and more sustainable food choices.

Key words
Healthy diet; Health personnel; Environmental health; The environment; Primary healthcare

Introduction

Understanding how people’s connection to nature forms and how this relation influences personal values and the planet’s health is a relevant topic, particularly given the current environmental crisis¹1 Restall B, Conrad E. A literature review of connectedness to nature and its potential for environmental management. J Environ Manage 2015; 15(159):264-278., marked by complex problems such as global warming, excessive waste generation, natural disasters, an increase in water vector-borne disease outbreaks, poor housing conditions and sanitation, and suffering, experienced mainly by the most vulnerable segments of society²2 World Health Organization. Secretarial of the Convention on Biological Diversity. Connecting global priorities: biodiversity and human health: a state of knowledge review [monograph on the Internet]. Geneva: WHO; 2015 [cited 25 Jun 2009]. 364 p. Available from: https://www.cbd.int/health/SOK-biodiversity-en.pdf.
https://www.cbd.int/health/SOK-biodivers... .

Climate change is the greatest threat to global health in the 21st century³3 Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, Friel S, Groce N, Johnson A, Kett M, Lee M, Levy C, Maslin M, McCoy D, McGuire B, Montgomery H, Napier D, Pagel C, Patel J, de Oliveira JA, Redclift N, Rees H, Rogger D, Scott J, Stephenson J, Twigg J, Wolff J, Patterson C. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009; 373(9676):1693-1733.. Attention should be paid to the fact that levels of greenhouse gases (GHG), which directly influence climate change, have far exceeded the natural variation in recent years as a result of human activities, including agriculture⁴4 The Intergovernmental Panel on Climate Change. IPCC Fourth Assessment Report: climate change 2007 [monograph on the Internet]. Geneva: IPCC; 2007 [cited 25 Jun 2018]. Available from: https://www.ipcc.ch/publications_and_data/ar4/wg1/en/spmsspm-human-and.html
https://www.ipcc.ch/publications_and_dat... .

Large-scale farming, marked by the use of genetically modified crops and dominated by the fertilizer, pesticide, and agricultural chemical industry–which grew 93% globally and 190% in Brazil between 2005 and 2015– has been accompanied by an increase in the consumption of ultra-processed foods, contributing not only to an increased prevalence of chronic diseases, but also climate change due to the emission of GHGs during the production and consumption processes⁵5 Carneiro FF, Silva LGA, Rigotto RM, Friedrich K, Búrigo AC, organizadores. Dossiê Abrasco: um alerta sobre os impactos dos agrotóxicos na saúde. Rio de Janeiro: EPSJV; São Paulo: Expressão Popular; 2015.

6 Ghvanidze S, Velikova N, Dodd TH, Oldewage-Theron W. Consumers' environmental and ethical consciousness and the use of the related food products information: the role of perceived consumer effectiveness. Appetite 2016; 1(107):311-322.^-77 Ribeiro H, Jaime P, Ventura D. Alimentação e sustentabilidade. Estud Avanç 2017; 31(89):185-198.. In addition, excessive packaging resulting from high levels of consumption of these foods is particularly worrying because it makes up a significant part of urban waste, with plastic alone accounting for 20% of the volume of waste in tons⁸8 Associação Brasileira de Empresas de Limpeza Pública e Resíduos Especiais - ABRELPE. Panorama dos resíduos sólidos no Brasil [monografia na Internet]. São Paulo: ABRELPE; 2016 [acessado 2018 Jun 28]. Disponível em: http://www.abrelpe.org.br/Panorama/panorama2016.pdf
http://www.abrelpe.org.br/Panorama/panor... ^,99 Landim APM, Bernardo CO, Martins IBA, Francisco MR, Santos MB, Melo NR. Sustentabilidade quanto às embalagens de alimentos no Brasil. Políms: Ciênc Tecnol [periódico na Internet]. 2016; 26:82-92 [acessado 2018 Jun 28]. Disponível em: https://www.redalyc.org/articulo.oa?id = 47043582013
https://www.redalyc.org/articulo.oa?id =... .

Despite this problem, a recent study by Cunha et al.¹⁰10 Cunha LM, Cabral D, Moura AP, Almeida MDV. Application of the food choice questionnaire across cultures: Systematic review of cross-cultural and single country studies. Food Qual Prefer. 2018; 64:21-36. shows that packaging was not a major factor influencing consumer purchasing decisions. The review explored the main factors influencing food choices among different populations based on studies using the Food Choice Questionnaire (FCQ) developed by Steptoe et al.¹¹11 Steptoe A, Pollard TM, Wardle J. Development of a measure of the motives underlying the selection of food: the Food Choice Questionnaire. Appetite 1995; 25(3):267-284..The FCQ assesses nine food choice factors, one of which is ethical concern, which includes a specific question about food packaging. According to the review, ethical concern was ranked among the lowest scoring factors among the general population. A validation study conducted by Heitor et al.¹²12 Heitor SFD, Estima CCP, Neves FJ, Aguiar AS, Castro SS, Ferreira JES. Tradução e adaptação cultural do questionário sobre motivo das escolhas alimentares (Food Choice Questionnaire - FCQ) para a língua portuguesa. Cien Saude Colet 2015; 20(8):2339-2346. that adapted the FCQ for use in Brazil using a sample of 86 students reported that more than half of the sample responded not at all important for two of the three items of the ethical concern factor.

There is little data on the views of health professionals on this topic. The only relevant study found, conducted by Sushma et al.¹³13 Sushma R, Vanamala N, Nagabhushana D, Maurya M, Sunitha S, Reddy C. Food choice motives among the students of a dental institution in Mysore City, India. Ann Med Health Sci Res 2014; 4(5):802-805. with 159 dental students in India, showed that ethical concerns cored higher than familiarity, convenience, and mood. The differences between the findings of this study and Cunha et al.’s literature review¹⁰10 Cunha LM, Cabral D, Moura AP, Almeida MDV. Application of the food choice questionnaire across cultures: Systematic review of cross-cultural and single country studies. Food Qual Prefer. 2018; 64:21-36. suggest that food choices may also be influenced by profession and cultural factors.

The Ministry of Health’s report “Inputs for Building a National Environmental Health Policy”¹⁴14 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Subsídios para construção da Política Nacional de Saúde Ambiental. Brasília: Editora do MS; 2009. (Série B. Textos Básicos de Saúde). clearly states that environmental health is a key aspect of health promotion and protection, given that an ecologically balanced environment is in consonance with the guiding principles of Brazil’s national health system, such as comprehensiveness, universality, equity, and public participation.

Health professionals have the responsibility to understand the inextricable links between health and the environment and take a critical and reflexive stance towards modes of production, consumer capitalism, and the environmental and health problems facing humanity today¹⁵15 Santos DAS, Azevedo PV, Azevedo JVV, Alves TLB, Souza AR. Percorrendo os caminhos da relação entre as políticas públicas de saúde e do meio ambiente. Rev Polit Públicas 2016; 20(1):137-152.. Health professionals should act as scientific knowledge brokers, contributing to the adoption of healthy habits and behavior¹⁶16 Alves VS. Um modelo de educação em saúde para o Programa Saúde da Família: pela integralidade da atenção e reorientação do modelo assistencial. Interface (Botucatu) 2005; 9(16):39-52..

Evidence has shown that nature connectedness, understood to be how people identify with the natural environment and the relationships they form with nature, is associated with pro-environmental behavior, reflecting more sustainable food choices¹⁷17 Dowd K, Burke KJ. The influence of ethical values and food choice motivations on intentions to purchase sustainably sourced foods. Appetite 2013; 69:137-144.^,1818 Lewis M, Townsend M. 'Ecological embeddedness' and its public health implications: findings from an exploratory study. Ecohealth 2015; 12(2):244-252.. This connection is also linked to psychosocial aspects such as subjective well-being and human values¹1 Restall B, Conrad E. A literature review of connectedness to nature and its potential for environmental management. J Environ Manage 2015; 15(159):264-278.^,1919 Pessoa, VS, Gouveia VV, Soares AKS, Vilar R, Freires LA. Escala de conexão com a natureza: evidências psicométricas no contexto brasileiro. Estud Psicol 2016; 33(2):271-282..

We were unable to find any studies on nature connectedness and/or motives for food choice involving health professionals²⁰20 Uhlmann K, Lin BB, Ro H. Who cares? The importance of emotional connections with nature to ensure food security and wellbeing in cities. Sustainability 2018; 10(6):1-16.. This article therefore presents the results of an unprecedented study that assessed these constructs and the association between them among a sample of primary healthcare professionals in Brazil.

Methods

Study design and sample

A cross-sectional study was conducted with health professionals working in primary healthcare(PHC) services in a municipality in the State of São Paulo. The municipality has an estimated population of 145,000 inhabitants, a Human Development Index of 0.8, 95.8% of households have adequate sewage disposal, and 25.8% of urban households are on public thoroughfares with adequate urban infrastructure (manholes, sidewalk/pavement, and curbs)²¹21 Instituto Brasileiro de Geografia e Estatística. Botucatu: Panorama [monografia na Internet]. Brasília: IBGE; 2019 [acessado 2019 Set 19]. Disponível em: https://cidades.ibge.gov.br/brasil/sp/botucatu/panorama
https://cidades.ibge.gov.br/brasil/sp/bo... .

Sample size (n = 135) was calculated based on an estimate taken from a meta analysis performed by Capaldi et al.²²22 Capaldi CA, Dopko RL, Zelenski JM. The relationship between nature connectedness and happiness: a meta-analysis. Front Psychol 2014; 5:976., adopting a power of 0.8,type I error of 0.05, and significance level of 0.05 (p < 0.05). It is important to note that, given the lack of studies on the association between nature connectedness and food choices, the correlation between connectedness to nature and well-being –the object of interest of the wider project that gave rise to this study – was used as the basis for calculating sample size.

According to the data provided by the local health department, during the collection period, 362 health professionals were working in PHC services, distributed across 22 different facilities and belonging to 13 different professions: 46 community health agents, 99 nursing assistants,31 nursing technicians, 35 nurses, 22 dental assistants, 25 dentists, 18 pharmacy technicians, 6 pharmacists, 3 psychologists, 2 physical therapists, 3 speech therapists, 4 nutritionists, and 68 doctors.

After calculating the minimum sample size (minimum n =135), professionals working in primary care centers and the Family Health Strategy were randomly selected in numbers proportional to the overall number of professionals in each profession. Subsequently, we decided to include professionals working in the Family Health Support Center (Núcleo de Apoio à Saúde da Família- NASF), since they also belong to and perform activities in PHC services and were not initially encompassed. Since only a small number of staff were working in the NASF, all professionals were invited to participate in the study and those who accepted were included in the sample, resulting in a further two professions: social workers and physical educators. As a result, for some professions the number of professionals in the sample was proportionately higher than the overall number of members of that profession working in the municipality, particularly the nutritionists.

The final sample consisted of 146 professionals.

The only inclusion criterion was that the professional belonged to a PHC team working in the municipality.

Ethics

The study was approved by the relevant research ethics committee (June 07, 2017). All participants signed an informed consent form.

Data collection

Data was collected in July 2017.

The questionnaires and instructions for filling them in were handed to the professionals during a visit to the health facilities. Due to time restraints, the questionnaires were completed during the visit in only four facilities. In the rest of the facilities the questionnaires were collected back a week later.

Variables and data collection instruments

Exposure

Nature connectedness refers to how integrated and connected a person feels with nature from an affective and individual perspective. It was assessed using the Connectedness to Nature Scale (CNS), validated for use in Brazil by Pessoa et al.¹⁹19 Pessoa, VS, Gouveia VV, Soares AKS, Vilar R, Freires LA. Escala de conexão com a natureza: evidências psicométricas no contexto brasileiro. Estud Psicol 2016; 33(2):271-282.. The scale contains 14 items responded on a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with a possible overall score of between 14 and 70, where the higher the score the greater the degree of connectedness.

The value for Cronbach’s alpha coefficient obtained by the version validated for use in Brazil by Pessoa et al.¹⁹19 Pessoa, VS, Gouveia VV, Soares AKS, Vilar R, Freires LA. Escala de conexão com a natureza: evidências psicométricas no contexto brasileiro. Estud Psicol 2016; 33(2):271-282. was 0.82, while the value for the present study was 0.77.

Outcomes

We used the version of the FCQ¹¹11 Steptoe A, Pollard TM, Wardle J. Development of a measure of the motives underlying the selection of food: the Food Choice Questionnaire. Appetite 1995; 25(3):267-284. validated for use in Brazil by Heitor et al.¹²12 Heitor SFD, Estima CCP, Neves FJ, Aguiar AS, Castro SS, Ferreira JES. Tradução e adaptação cultural do questionário sobre motivo das escolhas alimentares (Food Choice Questionnaire - FCQ) para a língua portuguesa. Cien Saude Colet 2015; 20(8):2339-2346.. This self-administered instrument assesses nine factors influencing food choice: 1) health, 2) mood, 3) convenience, 4) sensory appeal, 5) natural content, 6) price, 7) weight control, 8) familiarity, and 9) ethical concern. Respondents are asked to endorse the statement “It is important to me that the food I eat on a typical day...” for each item within the nine factors by selecting one of the following responses: not at all important, a little important, moderately important, and very important, scored from 1 to 4.

Three outcome variables were selected from these nine factors to determine the association between nature connectedness and motives for food choice: factor1 (health), with scores ranging from 6 to 25; factor 5 (natural content), with scores ranging from 3 to 12; and factor 9 (ethical concern), with scores ranging from3 to 12. We selected these three factors over the others based on the literature, which shows that people with a stronger sense of connection to nature are more likely to make healthy (aspects considered by factors 1 and 5 of the FCQ) and sustainable (assessed in some measure by factor 9) choices⁶6 Ghvanidze S, Velikova N, Dodd TH, Oldewage-Theron W. Consumers' environmental and ethical consciousness and the use of the related food products information: the role of perceived consumer effectiveness. Appetite 2016; 1(107):311-322.^,2323 Spendrup S, Hunter E, Isgren E. Exploring the relationship between nature sounds, connectedness to nature, mood and willingness to buy sustainable food: a retail field experiment. Appetite 2016; 1(100):133-141..

The value for Cronbach’s alpha coefficient for the FCQ administered by in this study was 0.92, compared to values ranging between 0.70 and 0.87 for the original version developed by Steptoe et al.¹¹11 Steptoe A, Pollard TM, Wardle J. Development of a measure of the motives underlying the selection of food: the Food Choice Questionnaire. Appetite 1995; 25(3):267-284. and 0.75 and 0.89 for the version adapted by Heitor et al.¹²12 Heitor SFD, Estima CCP, Neves FJ, Aguiar AS, Castro SS, Ferreira JES. Tradução e adaptação cultural do questionário sobre motivo das escolhas alimentares (Food Choice Questionnaire - FCQ) para a língua portuguesa. Cien Saude Colet 2015; 20(8):2339-2346..

Potential confounders

The following potential confounders were chosen: sex, age (< 35, 35-50, >50; ref= <35 years); degree (yes or no); length of service in the area of health (< 5, 5-10, > 10; ref = < 5 years);self-reported health (good, very good, fair, bad, very bad), and physical activity (yes or no).

Studies show that women are generally more concerned with health than men and that diet quality, which is associated with food choices, varies according to age and socioeconomic status²⁴24 McGowan L, Pot GK, Stephen AM, Lavelle F, Spence M, Raats M, Hollywood L, McDowell D, McCloat A, Mooney E, Caraher M, Dean M. The influence of socio-demographic, psychological and knowledge-related variables alongside perceived cooking and food skills abilities in the prediction of diet quality in adults: a nationally representative cross-sectional study. Int J Behav Nutr Phys Act 2016; 13(1):111.^,2525 Sijtsma FP, Meyer KA, Steffen LM, Shikany JM, Van Horn L, Harnack L, Kromhout D, Jacobs Junior DR. Longitudinal trends in diet and effects of sex, race, and education on dietary quality score change: the coronary artery risk development in young adults study. Am J Clin Nutr 2012; 95(3):580-586.. There is also evidence that physical activity influences healthy food choices²⁶26 Alexandre VP, Peixoto MRG, Schmitz BAS, Moura EC. Fatores associados às práticas alimentares da população adulta de Goiânia, Goiás, Brasil. Rev Bras Epidemiol 2014; 17(1):267-280.. This information was obtained using a sociodemographic questionnaire, which was self-administered together with the CNS and FCQ.

Analysis

The data was tabulated and stored using Epi Info™ for Windows. Consistency analysis was performed followed by descriptive statistical analysis.

The association between nature connectedness and scoring for the three motives for food choice (factors 1, 5 and 9 from the FCQ)was determined using multiple linear regression with normal response, including the potential confounders and the covariables that showed an association with the outcomes in the univariate analysis (p < 0.20). The analyses were performed using SPSS® Statistics 21 and adopting a significance level of 0.05.

Results

Table 1 shows the number of professionals who participated in the study by profession.

The study sample was composed mainly of women(82.3%), whites (83.6%), people aged between 20 and 50 years (84.9%), people with a degree or post-graduate qualification (58.2%), people living in urban areas (96.6%), and people who had been working in health for over five years (72.60%).

The overall average score for the CNS was 53.8 (SD 0.9), compared to 52and 59 for the 1^st and 2^nd terciles, respectively. The average score per item was 3.84. The minimum and maximum scores obtained were 26 and 70, respectively (data not shown).

The average scores for each factor of the FCQ are shown in Table 2. The highest scoring factor was factor 4 (sensory appeal), with a weighted average score per item of 3.67, whereas the lowest scoring factor was factor 9 (ethical concern), with an average score per item of 2.60. Health and natural content were ranked third and fifth, respectively.

The following scores were found for the different factors: factor1 (health)- minimum and maximum score of 6 and 24, respectively, median of 21 (1^st quartile 18 and 3^rd quartile 23), and interquartile range of 5; factor5 (natural content) -minimum and maximum score of 3 and 12, respectively, median of 10 (1^st quartile 8 and 3^rd quartile 12), and interquartile range of 4; factor 9 (ethical concern) - minimum and maximum score of 3 and 12, respectively, median of 8 (1^st quartile 6 and 3^rd quartile 10), and interquartile range of 4 (data not shown).

A positive significant crude association was found between CNS score and the factors health (p = 0.023), natural content (p = 0.002), and ethical concern (p < 0.001) (data not shown).

Table 3 shows that CNS score was positively and significantly associated with factor 1 of the FCQ (health) (p = 0.031) in the analysis adjusted for the confounders sex, age, degree, length of service in the area of health, and self-reported health. The FCQ1 score increased an average of 0.07 points for each one point increase in the nature connectedness score. There was also a significant association between CNS score and factor 5 (natural content) of the FCQ. The FCQ5 score increased an average of 0.06 points for each one point increase in the nature connectedness score (p = 0.001) after adjusting for the confounders age and length of service in the area of health. CNS score was also significantly associated with factor 9 (ethical concern) after adjusting for age, education, and length of service in the area of health, showing an increase of 0.09 points for each one point increase in the nature connectedness score (p < 0.001).

Discussion

This study investigated the association between degree of nature connectedness, measured using the CNS, and the level of importance placed on three food choice factors that are important from a health and environmental point of view: health, natural content, and ethical concern. The study population was chosen because of the potential that health professionals have to assume a health education role¹⁵15 Santos DAS, Azevedo PV, Azevedo JVV, Alves TLB, Souza AR. Percorrendo os caminhos da relação entre as políticas públicas de saúde e do meio ambiente. Rev Polit Públicas 2016; 20(1):137-152.^,1616 Alves VS. Um modelo de educação em saúde para o Programa Saúde da Família: pela integralidade da atenção e reorientação do modelo assistencial. Interface (Botucatu) 2005; 9(16):39-52.^,2727 Brasil. Ministério da Saúde (MS). Fundação Nacional de Saúde. Diretrizes de educação em saúde visando à promoção da saúde: documento base - documento I. Brasília: FUNASA; 2007.. To the best of our knowledge, this is the first study at both national and international level to investigate this association among this population group²⁰20 Uhlmann K, Lin BB, Ro H. Who cares? The importance of emotional connections with nature to ensure food security and wellbeing in cities. Sustainability 2018; 10(6):1-16..

The results show that the respondents showed weak low nature connectedness and ethical concern as a motive for food choice. However, we detected a positive association between nature connectedness and scoring for the factors health, natural content, and ethical concern of the FCQ. This suggests that increasing connectedness to nature may be one way of increasing the possibility that health professionals assume a leading role in environmental and food and nutrition education directed at service users, as proposed by the report “Inputs for Building a National Environmental Health Policy” prepared by Ministry of Health, Pan American Health Organization, Brazilian Public Health Association, and National Health Council¹⁴14 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Subsídios para construção da Política Nacional de Saúde Ambiental. Brasília: Editora do MS; 2009. (Série B. Textos Básicos de Saúde)..

To assess these complex constructs, we used scales developed by renowned researchers¹¹11 Steptoe A, Pollard TM, Wardle J. Development of a measure of the motives underlying the selection of food: the Food Choice Questionnaire. Appetite 1995; 25(3):267-284.^,2828 Mayer FS, Frantz CM. The connectedness to nature scale: A measure of individuals feeling in community with nature. J Environ Psychol 2004; 24(4):503-515. translated for use in Brazil¹²12 Heitor SFD, Estima CCP, Neves FJ, Aguiar AS, Castro SS, Ferreira JES. Tradução e adaptação cultural do questionário sobre motivo das escolhas alimentares (Food Choice Questionnaire - FCQ) para a língua portuguesa. Cien Saude Colet 2015; 20(8):2339-2346.^,1919 Pessoa, VS, Gouveia VV, Soares AKS, Vilar R, Freires LA. Escala de conexão com a natureza: evidências psicométricas no contexto brasileiro. Estud Psicol 2016; 33(2):271-282. to ensure the validity of the results summarized above and provide the basis for further research in this area at national and international level²⁰20 Uhlmann K, Lin BB, Ro H. Who cares? The importance of emotional connections with nature to ensure food security and wellbeing in cities. Sustainability 2018; 10(6):1-16.. One of the limitations of this study is that some of the professionals completed the questionnaires in the presence of a researcher, immediately after signing the informed consent form, while others, due to time restraints, filled in the questionnaire at home, returning them later. In addition, part of the sample was selected using convenience sampling. Furthermore, the size of the sample may be considered small to test the association of interest, meaning that type II error may be > 0.20. It is therefore recommended that future studies use larger samples and standardize data collection.

The average score per item (3.84) for the CNS was similar to that reported by Rosa et al.²⁹29 Rosa CD, Profice CC, Collado S. nature experiences and adults' self-reported pro-environmental behaviors: the role of connectedness to nature and childhood nature experiences. Front Psychol 2018; 26(9):1-10. in a study with 224Brazilian students doing different courses at a university in the Northeast Region (3.83), and slightly higher than studies with 322 French students (3.33)³⁰30 Navarro O, Olivos P, Fleury-Bahi G. "Connectedness to Nature Scale": Validity and reliability in the french context. Front Psychol 2017; 8(2180):1-8. and324 Canadian students (3.28)³¹31 Lee K, Ashton MC, Choi J, Zachariassen K. Connectedness to nature and to humanity: their association and personality correlates. Front Psychol. 2015; 6(1003):1-11.. However, it is considerably lower than that of a study undertaken in Sweden with 1,320 supermarket customers using a shortened version of the CNS (4.92)²³23 Spendrup S, Hunter E, Isgren E. Exploring the relationship between nature sounds, connectedness to nature, mood and willingness to buy sustainable food: a retail field experiment. Appetite 2016; 1(100):133-141.. Despite reduced comparability due to the use of a shortened version of the scale, the studies mentioned above suggest that cultural factors may influence degree of nature connectedness.

It is important to highlight that the least important motive to health professionals was ethical concern, with low scores for the items “Comes from countries where I approve of the way food is produced”; “Has the country of origin clearly marked”; “Is packaged in an environmentally friendly way”. The scores did not differ from those of the general population, who do not place much importance on these factors as motives for food choice¹⁰10 Cunha LM, Cabral D, Moura AP, Almeida MDV. Application of the food choice questionnaire across cultures: Systematic review of cross-cultural and single country studies. Food Qual Prefer. 2018; 64:21-36..

Furthermore, the respondents did not place much value on whether or not the foods contained chemical additives or artificial ingredients, with the factor natural content– with the items “Contains no additives”, “Contains natural ingredients”, and “Contains no artificial ingredients”– ranked fifth.

Comparisons of our findings with those of other studies suggest that both motives for food choice and nature connectedness are influenced by cultural factors. In this regard, a study with 165 women in Japan³²32 Prescott J, Young O, O'neill L, Yau NJN, Stevens R. Motives for food choice: A comparison of consumers from Japan, Taiwan, Malaysia and New Zealand. Food Qual Prefer. 2002; 13(7):489-495. reported that ethical concern was ranked fourth, while studies in Italy (n = 163)³³33 Markovina J, Stewart-Knox BJ, Rankin A, Gibney M, de Almeida MDV, Fischer A, Kuznesoff SA, Poínhos R, Panzone L, Frewerf LJ. Food4Me study: Validity and reliability of Food Choice Questionnaire in 9 European countries. Food Qual Prefer. 2015; 45:26-32., Poland (n = 1,045)³³33 Markovina J, Stewart-Knox BJ, Rankin A, Gibney M, de Almeida MDV, Fischer A, Kuznesoff SA, Poínhos R, Panzone L, Frewerf LJ. Food4Me study: Validity and reliability of Food Choice Questionnaire in 9 European countries. Food Qual Prefer. 2015; 45:26-32., and Taiwan (n = 263)³²32 Prescott J, Young O, O'neill L, Yau NJN, Stevens R. Motives for food choice: A comparison of consumers from Japan, Taiwan, Malaysia and New Zealand. Food Qual Prefer. 2002; 13(7):489-495. showed that the most important factor was natural content.

These findings draw us to the Ministry of Health guide Dietary Guidelines for the Brazilian Population³⁴34 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2ª ed. 1ª reimpr. Brasília: MS; 2014., which exhaustively warns of the risks of the excessive consumption of food additives, which are particularly common in ultra-processed foods. A growing number of studies have investigated the potential harmful effects of additives on our health, with evidence pointing to an association between abusive consumption of these substance and rhinitis and allergies (mainly color additives), child behavior problems (hyperactivity), intestinal inflammation and dysbiosis (emulsifiers and sweeteners), and metabolic syndrome³⁵35 Paula Neto HA, Ausina P, Gomez LS, Leandro JGB, Zancan P, Sola-Penna M. Effects of Food additives on immune cells as contributors to body weight gain and immune-mediated metabolic dysregulation. Front Immunol. 2017; 8(1478):1-11.^,3636 Polônio MLT, Peres F. Consumo de aditivos alimentares e efeitos à saúde: desafios para a saúde pública brasileira. Cad Saude Publica. 2009; 25(8):1653-1666..

We did not find any studies in the literature that investigated nature connectedness in relation tomotives for food choice. However, a study with 31,842 adults from the NutriNet-Santé cohort investigating the relationship between motives for food choice and diet quality showed that individuals who had a healthy diet were more likely to be concerned with ethics and the environment, local production of food, health, and absence of contaminants³⁷37 Allès B, Péneau S, Kesse-Guyot E, Baudry J, Hercberg S, Méjean C. Food choice motives including sustainability during purchasing are associated with a healthy dietary pattern in French adults. Nutr J 2017; 16(58):1-12..

Based on the findings of our study and the recommendations of the Ministry of Health¹⁴14 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Subsídios para construção da Política Nacional de Saúde Ambiental. Brasília: Editora do MS; 2009. (Série B. Textos Básicos de Saúde). and Dietary Guidelines for the Brazilian Population³⁴34 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2ª ed. 1ª reimpr. Brasília: MS; 2014., we might question whether these professionals are prepared and motivated to act as health promoters and raise awareness among service users of the importance of healthy and sustainable eating. It is possible that their education and training did not have an adequate focus on healthy eating and environmental education capable of encouraging the adoption of new habits and attitudes. It is also possible that they have little contact with natural environments such as parks, forests, and waterfalls, which can help promote greater nature connectedness and pro-environmental behavior¹1 Restall B, Conrad E. A literature review of connectedness to nature and its potential for environmental management. J Environ Manage 2015; 15(159):264-278. and provide physical and mental health benefits³⁸38 Cox DT, Shanahan DF, Hudson HL, Fuller RA, Anderson K, Hancock S, Gaston KJ. Doses of nearby nature simultaneously associated with multiple health benefits. Int J Environ Res Public Health. 2017; 14(172):8-13..

It therefore seems important to think/rethink environmental education on healthcare courses at undergraduate level in Brazil and in continuing education and training programs. More attention needs to be paid to environmental education for health professionals, both in everyday practice and during undergraduate training, particularly for those who work in primary healthcare and have the responsibility to transmit this knowledge to service users¹⁵15 Santos DAS, Azevedo PV, Azevedo JVV, Alves TLB, Souza AR. Percorrendo os caminhos da relação entre as políticas públicas de saúde e do meio ambiente. Rev Polit Públicas 2016; 20(1):137-152.^,2727 Brasil. Ministério da Saúde (MS). Fundação Nacional de Saúde. Diretrizes de educação em saúde visando à promoção da saúde: documento base - documento I. Brasília: FUNASA; 2007..

Discussing the importance of the role of the health sector in tackling climate change, McMichael et al.³⁹39 McMichael AJ, Neira M, Bertollini R, Campbell-Lendrum D, Hales S. Climate change: a time of need and opportunity for the health sector. Lancet. 2009; 374(9707):2123-2125. propose that professionals should encourage people to rethink their food choices, favoring production practices that do not pose health risks. Walpole et al.⁴⁰40 Walpole SC, Vyas A, Maxwell J, Canny BJ, Woollard R, Wellbery C, Leedham-Green KE Musaeus P, Tufail-Hanif U, Pavão Patrício K, Rother HA. Building an environmentally accountable medical curriculum through international collaboration. Med Teach. 2017; 39(10):1040-1050. highlight the need to include content on environmental issues in medical curriculums to prepare future health professionals and equip them with the appropriate tools to take the lead in developing positive attitudes towards environmental sustainability.

In short, our results show that the health professionals who participated in this study are not equipped to act as promoters of environmental health. It is necessary to develop health professionals’ knowledge of the environment as a key determinant of health and disease to help guide them, and consequently their patients, towards healthy and sustainable choices.

We believe that activities and projects aimed at facilitating contact with nature, such as walks in the park and other green spaces and nature trails, along the lines of forest therapy model developed in Japan, could help increase nature connectedness among health professionals and, consequently, promote pro-environmental behavior¹1 Restall B, Conrad E. A literature review of connectedness to nature and its potential for environmental management. J Environ Manage 2015; 15(159):264-278.^,3838 Cox DT, Shanahan DF, Hudson HL, Fuller RA, Anderson K, Hancock S, Gaston KJ. Doses of nearby nature simultaneously associated with multiple health benefits. Int J Environ Res Public Health. 2017; 14(172):8-13..

Conclusion

Respondents showed little nature connectedness and ethical concern was ranked last out of the nine motives for food choice. The factors that most influenced food choice were sensory appeal and price. Nevertheless, a positive association was found between degree of nature connectedness and scoring for the factors health, natural content, and ethical concern.

References

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History