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Diet after prostate cancer : gender influences on men’s food perceptions and practices Mróz, Lawrence William 2010

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DIET AFTER PROSTATE CANCER: GENDER INFLUENCES ON MEN’S FOODPERCEPTIONS AND PRACTICESbyLawrence William MrózB.Sc., King’s College, Dalhousie University, 1985M.Sc., Simon Fraser University, 1990A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTSFOR THE DEGREE OFDOCTOR OF PHILOSOPHYinTHE FACULTY OF GRADUATE STUDIES(Human Nutrition)THE UNIVERSITY OF BRITISH COLUMBIA(Vancouver)November 2010© Lawrence William Mróz, 2010iiABSTRACTAlthough nutrition might play a role in prostate cancer survival, most men make few dietchanges following this diagnosis.  Evidence that men tend to have poorer diets than womensuggests that gender helps shape men’s food practices, and might influence nutrition interventionuptake.  Gender theory provides insight into these observations, proposing that masculine idealsprevent men from adopting healthy eating practices.  Additionally, because many men rely onwomen for food provision, gender relations are also significant in men’s diets.This dissertation explores how masculinities and gender relations are implicated inshaping dietary understandings and food practices of men with prostate cancer.  The first phaseof the study produced an overview and synthesis of research on nutrition, prostate cancer,masculinities and food, and provides an analysis of diet and diet change behaviours for men withprostate cancer.  Masculinity and gender relations theory are discussed in the context of men’sfood practices, with suggestions for applications to nutrition and prostate cancer research.The second phase was an empirical qualitative study, involving in-depth, individualinterviews conducted privately and separately with 14 men with prostate cancer and theircohabiting female partners.  Findings are presented in two parts.  First, men’s accounts of theirdiets following prostate cancer and the rationales underpinning diet changes (or lack thereof) aredescribed.  The men framed their food perceptions and practices as important, action-orientedand autonomous suggesting that masculine ideals influenced if and how they engaged in dietchange.  Second, using a gender relations framework to interpret how gender performancesshaped men’s diets, couples’ dietary accounts revealed how they tended to limit men’s dietaryengagement and maintain hetero-normative food roles.  Complex couple power dynamics wereiiiapparent, reflecting and reproducing patriarchy through women’s deference to men’s preferencesand careful negotiation of support for men’s diet changes.Together, these findings demonstrate that although masculine ideals shape men’s foodperceptions and practices, complex couple interactions are also implicated.  Nutritionintervention planning for men is complex and findings show that to ensure success,understanding gender relations is essential to illuminate women’s roles in the food practices andnutritional health of men with prostate cancer.ivTABLE OF CONTENTSABSTRACT................................................................iiTABLE OF CONTENTS.....................................................ivLIST OF TABLES..........................................................viiLIST OF FIGURES........................................................viiiACKNOWLEDGEMENTS....................................................ixDEDICATION..............................................................xCO-AUTHORSHIP STATEMENT.............................................xiCHAPTER 1.  DIET AFTER PROSTATE CANCER................................1Introduction..........................................................................1Nutrition and Prostate Cancer..........................................................2Nutrition Recommendations for Men with Prostate Cancer...........................................5Nutrition Education and Food Practices of Men with Prostate Cancer........................6Behaviour Change and Food Choice Theory...............................................7Men’s Food Practices and Gender Theory...............................................10Masculinities, Men and Food..................................................................10Gender Relations and Food....................................................................12Summary...........................................................................14Thesis Objective and Overview.........................................................15References...........................................................................17CHAPTER 2.  MEN, FOOD AND PROSTATE CANCER:  GENDER INFLUENCES ONMEN’S DIETS.............................................................29Introduction.........................................................................29Methods.............................................................................31Findings and Discussion...............................................................32Diet After Cancer...........................................................................32Men, Masculinities and Prostate Cancer.........................................................34Men, Masculinities and Food..................................................................38Gender Relations and Men’s Food Practices......................................................43Older Men in Food Research..................................................................45Conclusions..........................................................................46References...........................................................................49vCHAPTER 3.  PROSTATE CANCER, MASCULINITY AND FOOD: RATIONALES FORPERCEIVED DIET CHANGE................................................60Introduction.........................................................................60Methods.............................................................................63Data Collection.............................................................................65Data Analysis..............................................................................66Results..............................................................................67Eating as Usual: No Diet Change...............................................................68‘Intensifying Efforts’ and/or ‘Adding-on’: Minor Diet Change.......................................70Overhauling Diet: Major Diet Change...........................................................75Discussion...........................................................................78Strengths and Limitations.............................................................84Conclusions..........................................................................85References...........................................................................87CHAPTER 4.  GENDER RELATIONS, PROSTATE CANCER AND DIET: RE-INSCRIBING HETERO-NORMATIVE FOOD PRACTICES........................92Introduction.........................................................................92Background: Masculinity, Femininity and Men’s Health...................................93Methods.............................................................................96Findings............................................................................98Men Increase Diet Involvement................................................................98Men as “Sous Chefs”.......................................................................100Women as Leaders in Food and Health.........................................................101Maintaining Hetero-normative Gender Power Relations............................................106Discussion and Conclusions...........................................................110References..........................................................................114CHAPTER 5.  DISCUSSION AND INTEGRATION OF STUDY FINDINGS...........119Masculinities and Food after Prostate Cancer...........................................119Masculinities and Femininities: Gender Relations and Power Dynamics.....................123Intersectionality of Race, Class and Age................................................127Reflections on the Research Process....................................................128Sampling Characteristics....................................................................128Data Collection............................................................................130Separate Interviews.........................................................................131My Role as Researcher......................................................................133Rigour and Trustworthiness of the Research.....................................................136Implications for Future Research......................................................136Implications for Practice.............................................................137Conclusions.........................................................................139References..........................................................................141viAPPENDICES............................................................144Appendix 1.  Food for Thought  © Parkurst, 2003 (Used by permission from Our Voice)........144Appendix 2.  UBC Research Ethics Board's Certificate of Approval........................147Appendix 3.  Recruitment Advertisement...............................................148Appendix 4.  Recruitment Brochure....................................................149Appendix 5.  Consent Form for Men with Prostate Cancer................................151Appendix 6.  Interview Guide for Men with Prostate Cancer...............................154Appendix 7.  Food Journal Booklet Templates (Cover, Instructions, Example of Completed Page,Blank Page)........................................................................158Appendix 8.  Demographics Form for Men with Prostate Cancer...........................162Appendix 9.  Field Notes Form........................................................164Appendix 10.  Coding Schedule........................................................165Appendix 11.  Consent Form for Women...............................................167Appendix 12.  Interview Guide for Women..............................................170Appendix 13.  Demographics Form for Women..........................................174Appendix 14.  Gender Relations Dyad Summary Template................................176Appendix 15.  Participant Characteristics...............................................177viiLIST OF TABLESTable 3.1  Summary of Participant Characteristics…………………………………………65Appendix 15.  Participant Characteristics ……………………….……………………...…177viiiLIST OF FIGURESFigure 1.1  A food Choice Process Model (Sobal et al, 2009)………………………………..9Figure 3.1  Constructing Rationales for Perceived Diet Change……...……………………..67ixACKNOWLEDGEMENTSI am grateful to all the support and assistance I have received throughout my doctoral trainingand would like to thank the following.For funding from the:Humanities and Social Sciences Research Grant (UBC HSS Fund)Nutrition Oncology Endowment Research Grant (Land and Food Systems, UBC)Nutritional Research Fellowship (Land and Food Systems, UBC)British Columbia Foundation for Prostate Disease (Thanks to Ted Butterfield, DanCohen, Les Gross and George Main)Funding and training from the:Psychosocial Oncology Research Training Program (PORT – McGill University; thanksCarmen Loiselle and Joan Bottorff)Assistance from:Joyce Davison and the Prostate Education and Research Centre, for early contributions tomy committee, proposal and recruitment.Cheri Van Patten, for assistance in research and grant proposal writing and recruitment atthe British Columbia Cancer Agency.Patrick Leung and other helpful staff at the Food, Nutrition and Health building.Colleagues and fellow students at the Nursing and Health Behaviour Research (NAHBR)unit at the UBC School of Nursing and in Food Nutrition and Health.Special thanks to my fantastic supervisory committee members, always helpful, supportive andpatient:For John Oliffe who has been a great mentor in masculinity and men’s health studies.For Joan Bottorff for helping me develop my critical evaluation skills.And for Gwen Chapman for her constant wisdom, encouragement and guidance.Finally thanks to my parents Margie and Ed, family and friends, especially my husband GaryProbe who patiently helped me along this path with love and support.xDEDICATIONI dedicate this dissertation to the men and women who gave so freely of their time andopened their homes to me.  Thanks for your candour and enthusiasm!xiCO-AUTHORSHIP STATEMENTThis research program was identified and designed by Lawrence W. Mróz with theassistance of his supervisory committee, Gwen Chapman, Joan Bottorff and John Oliffe.Lawrence W. Mróz conducted all of the recruitment and data collection and conducted dataanalysis and manuscript preparation with continuous guidance from his supervisory committee.1CHAPTER 1.DIET AFTER PROSTATE CANCERIntroductionOne in seven Canadian men is expected to develop prostate cancer in his lifetime.  Themost commonly diagnosed cancer for men, it is estimated that in Canada in 2009, 25,500 menwere diagnosed with and 4,400 men died of prostate cancer (Canadian Cancer Society, 2009).Improved treatments have lowered mortality rates in Canada and the Western world; however,because most men are over the age of 60 when diagnosed, there are also age-related co-morbidconditions associated with long-term survivorship, and a risk of recurrence for many men (Jemal,Siegel, Ward, Hao, Xu, & Thun, 2009).  Because of this and the growing number of mensurviving longer with prostate cancer, there is increased interest in dietary interventions forprostate cancer prevention, treatment and recovery.  A growing body of evidence suggests that inaddition to providing general health benefits, diet might play an important role in prostate cancerrecurrence and survival (Berkow, Barnard, Saxe, & Ankerberg-Nobis, 2007; Ornish, Weidner,Fair, Marlin, Pettengill, Raisin et al., 2005; Van Patten, de Boer, & Tomlinson Guns, 2008).Consequently, nutrition guidelines and diet modifications are of great interest to men withprostate cancer, their families, caregivers and nutrition educators.Despite available guidelines, Western men with prostate cancer typically have poor dietscompared to women and are unlikely to make diet changes when warranted, even if motivated todo so (Blanchard, Courneya, & Stein, 2008; Patterson, Neuhouser, Hedderson, Schwartz,Standish, & Bowen, 2003).  Health behaviour theory suggests that there are multiple2determinants of food choice (Furst, Connors, Bisogni, Sobal, & Falk, 1996; Raine, 2005; Sobal& Bisogni, 2009), but there is currently no published research on the factors that might beimplicated in shaping the food practices of men who experience prostate cancer.  Nutritioneducation programs for these men thus lack the foundation of an understanding of men’s foodchoice and diet change processes.  This problem forms the crux of this dissertation, whichexamines men’s and women’s perceptions of food and diet change in the context of prostatecancer experiences, using gender theory as a theoretical framework.Conceptually, this study is situated at the nexus of several disparate research areas, allwith a Western perspective.  They include: evidence for the role of nutrition and diet in prostatecancer incidence and recovery; the nutrition education needs and food practices of men withprostate cancer; behaviour change and food choice theory; knowledge developments in thenature of men’s food practices; and how gender and masculinity theory can help us betterunderstand the nutritional health and food practices of men with prostate cancer.  Each of theseresearch areas is introduced below, followed by articulation of the objectives of this researchproject.  The research base necessary for conceptualising the study is further detailed in Chapter2, which provides a review and synthesis of relevant research on how gender is implicated inshaping men’s food practices in the context of prostate cancer.Nutrition and Prostate CancerResearch examining the role of nutrition in prostate cancer incidence and survival has along history, beginning with exploratory observations of systematic variations in diet andprostate cancer risk among continents, countries and cultures.  These observations led tobiomedical and mechanistic laboratory research on the role of nutritional factors in prostatecancer aetiology and to the evaluation of diet interventions for men with prostate cancer.  This3section provides a brief overview of this evidence and how it was used to make dietrecommendations for men with prostate cancer.The evidence for nutritional influences on prostate cancer began with exploratoryobservations and epidemiological research.  These studies demonstrated that increased risk forprostate cancer is strongly associated with Western dietary patterns that are typically high inmeat, fat and processed food, and low in vegetables when compared to traditional Asian dietarypatterns, which are lower in meat and fat and higher in vegetables and legumes including soyproducts (Fair, Fleshner, & Heston, 1997; Hsing, Tsao, & Devesa, 2000; Messina, 2003; Meyer& Gillatt, 2002; Vlajinac, Marinkovic, Ilic, & Kocev, 1997).  Observational epidemiologyfindings were supported by research that linked diet to prostate cancer progression from micro-focal, indolent or asymptomatic forms, to clinically relevant disease (Jankevicius, Miller, &Ackermann, 2002; Meyer, Bairati, Shadmani, Fradet, & Moore, 1999; Shirai, Asamoto,Takahashi, & Imaida, 2002; Yip, Heber, & Aronson, 1999).  These observations led to a largebody of experimental biomedical research on the potential protective nature of low-fat diets, richin fruit and vegetables, and the preventive roles of certain dietary factors in prostate cancerdevelopment and recurrence (Brawley, Barnes, & Parnes, 2001; Brawley & Barnes, 2001;Clinton, 1999; Clinton & Giovannucci, 1998; Gronberg, 2003).  Consequently, mechanisticrelationships for protective and therapeutic dietary factors have been proposed and are thesubject of ongoing investigation (Clinton, 2005; Freedland & Aronson, 2009; Ho, Boileau, &Bray, 2004; Ornish, Magbanua, Weidner, Weinberg, Kemp, Green et al., 2008; Strom,Yamamura, Forman, Pettaway, Barrera, & DiGiovanni, 2008).  Preliminary laboratory researchon nutrients including selenium and vitamin E and non-nutrient plant-based factors such aslycopene and soy isolates prompted preventive and treatment intervention research (Duffield-4Lillico, Dalkin, Reid, Turnbull, Slate, Jacobs et al., 2003; Hwang, Kim, Jee, Kim, & Nam, 2009;Miller, Giovannucci, Erdman, Bahnson, Schwartz, & Clinton, 2002; Peters, Littman, Kristal,Patterson, Potter, & White, 2008; Song-Yi Park, Wilkens, Henderson, & Kolonel, 2008;Stacewicz-Sapuntzakis, Borthakur, Burns, & Bowen, 2008; Stratton, Reid, Schwartzberg,Minter, Monroe, Alberts et al., 2003).  In summary, findings from exploratory and biomedicalresearch suggest a link between diet and prostate cancer and that diet might therefore be animportant adjunct for usual prostate cancer care and recovery.Based on the available evidence, clinical trials with diet interventions for men diagnosedwith prostate cancer have been conducted and are described in more detail in Chapter 2.  Someof these intervention studies are encouraging; for example one demonstrated that adopting a low-fat, vegetarian diet for one year reduced prostate specific antigen (PSA) blood levels among menwith low-grade, early-stage prostate cancer undergoing active surveillance, a deferred treatmentprotocol whereby treatment is delayed until markers of disease progression indicate thattreatment is warranted (Ornish et al., 2005).  In another study, men with recurrent prostate cancerand rising PSA after treatment showed a significant decline in their rate of PSA rise after sixmonths on a plant-based diet (Saxe, Major, Nguyen, Freeman, Downs, & Salem, 2006).Although a crude marker of prostate cancer activity, lowered PSA can indicate slower tumourprogression and a potentially reduced risk of recurrence.  Despite these promising findings,reviews of nutrition intervention studies suggest that although diet might enhance survival, thereremains much uncertainty as to how effective diet change is in preventing prostate cancerincidence, progression, recurrence or mortality (Berkow et al., 2007; Van Patten et al., 2008).5Nutrition Recommendations for Men with Prostate CancerAlthough research is ongoing and not yet definitive, preliminary findings suggest thatdiet recommendations that are potentially prostate-protective are similar to general healthy eatingguidelines and therefore are useful in improving overall quality of life.  As a result, nutritionrecommendations for Western men with prostate cancer also address co-morbidities with clearevidence for the role of diet in prevention or management, including other cancers,cardiovascular disease and type-2 diabetes (Blanchard, Stein, Baker, Dent, Denniston, Courneyaet al., 2004; Brown, Byers, Doyle, Coumeya, Demark-Wahnefried, Kushi et al., 2003; Ravasco,Monteiro-Grillo, & Camilo, 2003).  In particular, diet recommendations for prostate cancer havealso been linked to heart-healthy guidelines and therefore might represent an important healthbenefit for men with prostate cancer who are also typically at high risk for heart disease (Moyad,2006a, 2006b; Newschaffer, Otani, McDonald, & Penberthy, 2000).Prostate specific nutrition recommendations include: lowering meat consumption andoverall fat intake (especially saturated fat from meat and dairy products); maintaining a healthybody weight; increasing consumption of vegetables (especially cruciferous vegetables andtomato products); consuming legumes and soy products (e.g., beans, tofu, soymilk); consumingfoods rich in vitamin E, omega 3 fatty acids and selenium (e.g., fish, walnuts, and brazil nuts).Some guidelines also recommend taking supplements such as calcium, vitamin D, vitamin E,selenium, lycopene, soy isoflavones and herbal preparations, although a number of researcherscontest the effectiveness and safety of consuming them (Klein, 2009; Lippman, Klein, Goodman,Lucia, Thompson, Ford et al., 2009; Shariat, Lamb, Lyengar, Roehrborn, & Slawin, 2008).Brochures and recipe books with variants of this information are available in Canada fromprostate cancer support organisations and cancer agencies.  For example Eating Right For Life, a22-page booklet is available through the Canadian Prostate Cancer Network (Trachtenberg,6Fleshner, Lancaster, & Casselman, 2000).  This group also publishes the Our Voice Magazine,which often has articles on nutrition and prostate cancer; see Appendix 1 for Food for Thought,an example of an article published in 2003 and commonly available as a print resource while thisresearch was being conducted (Fleshner, 2003).Nutrition Education and Food Practices of Men with Prostate CancerResearch findings linking diet and cancer are regularly communicated to the generalpublic through the media and hence in an international study Western men were able to identifydiet as a prostate cancer risk factor (Schulman, Kirby, & Fitzpatrick, 2003).  Accordingly, mensometimes express interest in dietary information after a prostate cancer diagnosis, and some dietchange researchers have positioned this time as a ‘teachable moment’ for nutrition education(Demark-Wahnefried, Peterson, McBride, Lipkus, & Clipp, 2000).  Surveys of men with prostatecancer in the US, UK and Canada indicated that up to 40% of informants considered diet to be asignificant component of complementary treatment (Cheetham, Le Monnier, & Brewster, 2001;Kao & Devine, 2000; Nam, Fleshner, Rakovitch, Klotz, Trachtenberg, Choo et al., 1999).Consequently, information about the potential role of protective lifestyle factors such as diet andexercise in prostate cancer recovery is of special interest to healthcare providers (Zlotta &Schulman, 2001) and represents an unmet education need for many men with prostate cancer(Boberg, Gustafson, Hawkins, Offord, Koch, Wen et al., 2003).  Other findings suggest thatsome men with prostate cancer seek information on complementary or alternative treatmentsfrom non-traditional sources and sometimes take nutritional health and dietary supplements aspart of their self-care (Kao & Devine, 2000; Ponholzer, Struhal, & Madersbacher, 2003).Overall, however, the interest men with prostate cancer show in nutrition does notgenerally result in dietary improvements.  Despite the potential benefits of healthy eating during7and after prostate cancer diagnosis and treatment, the majority of men with prostate cancer tendnot to change their diets, even when motivated to do so (Blanchard et al., 2008; Patterson et al.,2003).  Educational nutrition interventions have consequently had mixed success in effectingbehaviour change towards healthy eating in prostate cancer patients (Demark-Wahnefried, Aziz,Rowland, & Pinto, 2005; Demark-Wahnefried et al., 2000) indicating that despite the ‘teachablemoment’, there are barriers to diet change for cancer patients (Harnack, Block, Subar, Lane, &Brand, 1997).One reason for this lack of diet change success might be because the evidence forpotential prostate cancer specific benefits from diet change, although promising, is not yetdefinitive.  The uncertainty of diet intervention research findings is reflected in media reports ofcancer and diet research and authoritative dietary guidelines specific to men with prostate cancerare not available.  Men diagnosed with prostate cancer must therefore decide for themselves ifcurrently available prostate cancer specific diet change recommendations are warranted as part oftheir self-care or recovery.  Existing nutrition recommendations are similar to widely accepteddiet recommendations for co-morbid conditions for which men in this age group are at risk (e.g.,cardiovascular disease).  This suggests that men’s uncertainty of the efficacy of diet changecannot solely explain why men with prostate cancer remain unengaged in diet change and thatother factors contribute to shaping men’s food practices.  Further, it points to a need for effectivenutrition intervention programs for these men that consider the multiple determinants of foodchoice as introduced in the following section (Payette & Shatenstein, 2005).Behaviour Change and Food Choice TheoryHealth behaviour research has demonstrated that knowledge of healthy eating is not thebest indicator of eating behaviour; improved dietary knowledge alone is insufficient to ensure8dietary behavioural change in the general public.  Dietary practices are also influenced bycomplex individual, social, and environmental factors which act as determinants of food choicebehaviour.  These include biological (e.g., hunger, appetite, taste); economic (cost, income);physical (access to food, education, skills, time); social (culture, family, peers); andpsychological (mood, stress) determinants (Glanz, Rimer, & Lewis, 2002).  Health behaviourand food choice theory indicate that among these various determinants, psychosocial factorsincluding beliefs and attitudes about food are equally or more important in determining dietarybehaviour than knowledge (Bisogni, Connors, Devine, & Sobal, 2002; Furst et al., 1996;Harnack et al., 1997; Satia, Kristal, Patterson, Neuhouser, & Trudeau, 2002; Worsley, 2002).Several health behaviour models have attempted to understand, explain and predict foodchoice behaviours with limited success.  The Health Belief Model, Theory of Planned Behaviourand the Stages of Change Model have all been applied to diet change interventions; however,none of these models alone has successfully explained or predicted the wide range of food choicebehaviours possible (Nestle, Wing, Birch, DiSogra, Drewnowski, Middleton et al., 1998).  Thismay relate, in part, to ways that food behaviours differ from other health behaviours explainedby the above models.  The Cornell food choice research group has thus developed a food choiceprocess model that attempts to integrate multiple determinants of food choice into onecomprehensive framework (see Figure 1.1) (Furst et al., 1996; Sobal & Bisogni, 2009).9Figure 1.1  A Food Choice Process Model ©Springer, 2009. (Used by permission from theAnnals of Behavioral Medicine)‘A Food Choice Process Model’ describes how life course events shape multipleinfluences on food choice behaviour.  These influences include food ideals as well as personaland social factors, which shape personal food systems, and in turn, individual food choice events.Personal factors including personal identities as shaped over life course experiences areidentified in the model as integral to food choice decision-making and might include genderedfood roles (Bisogni et al., 2002).  This model thus provides a framework for understanding howmultiple determinants of food choice behaviour shape people’s food practices, however, it isunclear how gender is implicated.  Further exploration of the role of gender in shaping foodpractices of subgroups such as men with prostate cancer, would help further develop this model.In summary, health behaviour and food choice theories offer frameworks forconceptualising food choice behaviour.  However, there has been little exploration of men’sspecific dietary understandings and needs and these frameworks fail to illuminate why men with10prostate cancer do not change their diets.  In particular, the role of gender as a determinant offood choice warrants further investigation and is discussed in the next section.Men’s Food Practices and Gender TheoryGender is an important determinant of food choice.  Research suggests that Western mengenerally have poorer diets than women, revealing that men consume more meat and alcohol,while women often eat more fruit, vegetables and fish, and/or have overall healthier diets (Jensen& Holm, 1999; Liebman, Propst, Moore, Pelican, Holmes, Wardlaw et al., 2003; Prattala,Paalanen, Grinberga, Helasoja, Kasmel, & Petkeviciene, 2007; Roos, Lahelma, Virtanen,Prattala, & Pietinen, 1998).In relation to cancer populations, studies have shown that men with cancer tend to be lessinterested in engaging in nutritional self-care than women cancer survivors (Hopfgarten,Adolfsson, Henningsohn, Onelov, & Steineck, 2006; Kiss & Meryn, 2001; Nicholas, 2000).  Inaddition, older men who have a higher risk for prostate cancer are reported to have a lower intakeof fruit and vegetables than women, and are less aware of links between diet and disease (Baker& Wardle, 2003).  These observations of behavioural differences between men and women haveled to research exploring how gender and gender relations are implicated in shaping health, andespecially how masculinity shapes men’s food practices.  Masculinity theory provides aframework for better understanding men’s nutrition knowledge, perceptions, attitudes and foodpractices, and is introduced in the following section and described in more detail in Chapter 2.Masculinities, Men and FoodTheory regarding hegemonic masculinity has been developed to help explain genderdifferences between Western men and women’s health practices and men’s subsequent poorerhealth outcomes (Courtenay, 2000b).  Within this framework gender is conceptualised as socially11constructed and performed through people’s daily activities and social interactions.  Men andwomen demonstrate their masculinity or femininity respectively by embodying and enactingperceived normative or hegemonic ‘manly’ or ‘womanly’ attributes and behaviours (Connell,1995; Connell & Messerschmidt, 2005; Howson, 2006).  Hegemonic enactments are problematicfor men’s health because many health promotion practices, including nutritional self-care, areperceived as feminine endeavours and as a result men might signify alignment to hegemonicmasculinity by avoiding these and engaging in unhealthier ‘manly’ practices (Courtenay, 2000b;Moynihan, 1998).  Recent developments in men’s food choice research provide avenues toexplore how masculinities might be implicated in the food practices of men, and in this context,men with prostate cancer.Research exploring factors influencing food practices has traditionally involved womenand issues such as body image or weight control (Barr & Chapman, 2002; Chapman, 1997, 1999;Chapman & Maclean, 1993; Farrales & Chapman, 1999) and breast cancer (Adams & Glanville,2005; Beagan & Chapman, 2004a, 2004b; Chapman & Beagan, 2003; Thomson, Rock, Caan,Flatt, Al-Delaimy, Newman et al., 2007).  Femininity and food research demonstrates thatwomen typically perceive food work as nurturing and a part of their feminine identities as wivesand mothers (DeVault, 1991; Furst, 1997; Lupton, 2000; Lyons & Willott, 1999).  Researchfocussing specifically on men's food choice processes is scarce, but recently there has beenincreased interest in the role of masculinity in health care and diet (Bird & Rieker, 1999;Cameron & Bernardes, 1998; Courtenay, 2000a; Lee & Owens, 2002; O'Brien, Hunt, & Hart,2005; Roos, Prattala, & Koski, 2001; Smart & Bisogni, 2001; Sobal, 2005).  Differences betweenmen’s and women’s diet habits are well documented and suggest that masculinity is a keydeterminant of men’s poorer food practices and contributes to men’s poorer nutritional health12outcomes (Berrigan, Dodd, Troiano, Krebs-Smith, & Barbash, 2003; Bourdieu, 1984; Jensen &Holm, 1999; Millen, Quatromoni, Pencina, Kimokoti, Nam, Cobain et al., 2005; Oakes &Slotterback, 2001; Patterson et al., 2003; Roos et al., 1998).  These findings suggest thatmasculine food ideals might inhibit the uptake of nutrition intervention programs for men withprostate cancer and indicates that gender theory should be considered in the design and deliveryof such programs; however, because of the lack of empirical research in this area, it remainsunclear how to do so.  There is a small but growing body of literature that examines howmasculinities are implicated in shaping Western men’s food practices; however, much of theresearch has focused on men younger than those typically diagnosed with prostate cancer(Gough & Conner, 2006; Roos et al., 2001; Roos & Wandel, 2005; Sellaeg & Chapman, 2008;Sloan, Gough, & Conner, 2009; Smart & Bisogni, 2001).  Some research indicates that oldermen are less likely than younger men to perceive healthy eating positively (Drummond & Smith,2006; Moss, Moss, Kilbride, & Rubinstein, 2007), but no published studies have focused on thefood and diet perceptions and practices of men with prostate cancer who are typically diagnosedbetween 60-69 years of age in Canada (Canadian Cancer Society, 2009).  The role of gender inshaping men’s and women’s health and food practices is detailed in chapter 2.Gender Relations and FoodAlthough masculinity theory affords a framework for understanding men’s perceptions ofdiet and food practices, it must also be considered in relation to women and femininity.  This isbecause masculinity is defined in relation to femininity but also because interactions or genderrelations between men and women are also important in shaping men’s health behaviours(Lyons, 2009; Schofield, Connell, Walker, Wood, & Butland, 2000).  Gender relations theory isparticularly useful for better understanding many men’s food practices because women tend to13be leaders in food and nutrition.  Men’s general dietary practices are greatly influenced by theirfamily relationships, especially co-habiting partners (Bove, Sobal, & Rauschenbach, 2003;Harnack, Story, Martinson, Neumark-Sztainer, & Stang, 1998; Schafer, Schafer, Dunbar, &Keith, 1999).  Furthermore, families and female partners of heterosexual men with prostatecancer are important contributors to their health (Arar, Thompson, Sarosdy, Harris, Shepherd,Troyer et al., 2000; Gray, Fitch, Phillips, Labrecque, & Fergus, 2000; Harvei & Kravdal, 1997).At the time of diagnosis, men with prostate cancer tend to make final treatment decisionsindependently (Boehmer & Clark, 2001a, 2001b; Davison, Goldenberg, Gleave, & Degner,2003).  However, men's co-habiting partners do take active roles in helping them manage theirillness through provision of health care and general support (Gregory, 2005; Harden,Schafenacker, Northouse, Mood, Smith, Pienta et al., 2002; Helgeson, Novak, Lepore, & Eton,2004; Navon & Morag, 2003).  Given the influence of men’s co-habiting partners on their diets,constructions of masculinity and overall health care, it is important that female partners’perceptions and roles are included in addressing the dietary practices and beliefs of men withprostate cancer (Schofield et al., 2000).The complexity of hetero-normative interactions calls for a better understanding of howgender relations are implicated in family food practices and men’s health.  In addition, a morenuanced incorporation of femininity into masculinity theory as suggested by Schippers (2007)would provide a better understanding of how gender relations are implicated in maintainingtraditional gender power structures that in turn sustain gender hegemony or patriarchy.Masculinity and food research has focused on men’s perceptions of food but has not consideredhow gendered interactions between men and women are implicated in men’s food and healthpractices.  Furthermore, although masculinity theory assumes the existence of a gender hierarchy14in which masculinity is dominant, gendered interactions around food have not been examined inways that illuminate how power dynamics are implicated, nor how these are shaped throughmen’s illness experiences.  Although there are separate literatures on masculinity and food, andfemininity and food there is a lack of research that links men and women’s ‘food worlds’.  Lyons(2009) has called for research that exposes how links between men’s performances ofmasculinity and women’s performances of femininity through food and health behaviours areimplicated in shaping men’s nutritional health and food practices.  Exploring how experiencingprostate cancer can impact gender relations and power structures that shape men’s food practicesis a focus of this research.SummaryIn this background review, I sought to integrate several areas of inquiry in men’s healthin order to better understand men’s disinclination to change their diets when diagnosed withprostate cancer.  Central to this issue is the growing evidence for the protective nature of healthyeating for men with prostate cancer, and that many men express an interest and desire fornutrition knowledge and education after a prostate cancer diagnosis.  Despite potential healthbenefits, there is little evidence that men with prostate cancer make significant diet changeswhen warranted, even if apparently motivated to do so.  Understanding why this is so isimportant to help develop and deliver effective nutrition programming for men with prostatecancer.  The reasons for men’s disinclination for diet change are unknown, but health behaviourand food choice theory suggest that gender is an important determinant of food choice andprovide important avenues to investigate food choice processes.  Emerging research inmasculinity and food provides insight into this by demonstrating how gender and genderrelations can be implicated in shaping men’s food practices.  However, there has been no15examination of men’s dietary practices following a prostate cancer diagnosis from a masculinityperspective and no published research that integrates masculinity, femininity and men’s foodpractices and health, using a gender relations approach.  This dissertation research thereforeaddresses these knowledge gaps.Thesis Objective and OverviewIn this chapter, the need for research into the dietary perceptions and food practices ofmen with prostate cancer and their female partners has been described.  It is apparent thatmultiple psychosocial issues must be considered when creating nutrition programs (Visser & vanAndel, 2003) and that the role of gender and gender relations is poorly understood in this area,warranting in-depth exploration.  The purpose of this dissertation research was thus to explorehow masculinity and gender relations are implicated in shaping dietary understandings and foodpractices of men with prostate cancer.I have approached this research from a social constructionist perspective that recognisesthat gender and health behaviours are configurations of practice that develop through socialinteractions (Berger & Luckmann, 1980; Brickell, 2006; Courtenay, 2000b).  In this sense foodpractices are social phenomena that are created through a dynamic process reproduced whenpeople act on their knowledge and understandings about food and eating, and can furthermore beconceptualised as performances of gender.  Because the extant literature on nutrition and prostatecancer is separate from masculinity and food research, there has been little conceptualization ofthe role of masculinity in shaping men’s dietary perceptions and food practices in the context ofprostate cancer.  The first phase of the dissertation research thus entailed reviewing andintegrating empirical research on nutrition and prostate cancer, and masculinity and food, usinggender and gender relations theory as a conceptual framework.  This review is presented in16Chapter 2 of the dissertation, expanding on several of the areas of inquiry introduced in thisIntroduction chapter, providing a synthesis of knowledge developments in men’s gendered foodchoice processes, and discussing the significance of this in the context of prostate cancersurvivorship.The second component of the dissertation research was an empirical qualitative study,involving individual, semi-structured interviews with 14 men who had been diagnosed withprostate cancer and their co-habiting female partners.  Interviews were conducted in private, withmen from each couple interviewed first and separately from his partner.  Data collection andanalysis were guided by constructivist grounded theory methods as described by Charmaz(2006).  The research methods and findings are presented in Chapters 3 and 4.  The first of these,Chapter 3, focuses on the men’s perceptions of diet and food practices in the context of prostatecancer and the rationales they provide for perceived diet changes (or lack thereof) in theirrecovery and self-care.  Masculinity theory is used as a framework to interpret these findings.Chapter 4 responds to calls for research that explores how performances of masculinity andfemininity interact to help shape men’s food and health practices, and expose how genderrelations sustain patriarchal power structures.  This chapter integrates accounts from the men andwomen’s interviews to expose how gender relations are implicated in both complex couplepower dynamics and men’s food practices.  The dissertation concludes with a discussion of thesignificance, implications, strengths and weaknesses of the study, presented in Chapter 5.17ReferencesAdams, C., & Glanville, N. T. (2005). The meaning of food to breast cancer survivors. 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Lancet, 357(9253), 326-327.29CHAPTER 2.MEN, FOOD AND PROSTATE CANCER:  GENDERINFLUENCES ON MEN’S DIETS1IntroductionThe role of diet in prostate cancer has received considerable attention followingobservations that compared to typical Western diets, which are high in energy, meat and fat,traditional Asian diets rich in vegetables and legumes are associated with lower prostate cancerincidence (Grant, 2004).  Subsequent research on diet and prostate cancer progression andrecurrence is of interest given the large and growing number of long-term survivors in Westerncountries (Jemal, Siegel, Ward, Hao, Xu, & Thun, 2009).  Prostate cancer diet intervention trialshave demonstrated that adopting plant-based diets can reduce markers of prostate cancerprogression and alter prostate tumour gene expression, and might therefore inhibit recurrence(Ornish, Magbanua, Weidner, Weinberg, Kemp, Green et al., 2008; Ornish, Weidner, Fair,Marlin, Pettengill, Raisin et al., 2005; Saxe, Major, Nguyen, Freeman, Downs, & Salem, 2006).Recent reviews of diet and prostate cancer research identify obesity and excessive meat, fat andcalorie intake as modifiable ‘risk factors’ in disease progression and recurrence (Berkow,Barnard, Saxe, & Ankerberg-Nobis, 2007; Demark-Wahnefried, 2007; Freedland & Aronson,2009; Van Patten, de Boer, & Tomlinson Guns, 2008).  Overall, there is growing evidence thathealthy diets might improve long-term survival of men with prostate cancer, up to 40% of whomare at high risk for recurrence after treatment (Chan, Holick, Leitzmann, Rimm, Willett,Stampfer et al., 2006).  As well, for men who manage their low-risk prostate cancer through                                                  1 A version of this chapter has been published online. Mróz, L.W., Chapman, G.E., Oliffe, J.L. and Bottorff, J.L.,(August 26, 2010). Men, food and prostate cancer:  Gender influences on men’s diets. American Journal of Men’sHealth doi:10.1177/155798831037915230active surveillance, a deferred treatment protocol, diet changes might allow them to extenddelays or even avoid active treatments and their associated morbidities (Frattaroli, Weidner,Dnistrian, Kemp, Daubenmier, Marlin et al., 2008).Given these findings there is need for nutrition guidance for prostate cancer survivors;however, little is known about what might constitute effective targeted interventions.  Nutritionpromotion efforts reveal that diet change is generally difficult to accomplish, stimulating effortsto develop more detailed conceptualizations of food choice processes (Furst, Connors, Bisogni,Sobal, & Falk, 1996; Raine, 2005).  This work recognizes that food choice is influenced bycomplex interconnections among biological, environmental, economic, psychosocial and otherdeterminants that interact within an individual’s life context (Gedrich, 2003).Gender is a key determinant of food choice, as demonstrated by evidence that throughoutthe Western world men’s diets are different and often poorer than women’s diets (Wardle, Haase,Steptoe, Nillapun, Jonwutiwes, & Bellisle, 2004).  However, the intricate ways in which gendershapes men’s eating habits are poorly understood (Roos, Lahelma, Virtanen, Prattala, & Pietinen,1998).  The influence of masculinity and gender relations on men’s experience of prostate canceris also complex but affords an integral context for understanding men’s diets following prostatecancer.  To develop effective nutrition interventions for men with prostate cancer, it is thereforeimportant to consider the particular ways their food practices are shaped by gender.The purpose of this chapter is to provide a synthesis of knowledge developments inmen’s gendered food practices and discuss the significance of this work in the context of prostatecancer survivorship.  Specifically, in this chapter I synthesize the evidence around men’sdisinclination for diet change after prostate cancer, and discuss how gender shapes men’s foodpractices.  I outline how masculinity theory as depicted by Connell (1995), Courtenay (2000a,)31and others can increase our understandings about how masculinities, prostate cancer and men’sfood practices are connected.  In reviewing the growing literature on masculinity and men’s foodpractices, I describe how these understandings might guide intervention efforts.  Drawing on thework of Lyons (2009) and recommendations by Schofield, Connell, Walker, Wood, & Butland(2000), I also explain how complex gender relations can influence men’s health and foodpractices.MethodsArticles providing a broad perspective on diets of men with prostate cancer and men’sfood choice behaviours were selected by searching online databases, primarily the Web ofScience (Science Citation Index Expanded, Social Sciences Citation Index, Arts and HumanitiesCitation Index) and EBSCO databases (Academic Search Complete, Biomedical ReferenceCollection, CINAHL, Humanities International Index, MEDLINE, PsycARTICLES), for articlespublished in 1987 through August 2009.  Search terms included ‘masculinity’, ‘men’, ‘men’shealth’, ‘gender’, ‘diet’, ‘food’, ‘food choice’, ‘prostate cancer’, ‘cancer’, ‘health’ and ‘healthbehaviour’.  Because of the broad nature of many of these search terms, hundreds of titles werereturned.  Titles found were reviewed to ascertain relevance to the topic and those determined tobe unrelated were discarded.  Similarly, abstracts for the remaining titles were read and ifdetermined relevant, the article was retrieved, read and included in this review.  Consequently awide range of articles including empirical reports, literature reviews and theoretical discussionsaddressing diets of cancer survivors, diet and prostate cancer intervention research, and the roleof gender in shaping eating habits and health of men in Western countries were reviewed.  Whilerecognizing that constructions of masculinity vary across culture and place, and therefore withinand between Western countries, the current research yielded insight into some prevailing patterns32across Western countries.  Although it was not possible to focus on any one Western culture inthis review, the various study locales are provided to signal acknowledgement thatgeneralizations about masculinities across cultures cannot always be made.  In this chapter Isummarize literature addressing and informing dietary practices of prostate cancer survivors, andfocus on how masculinities influence food choice, while signalling how gender relations theorymight add important insights to advance those understandings.Findings and DiscussionDiet After CancerThe potential benefits of healthy eating and the opportunity or ‘teachable moment’ fordiet education after a cancer diagnosis has stimulated interest in nutrition interventions for cancersurvivors.  However, reviews of Western large-scale diet and lifestyle assessments suggest thatdespite increased motivation for dietary change, most cancer survivors have the same behaviourrisk factors as the general population and are unlikely to change their diets (Demark-Wahnefried,Aziz, Rowland, & Pinto, 2005; Jones & Demark-Wahnefried, 2006).  As well, high levels ofobesity and low levels of physical activity are prevalent in multi-site cancer survivors, oftenexisting at similar levels found in the general population (Pinto & Trunzo, 2005).  Although twostudies have reported lower obesity levels and higher consumption of fruit and vegetables inNorth American male cancer survivors compared to non-cancer controls (Coups & Ostroff,2005; Courneya, Katzmarzyk, & Bacon, 2008), most studies reveal male cancer survivors as lesslikely to have healthy diets than female cancer survivors.  Healthy eating improvementsincluding compliance with fruit and vegetable intake recommendations were lower among USprostate cancer survivors than breast and uterine cancer survivors (Blanchard, Courneya, &33Stein, 2008; Demark-Wahnefried, Peterson, McBride, Lipkus, & Clipp, 2000) and in men withprostate or colorectal cancer compared to women with breast or colorectal cancer (Patterson,Neuhouser, Hedderson, Schwartz, Standish, & Bowen, 2003).  Some men with prostate cancershow reluctance to make long-lasting or comprehensive diet changes.  For example, only 13% of822 Austrian men reported adopting a low fat diet as part of their prostate cancer self-care(Ponholzer, Struhal, & Madersbacher, 2003).  In one survey 25% of Swedish men newlydiagnosed with localized prostate cancer reported they would prefer a shortened life span ratherthan reduce their consumption of beef or pork (Hopfgarten, Adolfsson, Henningsohn, Onelov, &Steineck, 2006).  Overall, although research in this area is scarce, the disinclination for men withprostate cancer to change their diets appears to be a prevailing pattern.Further evidence of reluctance for men with prostate cancer to make healthful dietchanges comes from US clinical trials addressing diet change and survival.  Difficulties withadherence to intervention diets and associated attrition problems might have contributed toinconclusive findings about the role of diet in prostate cancer recovery (Stull, Snyder, &Demark-Wahnefried, 2007).  These trials required adherence to strict, low-fat, plant-based dietsthat are typically more extreme than general healthy eating guidelines for men with prostatecancer.  Researchers have found it necessary to provide extensive nutrition education andcounselling programs to achieve adherence and even then, success in attaining compliance withstudy protocols has been mixed.  A few small US studies with interventions ranging from elevenweeks to six months that included counselling with nutritionists, regular support group meetingsand/or individually tailored nutritional information modestly increased vegetable intake but didnot achieve significant long-lasting diet improvements (Carmody, Olendzki, Reed, Andersen, &Rosenzweig, 2008; Nguyen, Major, Knott, Freeman, Downs, & Saxe, 2006; Parsons, Newman,34Mohler, Pierce, Paskett, & Marshall, 2008).  Several larger trials were able to modestly increasefruit and vegetable consumption and/or decrease fat intake for US prostate cancer patients usingmore intensive interventions lasting 10 – 12 months (Demark-Wahnefried, Clipp, Lipkus,Lobach, Snyder, Sloane et al., 2007; Dewell, Weidner, Sumner, Chi, & Ornish, 2008; Link,Thompson, Bosland, & Lumey, 2004; Ornish et al., 2005).  These dietary interventions wereinstrumental in conducting much needed clinical trials and achieved modest short-term dietchanges, but were comprehensive and labour intensive and would be difficult to apply to largerpatient populations.  In addition, many were adapted from programs originally developed forwomen’s diet interventions studies and were not gender savvy in their design and delivery(Demark-Wahnefried et al., 2007; Link et al., 2004; Parsons et al., 2008).In summary, the literature suggests that men tend not to adhere to healthy eatingguidelines nor improve their diets after a cancer diagnosis, and they may be less compliant todiet changes than women who have had cancer.  This suggests that gender is an importantdeterminant of men’s dietary responses to prostate cancer.Men, Masculinities and Prostate CancerA growing body of literature has examined the role of gender in men’s health and caninform our understandings of the food practices of men with prostate cancer.  Men are morelikely to suffer ill-health, have higher death rates for most major illnesses, and have shorter lifeexpectancies than women.  Worldwide, men live an average of 3.9 years less than women(Mathers, Sadana, Salomon, Murray, & Lopez, 2001), while US men live on average 5.2 yearsless than women and are more likely to suffer and die from the 12 leading mortality causes(Dodson, 2007).  Similarly in Canada, men have a life expectancy that is approximately 4.7 yearsless than women (Statistics Canada, 2010).  A physiological perspective, whereby biological35determinants based on sex are thought to govern differential health outcomes, has often been putforward to explain this disparity.  In this ‘sex destiny’ view, men’s health is determined by malespecific anatomy (penis and testes) and physiology (testosterone), sex roles are seen as inheritedand rigid, and therefore, men’s negative health outcomes are inevitable (Courtenay, 2000a;Moynihan, 1998).In contrast, a social constructionist perspective has developed, whereby gender isunderstood as conceptualizations of masculinity and femininity that people within a societydevelop, share and enact within everyday social exchanges and that are demonstrated by beliefsand practices that people embody and perform (Brickell, 2006).  Dominant ideals of masculinityand femininity endure in society as models for action that guide and prescribe men’s andwomen’s behaviours.  Following this perspective, men constantly construct and reconstruct theirgender in ways that demonstrate varying relationships to dominant ideals of masculinity(Courtenay, 2000a; Moynihan, 1998; Phillips, 2006).  ‘Hegemonic masculinity’ refers tonormative ideals that men try to embody and emulate, amid the avoidance of what is perceived tobe feminine behaviours, which produces and maintains male social dominance.  There issignificant variation in how men perform masculinity and therefore multiple masculinities existas complicit, subordinate and marginalized to the normative form.  Most men are complicit insustaining hegemonic ideals regardless of their actual gendered performances.  In addition, manymen are not represented by the benchmarks of Western hegemonic masculinity, which typicallyinclude white, middle-class, educated and heterosexual men (Oliffe, Grewal, Bottorff, Dhesi,Bindy, Kang et al., 2010).  ‘Marginalized’ masculinities are thus shaped by social structuresincluding age, ethnicity, race and class, while ‘subordinated’ masculinities are most often shapedby sexual orientation.  Within the gender order, hegemonic masculinity ascends to the highest36status above other masculinities and is defined by characteristics including autonomy and self-reliance and power over others.  Performances of hegemonic masculinity are typified as beingopposite to what is considered feminine behaviour and consequently, masculinity is understoodas being constructed in relation to femininity (Connell, 1995; Connell & Messerschmidt, 2005).This has negative implications for men’s health because men see many healthy behaviours asfeminine and therefore to be avoided whilst unhealthy or risky behaviours are perceived asnormative for men (Mahalik, Burns, & Syzdek, 2007).In men’s health masculinity is associated with reluctance to seek help, as demonstratedby evidence that men are generally poorer consumers of health care services and less likely toacknowledge symptoms of illness than women (Courtenay, 2000b; Galdas, Cheater, & Marshall,2005; Lee & Owens, 2002).  Adherence to masculine ideals has been implicated in men’s poorhealth outcomes (Robertson, 2007; Schofield et al., 2000).  For example, British men withbenign prostate disease confessed to having little health knowledge or desire to learn and avoidedhealth promotion activities and help seeking, even after experiencing long-term clinicallyrelevant prostate symptoms (Cameron & Bernardes, 1998).  Of course, not all men subscribe tothese masculine ideals and the existence of multiple masculinities within and between men hasenabled researchers to describe diversity as well as prevailing patterns among men’s healthpractices.  Some men may actively reject certain ideals of masculinity; however they arenonetheless influenced by these ideals, often resulting in men’s generally poorer health outcomes(Connell, 1995; Donaldson, 1993; Sabo, 2000).Masculinity also has considerable influence on men’s experiences with cancer (Nicholas,2000), especially prostate cancer.  American men are less likely than women to have knowledgeof and adopt cancer preventive health behaviours, including reducing dietary fat intake and37maintaining healthy body weights (Wilkinson, Vasudevan, Honn, Spitz, & Chamberlain, 2009).Overall, American and British men are more likely to suffer from and die of most types of cancerthan are women (Cancer-Research-UK, 2009; Jemal et al., 2009).  Western men also show poorpsychosocial adaptation after a cancer diagnosis, suggesting masculinity might hinder men’sacceptance and adoption of self-care cancer recovery care activities including improving diet(Kiss & Meryn, 2001).  Differences in how men and women experience cancer are reflected inthe field of psycho-oncology, which has traditionally focused its attention on the psychosocialadjustment of women after a cancer diagnosis.  The implicit message is that men are expected tobe stoic and better able to privately cope with cancer than women.  The expectation to ‘take itlike a man’ and not need or expect psychosocial services can also be perpetuated by physicianand caregivers’ gendered expectations and is reflected in doctor-patient communication (Oliffe& Thorne, 2007; Street, 2002).  Consequently, Canadian men tend to avoid psychosocial healthcare although research indicates an unmet need for such services (Manii & Ammerman, 2008).These findings can help cancer researchers understand how men experience cancer differentlythan women, especially in the context of self-care activities such as diet behaviour change.  Menmight be unwilling to engage in self-care behaviours if they are thought of as contrary to what aman with cancer is ‘supposed’ to do (Moynihan, 2002).Research examining men’s experiences with prostate cancer has shown reciprocal andoften negative relationships between masculinity and prostate cancer for British (Chapple &Ziebland, 2002), Israeli (Navon & Morag, 2003) and Australian men (Oliffe, 2005; Wall &Kristjanson, 2005).  For example, some Australian men described how investigative diagnosticand treatment procedures disrupted their self-perceptions as men and negatively influenced theirexperiences involving treatment decision-making (Broom, 2004).  Others described tolerating38unnecessarily painful biopsy procedures without anesthetic, demonstrating masculine stoicacceptance (Oliffe, 2004).  Adherence to masculine ideals shaped some men’s experiences withsexual and urinary dysfunction after definitive prostate cancer treatment and negativelyinfluenced their psychosocial adjustment and mental health (Burns & Mahalik, 2007).  Theseoutcomes might negatively affect diet through changes in appetite or psychological distressrelated to urinary or fecal incontinence (Palmer, Fogarty, Somerfield, & Powel, 2003).  SomeCanadian men who managed their low-risk prostate cancer with active surveillance minimizedtheir cancer by framing it to researchers as benign and not requiring their attention.  Thispositioning suggested that masculine ideals of control and self-reliance might have limited theiradoption of self-care activities (Oliffe, Davison, Pickles, & Mroz, 2009).  From these findings itis apparent that masculinity is an important influence on men’s health and may hinder self-careactivities of men with prostate cancer.  In considering the potential benefits of diet change, it isnecessary to include consideration of how masculinity exerts influence on these men’s foodchoices.Men, Masculinities and FoodFood consumption surveys confirm gender differences in Westerner’s dietary habits,revealing that men consume more meat and alcohol, while women often eat more fruit,vegetables and fish, and/or have overall healthier diets (Jensen & Holm, 1999; Liebman, Propst,Moore, Pelican, Holmes, Wardlaw et al., 2003; Prattala, Paalanen, Grinberga, Helasoja, Kasmel,& Petkeviciene, 2007; Roos et al., 1998).  These findings are not always consistent in that someNorth American nutrition surveys show men to be more likely to consume the recommendednumber of servings of fruits and vegetables and/or dairy products (Garriguet, 2006; Johnston,Taylor, & Hampl, 2000).  However, this is associated with men’s overall greater food39consumption rather than better diet quality, and most men surveyed ate less than therecommended number of servings.  The consequence is that US men’s less healthy diets areassociated with increased risk for diet-related chronic disease compared to women (Millen,Quatromoni, Pencina, Kimokoti, Nam, Cobain et al., 2005).  These gender differences in foodconsumption can be linked to diverse meanings of food and eating, including what constitutes‘healthy eating’, domestic cooking ideals, and how gender relations influence family foodpractices.  Each of these areas is reviewed below noting both dominant and alternativeconstructions of masculinity and food.Research on gender and diet has shown that men ascribe different meanings to food andeating than women do.  For example, in surveys conducted in 23 Western countries and a studyin Australia, women typically framed the concept of ‘dieting’ as a means to attain and manage anidealized body shape and weight.  In contrast, men tend to frame dieting as a means to attainfitness and maintain strength and work prowess (Wardle et al., 2004; Wright, O'Flynn, &Macdonald, 2006).  Eating small, light meals is associated with femininity for Canadians(Chaiken & Pliner, 1987), while Western men typically envision meals as needing to be heartyand meat-centred and judge salads and soups as poor ‘male’ choices (Jensen & Holm, 1999).Such gendered food ideals are widespread in Western culture and may contribute to men’s poordiets.  An analysis of constructions of masculinity in articles published in Men’s Healthmagazine (June-December, 2000) revealed unhealthy dietary behaviours as masculine‘makeovers’ (Stibbe, 2004).  Distributed in 43 countries around the world, this magazineprovides an excellent example of the portrayal of Western hegemonic masculine ideals, whichfavour American, White, middle-class and youthful perspectives.  Rather than cook at home,men were encouraged to eat convenience food and meat, and drink beer.  Accordingly these40unhealthy behaviours were explicitly described and embraced as manly, while healthierbehaviours such as vegetarianism or domestic cooking were denigrated and described asfeminine, un-masculine and therefore to be avoided (Stibbe, 2004).  Likewise, a study of youngAustralian men’s food attitudes revealed fruits and vegetables as discordant with masculine‘culture’ (Dumbrell & Mathai, 2008).Meat consumption or “doing meat” in particular has been viewed as a way of signifyingmanliness (Bourdieu, 1984), but it might also vary in meaning according to social context.Masculine ideals including ‘strong men’, ‘wealthy men’, ‘healthy men’ or other conceptions ofWestern masculinity that can be invoked, influence how meat is perceived and consumed.Although all are framed as masculine, some explicitly reflect dominant ideals while others offercollateral identities by providing alternate justifications for differing meat consumption.  Forexample a ‘strong man’ ideal might be embodied to justify the regular consumption of meat forenhancing muscular strength while other men might invoke ‘a healthy man’ ideal to justifyreduced meat consumption (Sobal, 2005).  Increased meat consumption has also been viewed asa sign of renewed traditional masculinity or a rejection of modern, effeminized or ‘metrosexual’masculinity.  In a US cultural analysis eating beef was re-affirmed as a way of re-claiming orstrengthening traditional masculinity in the face of alternative masculinities that indicatefemininity and signal weakness (Buerkle, 2009).Men’s perceptions of healthy eating also differ from those of women, who tend to assesshealthy foods and healthy eating guidelines more favourably than men, as demonstrated instudies conducted in the US (Oakes & Slotterback, 2001; Rappoport, Peters, Downey, Mccann,& Huffcorzine, 1993), Finland (Roos et al., 1998), Australia (Turrell, 1997) and the UK (Gough& Conner, 2006).  For example, the UK study found that men perceived healthy food as41unappealing, poor tasting and unsatisfying.  Additionally, participants were cynical anddismissive of government produced healthy eating messages.  These perceptions were identifiedas important barriers to healthy eating for these men (Gough & Conner, 2006).  Because healthyeating recommendations often mimic ‘feminine’ ways of eating, including emphasis onvegetables and fruits and smaller portion sizes, and encourage decreased consumption ofmasculine foods (Jensen & Holm, 1999), ‘manly’ food habits are positioned as conflicting withhealthy eating guidelines and health promotion efforts.Men’s perceptions of healthy eating can vary by social class and culture, reflectingalternative masculine food ideals as seen in a study of Finnish carpenters and engineers wherebyengineers displayed more middle class perspectives compared to carpenters when they framedhealthy eating as acceptable for ‘fit men’ (Roos & Wandel, 2005).  Likewise in a Canadianstudy, men who lived alone expressed alternate masculine ideals that might have been a functionof the men’s higher social class, temporal changes in views about men and food, or the particularNorth American West Coast urban culture where the men lived (Sellaeg & Chapman, 2008).  Ananalysis of the connections between food, masculinity and male body image in Western men’sfitness magazines demonstrated a shift whereby healthy eating facilitated the embodiment ofmasculine ideals of strength and fitness.  Here, the pursuit of a muscular and lean male bodyrepresented the expression of masculine control or dominance of the weak, excessive andtherefore feminine appetite.  Food was portrayed as a scientific tool to be used in men’s battles toproduce a rational masculine mind, the antithesis of female nurturing (Parasecoli, 2005).  Thesefindings showed how gendered notions about food and eating are perceived and perpetuated inthe popular media, in this case to promote healthy eating as a conduit for male fitness.  Theseperceptions are reflected in men’s food research, which found that American male college42athletes framed healthy eating in the context of attaining athletic prowess (Smart & Bisogni,2001).  Similarly, British men who pursued healthy lifestyles distanced healthy eating fromfeminine behaviour by disassociating their health practices from female health concerns andreframing their choices as performance based (Sloan, Gough, & Conner, 2009).Men’s relationships to domestic cooking have been another area of study for masculinityand food researchers and provide insight into men’s food practices.  With few exceptions,household food provision and preparation have predominated as domestic female endeavours.Accordingly, men who are not professional chefs are often portrayed as inept in the domestickitchen.  Bumbling, incompetent and clumsy, ‘real’ men are not expected to care about food andcooking (Julier & Lindenfeld, 2005).  Finnish men embracing female perspectives on healthyeating tended to show masculine cooking perspectives, describing cooking as ‘women’s work’,and distancing themselves from ‘fancy’ or domestic cooking (Roos & Wandel, 2005).Alternatively, some social constructions of masculinity depict men as proficient homecooks, but only under certain circumstances.  Men as cooks are typically carefully portrayed asgourmands, whereby masculine cooking is reframed as clean, efficient and ‘urbane’ and anactive rejection of female domesticity (Hollows, 2002).  The social portrayal of women as cooksand men as chefs continues in the media where the construction of the masculine home cookrejects ‘regular’ cooking as female domestic labour and reframes it as a fun, leisure masculineactivity (Hollows, 2003).  Thus men’s cooking is decidedly different from domestic, everydaywomen’s cooking where men tend to cook less than women (Harnack, Story, Martinson,Neumark-Sztainer, & Stang, 1998).These widespread ideals of acceptable men’s cooking practices have tended to positionmen’s willingness to do domestic cooking as necessary for male autonomy and control.  Young43urban Canadian bachelors presented positive views regarding men’s involvement in cooking,believing it was important for their independence and self-sufficiency (Sellaeg & Chapman,2008).  Similarly men living in all-male environments of US urban firehouses demonstratedcooking prowess that they would not display at home because it was an expression ofcompetency at work.  In this environment, hyper-masculine language was used to separate theimportant work of cooking for other workingmen from feminized household food provision(Deutsch, 2005).  Likewise, Nordic men who adopted more typically feminine cooking roles athome revealed that they did not simply reject masculine ideals.  Rather, they redefined familyfood work as masculine projects or de-gendered that work as family food provision (Aarseth &Olsen, 2008).These findings reveal men’s perceptions of nutrition, healthy eating, household foodwork and provision and food choice as intricately connected to masculine ideals, and stronglyimplicated in men’s typically poorer diets compared to women.  Masculinities alone, however,are not solely responsible for shaping men’s actual food practices and gender relations, mostoften the interactions between men and the women in their lives, must also be considered despitethe lack of research in this area.Gender Relations and Men’s Food PracticesWhen considering many men’s food choice behaviours, the household context is a keyconsideration because most decisions about food occur within a family setting.  Domestic foodchoices are rarely singular events but complex evaluations that involve negotiating divergentfactors including likes and dislikes, deference and workload (Henson, Gregory, Hamilton, &Walker, 1998).  Because North American women tend to control family food provision (Harnacket al., 1998), contribute more to family dietary quality (Schafer, Schafer, Dunbar, & Keith, 1999)44and express goals for healthy family diets (Beagan, Chapman, D'Sylva, & Bassett, 2008), itmight be expected that men partnered with women would have healthy eating patterns.  The factthat the opposite is commonly observed might be due to traditional feminine ideals that womenprovide their husbands with the food their men prefer rather than healthy food.  This reflects theintricacy of heterosexual relationships, gender relations and the gendered expectations of foodprovision (Schofield et al., 2000).  Such expectations have implicit assumptions, unspoken anddeeply embedded in couple interactions (Beagan et al., 2008).  They can also be consistent withconcepts of masculine dominance and female subordination that influence women to defer totheir husbands’ wishes and preferences (DeVault, 1991).These relationships might change in the context of chronic illnesses, including prostatecancer.  For example, female partners have been reported to positively influence Swedish men’sdietary health behaviours (Kullberg, Aberg, Bjorklund, Ekblad, & Sidenvall, 2008).  Otherresearch, however, has shown the opposite effect whereby efforts of some US prostate cancersurvivors’ wives to encourage their husbands to improve their diets, increase exercise and reducesmoking resulted in negative behaviour changes (Helgeson, Novak, Lepore, & Eton, 2004).Masculinity and gender relations theory suggests that the men’s expression of masculineresistance to their wife’s health promotion beliefs and activities may have been a salientdeterminant and demonstrates how complex gender relations might influence men’s healthpractices (Schofield et al., 2000).  However, the links between performances of masculinity andfemininity in relation to men’s health and food practices are poorly understood and warrantfurther investigation (Lyons, 2009).45Older Men in Food ResearchTo date, most of the food behaviour literature has focused on men younger than thosetypically diagnosed with prostate cancer, and the research reviewed here represents the body ofliterature available.  I recognize that younger men might perform masculinity differently thanolder men, however, there is insufficient research in this area to empirically support thatconclusion.  Role changes, transitions or turning points such as retirement or health eventsincluding being diagnosed with cancer have the potential to alter older men’s perceptions of foodand their health behaviours (Devine, 2005; Oliffe, 2009).  Some studies have found that oldermen had positive perceptions about healthy eating; however, their knowledge of healthy eatingand lack of health literacy were barriers to diet change for Australian (Drummond & Smith,2006) and US men (Holmes & Gates, 2003).  These findings indicate that nutrition educationprograms might benefit from increasing men’s health decision-making literacy skills andknowledge.  One community-cooking program for Canadian men over age 75 found thatincreasing men’s cooking skills improved their healthy eating practices demonstrating that oldermen can learn to cook in a supportive group environment (Keller, Gibbs, Wong, Vanderkooy, &Hedley, 2004).Other research on older men has shown how masculinity interacts with age to affect foodchoice.  An American study assessing correlates of dietary behaviour from the health beliefmodel of behaviour change found that older men reported higher self-efficacy for diet changethan younger men.  The authors speculated this might be due to a reframing of masculinity inolder men and demonstrates how masculinities can shift with age improving men’s capacity formaking diet changes (Keith & Schafer, 1997).  Alternatively, a study of ‘frail’ older Americanmen (>75 years old and with mobility or daily living limitations) revealed a “pervasive need forthe maintenance of masculinity”, which prevented them from engaging in diet change.  Although46good nutrition was an important part of their survival and physical functioning, men distancedthemselves from food provision activities and framed knowledge and skills about healthy eatingas female responsibilities (Moss, Moss, Kilbride, & Rubinstein, 2007).  These findings illustratethe challenges that nutrition educators might have in engaging ill men in diet change, even ifthey are philosophically receptive to it.  Overall these findings demonstrate the complexities ofhow gender, age and disease intersect to influence food choice behaviour for men with prostatecancer and how a better understanding of older men’s perceptions about food and health isneeded.ConclusionsThis review confirms men’s self-health activities, including food choice behaviours, areshaped by dominant ideals of masculinity.  Although a plurality of masculinities exist, manydominant masculine ideals conflict with healthy eating practices resulting in men’s inadequatediets and poor health outcomes.  I argue that dominant ideals of masculinity can contribute tomen’s poorer prostate cancer outcomes by inhibiting their adoption of prostate-friendly dietrecommendations and should be thoughtfully addressed in advocating diet change.  There is littleevidence on how to improve men’s uptake of health services (Robertson, Douglas, Ludbrook,Reid, & van Teijlingen, 2008).  However, nutrition education or counselling programs designedfor men with prostate cancer would benefit from considering how gender relations andmasculinity both facilitate and block healthy eating.  There is currently no research on howmasculinity influences the uptake of prostate cancer nutrition interventions.  Qualitative researchis valuable in identifying men’s diet and health attitudes, beliefs and behaviours, and can informintervention development, which in turn can promote healthier eating.  Such studies could reveal47how social structures including age, class and race intersect with prostate cancer experiences toshape men’s performances of masculinity through their food practices.  This could provide anunderstanding of men’s perceptions about the role of diet in health and prostate cancer recoveryand how they experience diet and diet change.  Research similar to that conducted with Finnish(Roos & Wandel, 2005) or British (Gough & Conner, 2006) men could be conducted on menwith prostate cancer from different cultural groups to illuminate the role of multiplemasculinities in shaping men’s nutritional health.  Although female partners are acknowledged tobe important influences on men’s food practices there is little research in this area.  Anunderstanding of how men’s performances of masculinity are shaped by women’s performancesof femininity and how this is implicated in men’s food choices is lacking (Lyons, 2009).  Thusresearch on masculinity and hetero-normative food practices of men with prostate cancer iswarranted and should include female partners.  Other family structures should also be examinedincluding men who live alone or in same-sex relationships.  There are currently few studies onmasculinity influences on food practices of men, especially older men, and none specifically onmen with prostate cancer.The findings reviewed here offer several avenues for designing nutrition interventions formen with prostate cancer, and where appropriate their female partners, while consideringmasculinity influences on men’s food choices.  Changing men’s dietary perceptions can involvere-framing healthy eating as less feminine and/or more masculine.  Although no research in thisarea has been conducted, this review suggests that some foods might be given a ‘masculinemakeover’ by re-positioning healthy eating as expressions of masculine autonomy and self-control.  For example, encouraging men to eat prostate friendly foods including broccoli or soyproducts could be framed as a means to maintain fitness or health in order to foster autonomy48and self-management in the face of chronic illness.  Research on men who do engage in familyfood provision and healthy eating provides clues as to how masculinity can be reconstructed associetal norms shift over time and place.  This suggests that embracing ‘newer’ masculine idealsaround men’s involvement in family food provision or preparation might be more effective thanattempting to counteract traditional masculine ideals.  Here, for example, as Aarseth & Olsen,(2008) found, men’s food work could be framed as important and necessary aspects of ‘modern’male provision for the family.  As well, behaviour change within existing masculine ideals mightbe advanced by social marketing techniques to reach men in the places that they ordinarilycongregate (Courtenay, 2004) including prostate cancer support groups and urology clinics.Although masculinity has often been framed as a problem in men’s health, some characteristicfeatures can advance and/or be re-framed as health promoting (O'Brien, Hunt, & Hart, 2005;Sloan et al., 2009).  For example, mobilizing masculine ideals of strength, self-reliance andathletic prowess might advance men’s consumption of fruit, vegetables and low-fat healthy dietsas performance-based manly endeavours.Men with prostate cancer might also be more willing to change, but whether educatingthis target group or men in the general population, widespread and diverse discourses on foodchoice behaviour and masculinities and gender relations will need to be studied, compared andincorporated into program planning.  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Sex Roles, 54(9-10), 707-716.60CHAPTER 3.PROSTATE CANCER, MASCULINITY AND FOOD:RATIONALES FOR PERCEIVED DIET CHANGE2IntroductionProstate cancer survivorship and lifestyle issues have gained increased attention inWestern countries as more men are being diagnosed and living longer with the disease (Jemal,Siegel, Ward, Hao, Xu, & Thun, 2009).  The role of nutrition in prostate cancer prevention andrecovery has attracted interest in recent decades due to observations that typical Western eatingpatterns, high in meat and fat while low in fruit and vegetable consumption, are associated withhigh incidence and mortality (Sonn, Aronson, & Litwin, 2005).  Dietary modifications thatdecrease meat and fat intake and increase fruit and vegetable consumption can reduce prostatespecific antigen (PSA) markers of disease progression in some men with low-grade prostatecancer (Carmody, Olendzki, Reed, Andersen, & Rosenzweig, 2008; Nguyen, Major, Knott,Freeman, Downs, & Saxe, 2006; Ornish, Weidner, Fair, Marlin, Pettengill, Raisin et al., 2005).Although PSA testing is a crude measure of prostate cancer progression, emergent evidencesuggests that diet might be a valuable adjunct to conventional treatment(s) for some men withlow-grade disease.  Reviews of evidence for the protective and therapeutic nature of low-fatplant-based diets and controlling overweight and obesity to improve prostate cancer recovery arealso promising (Berkow, Barnard, Saxe, & Ankerberg-Nobis, 2007).  Although more definitivestudies are needed, many researchers and care providers have argued that the preliminaryevidence is compelling enough that these diet factors should be included in prostate cancer                                                  2 A version of this chapter has been published. Mróz, L.W., Chapman, G.E., Oliffe, J.L. and Bottorff, J.L. (2010)Prostate cancer, masculinity and food: Rationales for perceived diet change. Appetite, 55(3), 398-406.61nutrition care guidelines (Demark-Wahnefried, 2007).  As well, healthy eating recommendationshave been made for prostate cancer patients to prevent or manage common co-morbidities inolder men, such as cardiovascular disease and diabetes (Moyad, 2004).As a result of these recommendations and widespread media reports linking diet andprostate cancer management, men and their caregivers have become increasingly interested innutrition education and dietary modifications (Demark-Wahnefried, Peterson, McBride, Lipkus,& Clipp, 2000).  As uptake of screening increases and definitive treatments improve, the numberof men diagnosed with and surviving prostate cancer will increase.  This will further increasedemand for diet information and nutritional services.  Therefore health care providers need tomake accessible effective nutrition information and services to assist men with prostate cancer toimprove their diets.  Yet research reveals that few men diagnosed with prostate cancer actuallymake significant or long-lasting diet changes (Patterson, Neuhouser, Hedderson, Schwartz,Standish, & Bowen, 2003).  Additionally, some patients choose to sacrifice potential increases insurvival time rather than adopt healthier eating patterns (Hopfgarten, Adolfsson, Henningsohn,Onelov, & Steineck, 2006).  Together these observations point to the need to better understandhow men who have prostate cancer make food choices; such understandings are required toimprove the effectiveness of nutrition education or dietary counselling programs.Health behaviour theories attempt to explain why individuals make food choices byexamining complex interactions among various health determinants (Glanz, Rimer, & Lewis,2002).  Behavioural determinants of food choice have been conceptualized as individual(physiological, personal and behavioural) and collective (social, cultural, environmental andpolitical) (Furst, Connors, Bisogni, Sobal, & Falk, 1996; Raine, 2005; Wetter, Goldberg, King,Sigman-Grant, Baer, Crayton et al., 2001).  Although gender has been depicted as a health62determinant, the ways gender influences diet have not been fully explored in food choice models.Much of the research on gender and food has focused on household food provision and women’sfood choices (DeVault, 1991), but studies focused on gender and men's food choice processesare scarce.  One way gender may influence food choice is by shaping men’s food idealsincluding dietary understandings and healthy eating perceptions; however, little is known abouthow this might occur (Paquette, 2005).Masculinity theory provides a framework for better understanding men’s healthbehaviours, including their dietary knowledge, perceptions, attitudes and food practices.  Genderis conceptualized as socially constructed and performed through people’s daily activities andsocial interactions and thus men and women demonstrate masculinities or femininitiesrespectively by embodying and enacting idealized or hegemonic ‘manly’ or ‘womanly’ practices(Connell, 1995; Connell & Messerschmidt, 2005).  This can be problematic for men’s healthbecause many health promotion practices, including nutritional self-care, are perceived asfeminine and as a result men might signify their alignment to hegemonic masculinity by avoidingthese and engaging in less healthy ‘manly’ practices (Courtenay, 2000).  Few men fully embodyhegemonic masculinity and hence multiple masculinities emerge in and around masculine idealsand are shaped by social context (including culture, ethnicity, race, economics and/or sexualorientation).  Thus multiple, complex and sometimes contradictory, masculine health and foodideals are found in contemporary Western society.The few studies that have examined how social constructions of masculinity might beimplicated in men’s health and dietary behaviours have reported typical masculine ways ofdescribing food as fuel or a necessity to satisfy hunger and ensure bodily performance (Roos,Prattala, & Koski, 2001; Smart & Bisogni, 2001).  A minority of men expressed more feminine63diet evaluations such as caring about food and health; however food as health promotionremained framed as women’s concerns (Roos & Wandel, 2005; Sellaeg & Chapman, 2008).Cynicism about healthy eating messages and an overall perception of healthy food as inferior andunsatisfying are barriers to healthy eating for some men (Gough & Conner, 2006).  Additionally,some older men’s lack of concern about diet and health was attributed to low health-literacyskills, lack of interest in self-care and reliance on female partners for health care (Drummond &Smith, 2006).Much of this research has focused on healthy and younger men, although recently theimportance of maintaining masculine identity in older frail men was implicated in shaping theirself-care activities (Moss, Moss, Kilbride, & Rubinstein, 2007).  However, no published studieshave addressed men’s perceptions of food and health after a health crisis, and specifically in thecontext of prostate cancer.  Accordingly, the aim of this study was to describe men’s perceptionsof their diets and diet changes in response to their prostate cancer, and illuminate the reasonsunderpinning diet changes (or lack thereof) in their recovery and self-care.MethodsThe qualitative research design and methodology employed in this study was guided bygrounded theory methods, including concurrent data collection and analysis and the use ofinductive reasoning to generate theoretical explanations about the processes by which men makediet-related decisions (Strauss & Corbin, 1998).  The research utilizes a social constructivistperspective whereby people are understood to create meaning about the world through dynamicsocial processes.  In this sense knowledge and understandings about food, eating and health areconstructed through daily social interactions and reproduced through food practices.  Likewise,the product of interpretive research about people’s food perceptions and practices presented here64is understood to be co-created by researcher and participant as described by Charmaz (2006) inher approach to grounded theory methods.  Ethics committees approved all procedures andinstitutional ethical guidelines were followed (see Appendix 2 - ethics certificate).Study participants were recruited by distributing notices in a urology clinic in a westernCanadian hospital, prostate cancer support groups (PCSGs), and prostate cancer forums (seeAppendices 3 and 4 - recruitment materials).  Eligible participants had been diagnosed withprostate cancer for no longer than five years, were living in non-institutional settings withindependent household food provision, and were fluent in English.  The sample was primarily aconvenience sample, but when possible, purposive sampling was used to select participants froma variety of social backgrounds (e.g., different education levels and incomes), and prostatecancer experiences (e.g., different cancer grades and stages).  Concurrently, using theoreticalsampling, interview questions were adjusted as data collection progressed to explore thedimensions of emerging themes.  For example, I explored the domain ‘orientation towardsprostate cancer’ by seeking informants with differing cancer severity and by asking probingquestions about how they interpreted the nature of their cancer (e.g., as cured or managed) andhow this influenced their food perceptions and practices.  The final sample included 14 Anglo-Canadian men who lived with female partners and ranged in age from 48 to 78.  As shown inTable 3.1, most were retired, college educated and middle-class and had been diagnosed withlow-risk prostate cancer for which a variety of treatments were undertaken..65*RP = radical prostatectomy; EBT = external beam radiation;AS = active surveillance; ADT = androgen depravation therapy; BT = brachytherapy;HIFU = high intensity focused ultrasound**Estimated from Gleason and Stage scores when availableTable 3.1  Summary of participant characteristicsData CollectionData were collected through individual, private, semi-structured, in-depth interviewslasting 60 to 90 minutes.  Prior to interviews, participants provided informed consent and weregiven ‘food journal’ diaries to record eating events over one week (see Appendix 5 – consentform, Appendix 6 – interview guide, and Appendix 7 – food journal template).  Food journals areuseful in eliciting discussions about food choices and illuminating tacit diet understandings(Ristovski-Slijepcevic & Chapman, 2005; Sellaeg & Chapman, 2008).  Demographicinformation, disease characteristics and treatment histories were also collected (see Appendix 8 –CharacteristicFrequencyCharacteristicFrequencyAge (mean 66)Disease Risk (Self-reported)**  <50 1   Low8  50-592   Moderate3  60-696   High3  70-795 Months since DiagnosisWork Status  <12 4  Retired9   12-235  Part-time2   24-352  Full-time3   36-471Treatments*48-602 ADT & EBR3 Months since First Treatment ADT & RP3   <126 ADT & RP & EBR1   12-230  AS 3   24-351  AS (BT pending)1   36-471  HIFU1   48-602  RP 2   Untreated466demographic form) and field notes were taken (see Appendix 9 – field notes form).  Thecandidate (LWM) conducted all interviews in the men’s homes and was sensitive to and preparedfor the unique challenges facing researchers when interviewing male participants about healthand illness (Oliffe & Mróz, 2005).  The interviewer was a man in his 40s who presented himselfas a nutrition student, and as a competent, informed learner seeking the unique perceptions of theparticipants without judgment, rather than as a health or nutrition ‘expert’.  Interview questionsaddressed issues including beliefs about the role of diet in health and prostate cancer preventionand recovery, healthy eating understandings and practices, and the impact of prostate cancer ondiet.  Some questions were personalized, guided by individual entries from the participant’s foodjournal, which allowed for more detailed discussion about specific food choices.  Interviewswere digitally recorded, transcribed verbatim and checked by the interviewer for accuracy.  Inappreciation of participants’ contribution to the research, they were given a $30 honorarium.Data AnalysisInterview transcripts were conceptually coded by the interviewer, whereby emergentconcepts and themes were labelled with identifying codes (Charmaz, 2006).  This was doneusing Atlas/tiTM software, a program designed to facilitate organising, storing and retrieving data(Weitzman & Miles, 1995).  Employing constant comparison analysis, open codes were groupedunder descriptive abstract categories and emerging themes were defined in memos (Hallberg,2006).  Coding and analysis was discussed and developed at investigative team meetings (seeAppendix 10 – coding schedule example).  Through this iterative process major concepts andthemes were identified, summarized and compared to the interview data to ensure theoreticalaccuracy.  As data collection and analysis proceeded, theoretical sampling techniques were usedto ensure that information obtained from the participants afforded rich descriptions of emergent67themes (Strauss & Corbin, 1998).  Trustworthiness was enhanced through data triangulation(interviews, food journals and field notes).ResultsThe themes that emerged regarding participants’ understandings of diet, health, self-careand the role of diet in prostate cancer care underpin each participant’s personal rationale forchanging or not changing his diet on an on-going basis after diagnosis.  Participants describedvarious dietary patterns, which reflected these understandings and represented varied degrees ofperceived diet change (or lack thereof).  This is illustrated in the ‘Constructing rationales forperceived diet change’ framework (see Figure 3.1).Figure 3.1  Constructing Rationales for Perceived Diet Change.Perception of Pre-Prostate Cancer DietDiet Change ContinuumEating as Usual  Intensifying efforts          Overhauling Diet(No changes)      & Adding-on     (Major changes)Diet & HealthUnderstandingsNeed for “DoingSomething”Orientation TowardsProstate Cancer68In this model diet change is conceptualized as existing along a ‘diet change continuum,’ranging from no changes to major changes, that forms the core of the framework.  Although afew men reported making no significant or on-going changes and were ‘eating as usual’ at thetime of their interview, most participants described making minor diet changes (labelled‘intensifying efforts’ and/or ‘adding on’) and several men described making major changes(labelled ‘overhauling diets’).  Participants were grouped in distinct clusters along the dietchange continuum but their reported diet behaviour was variable and sometimes overlappedclusters.  However, analysis of the explanations men provided for their food choices revealedfour main domains that best informed diet cluster patterns.  These were grouped under theoverarching theme ‘constructing rationales for perceived diet change’ and labelled: a) perceptionof pre-prostate cancer diet, b) diet and health understandings, c) orientation towards prostatecancer, and d) need for ‘doing something’ about their cancer.  Each domain had a range ofdimensions, and domains were evaluated and combined in complex ways by the men.  Thefollowing describes each diet pattern cluster and how participants’ narratives reflected these fourdomains differently in their constructions of rationales for their diet pattern and perceived dietchanges or lack thereof.  Illustrative quotes are identified with participant labels numbered fromP1 to P14.  Specific participants’ characteristics including age, disease risk or treatment did notappear to inform observed dietary patterns.Eating as Usual: No Diet ChangeThree men reported having made no changes or minor, temporary diet changes and at thetime of interview were eating as they had before their prostate cancer diagnoses.a) Perception of pre-prostate cancer diet: “Already had a healthy diet.” The menwho were ‘eating as usual’ perceived they already had a healthy diet before they were diagnosed,69and because eating healthily had not prevented their prostate cancer, it was thought to beunimportant in their recovery.  One man commented that “I’ve always eaten healthily and I willcontinue to eat healthily but I’m not expecting it to cure cancer” (P2).  Another participant madea similar comment, saying: “I’m eating the way I always ate... All the stuff that’s supposed tokeep you from getting prostate cancer, I can’t eat enough of that stuff…. I guess I’d just eat theway I was” (P7).b) Diet and health understandings: Diet does not affect prostate cancer recovery.Although participants acknowledged the importance of diet in general health, these men did notbelieve that diet change could influence their prostate cancer because of its idiopathic nature.  Asone man said, “It’s not a disease that once you’ve got it diet’s going to do much for you” (P2).They discounted scientific evidence connecting diet with prostate cancer and believed dietchange was unlikely to assist them in their recovery or survival.  As one man asserted, when itcame to diet “there’s no data on prostate cancer, there’s absolutely no reliable information aboutwhat works and what doesn’t” (P6).  Another man elaborated that although nutrition expertsmight have some evidence, he mistrusted them and resisted diet changes.Oh, I don’t think the evidence is in.  I mean I’m not saying that they don’t haveevidence that certain foods are good ... I’m not saying that they don’t know that,but I don’t believe it.  I mean I think that so called cures occur occasionally forreasons, which people don’t really understand, and food I don’t think has much todo with it.  (P2)c) Orientation towards prostate cancer: “Won the war”.  Positioning themselves ashaving effectively managed their prostate cancer through biomedical treatments permitted thesemen to continue ‘eating as usual’ or as one participant suggested about diet “you might as wellgo out and do what you want” (P2).  This participant further refuted the need for diet change70quipping that the benign nature and slow growth of prostate cancer would probably result in himdying of something other than prostate cancer.Another man made a few minor diet changes during medical treatments but in presuminghe was cured he abandoned them after treatments were completed.  Returning to pre-cancereating habits marked his return to a normal life and re-engagement with physical activities,having ‘won the fight’ against cancer.  His use of a war and victory metaphor to describe histreatment(s) revealed the bracketing of his prostate cancer and a desire to erase the treatmentchallenges and focus on the hard-fought win: “I took the all out war approach to cancer and itlooks like we won and so now we have peace and I’m not going to make my life unpleasant”(P6).  Returning to pre-cancer eating patterns designed primarily for weight control as part of hisathletic training and performance marked prostate cancer as a challenging but transitory timenow passed.d) Need for doing something: Already doing enough.  Only one man in this groupexpressed a need for ‘doing something’ about his prostate cancer during his “all out warapproach” (P6); however that need ended with his treatments.  ‘Eating as usual’ was moreimportant to him than eating for prostate cancer in maintaining a normal life after he haddetermined that the war was over.  Likewise for the other men who were ‘eating as usual’,undergoing conventional treatments and maintaining their previously healthy diets and lifestylessatisfied their need to be doing something, because they decided that they were already doingenough about their cancer.‘Intensifying Efforts’ and/or ‘Adding-on’: Minor Diet ChangeMost participants made minor diet changes in response to prostate cancer and weregrouped together as ‘intensifying efforts’ in healthy eating and/or ‘adding-on’ to their usual diets.71The most common changes were ‘adding-on’ natural health products including lycopene,nutritional supplements including selenium, and ‘prostate friendly’ foods including soy products,tomatoes or broccoli, to their regular diets.  Alternatively, ‘intensifying efforts’ were general,modest, healthy eating improvements including eating more vegetables and less red meat.Changes were typically viewed as minor, easily made and complementing their previously heldhealthy eating knowledge and beliefs.  Most changes were integrated as part of broader healthimprovements and described in vague, general terms that signified eating more healthily such as“eating more carefully,” “being stricter about diet” and “paying more attention to diet”.  Becausemost men who engaged in ‘adding-on’ to their diets also began ‘intensifying efforts’ thesepatterns are subsequently discussed together.a) Perception of pre-prostate cancer diet: Healthy, but could ‘do better’. Similar tothose ‘eating as usual’, many participants in this group perceived they already had healthy dietsbefore their diagnoses and that major changes were not warranted.  However, they differed byconceding that their diets needed some improvement and used this as impetus for minor changes.They framed diet changes as a personal responsibility or something that they ‘should’ do toimprove their health.  For example, one man explained, “I’ve always had a good diet but I’ve gotto be more strict about it since the prostate thing” (P8).  Learning about prostate-healthy eatingconfirmed another man’s previously held beliefs about diet and his desire to “just be consciousabout what I eat” (P5). ‘Adding on’ and ‘intensifying efforts’ were both parts of his recoveryplan:72I’m just doing things a little bit more intensely, and maybe varying orsupplementing what I used to eat with things such as blueberries and sardines andfish.  That’s really I think the only, the best way to say it is that I’m intensifying,always trying on a healthy diet, but now I’m just doing it a little bit moreintensely and more consciously. (P5)b) Diet and health understandings: Diet might affect prostate cancer.  Confident ofdiet’s role in good health, participants in this group eagerly recounted prostate-specific dietdiscourses heard from support groups, public forums and the media.  Some asserted that specificfoods and supplements might suppress prostate cancer, and potentially be more effective thantraditional medicine.  One man snacked on walnuts and almonds believing they were “more anti-cancer fighting” than peanuts and “the more you can get into that, I think it’s far better for youthan all the medicine they can ever shove into you” (P4).  Others began taking supplements andeating certain vegetables because of hearing that they were beneficial for prostate cancer.  Thiswas often coupled with reducing red-meat because they had heard that excessive meatconsumption was harmful for men with prostate cancer.Despite these diet changes, participants subsequently revealed uncertainty about thetherapeutic value, seemingly contradicting some previously stated beliefs.  For example severalmen drank soymilk for its curative properties but admitted they were unsure it was effective.Despite hoping that diet change might help, most participants in this group admitted they did notfully understand potential connections between diet and prostate cancer.  They cited anecdotalevidence about prostate friendly supplements and foods and, although uncertain, expressed “ohwell, maybe try that” (P9) as long as it wasn’t too expensive, difficult to prepare or find, orpotentially harmful.  When asked if they thought diet change might directly help with prostatecancer recovery a common response was “I don’t know but I’m going to try” (P5).  Uncertainty73about dietary influence on cancer was juxtaposed with an acceptance that diet influences otherhealth concerns including heart disease, diabetes or high cholesterol.  One man grappled withdifferentiating how diet connected with various diseases, but remained certain that the prostategland was less directly affected:I think diet is important.  Yeah, somehow or other there’s something that impactson your system.  Your cholesterol in particular, I’m sure diet impacts on that.  Ican’t say about the prostate though.  You know, it’s basically just sitting there.  Idon’t think it gets any, you know, nutrition.  I mean obviously it does or else itwouldn’t be still kicking but I can’t think of any nutrition in particular that wouldhelp it.  (P9)Changes initially made to fight prostate cancer were ultimately framed as worthwhilebecause they were beneficial for general health, and there was still a possibility that they wouldprovide a “better shot” at prostate cancer recovery.  Although participants revealed uncertaintyregarding the impact of diet on prostate cancer, they were willing to consider scientific evidencefor potential benefits, even if they remained unconvinced of its efficacy.c) Orientation towards prostate cancer:  Living with prostate cancer.  As participantsadapted to living with prostate cancer, these men positioned cancer as a chronic condition.  Thiswas reflected in how they incorporated diet change into their daily lives as part of coping withhaving prostate cancer.  Despite concluding he was cured of prostate cancer after his radicalprostatectomy, one man hoped minor diet changes would benefit his general health and recovery.His desire for a good retirement included eating for pleasure; however, the constant threat ofrecurrence kept him attentive to his diet and he was prepared to intensify his diet change effortsin the future if needed:74I’m not there trying to increase my chances of surviving prostate cancer because Ithink that’s pretty well been taken care of, if it turns out that there’s a PSA showsup well then I’ll probably get a little excited again and then go on, figure out whatto do.  But then I’ll probably start learning a lot more about fine-tuning my diet orwhatever, but mostly we’re now kind of sort of general health …we’d like to havea good retirement. (P14)The fear of progression or recurrence expressed by many men was part of the uncertaintyinherent to living with prostate cancer.  This was mediated by the hope that diet change couldassist their long-term survival, as cancer became part of their daily lives.d) Need for doing something: Doing something to help. Despite their uncertaintyabout how diet might influence prostate cancer recovery, healthy eating changes were framed asa personal way of ‘doing something’ to help themselves.  These men presented themselves asautonomous, capable of change and in control: “I figure, if I can do anything to help myself I’lldo it, and if it’s intensifying my diet, I’m going to do that” (P5).Diet change offered participants an opportunity to self-manage the uncertainties of livingwith prostate cancer.  This was framed as a desire to help themselves by improving their healthand helping them cope with cancer.  One man described how making diet changes was anobvious and perhaps default position because “what else can you do, you know, I can sweep thedeck [but] it ain’t going to fix my prostate cancer” (P8).  Diet, exercise and a positive attitudewere important parts of his self-care and helped him live with the uncertainties of having cancerby doing something to ensure his well-being.There were limits to the amount of effort men in this group were willing to make to ‘dosomething’ in relation to diet to aid their recovery.  Most men initiated and maintained minordiet changes as long as they were convenient, non-disruptive and affordable.  As such, thesemen’s changes were framed as feasible, sustainable and not requiring major shifts in eating75habits and beliefs, and were consistent with existing long-term and ongoing changes andprevious patterns of self-care.Overhauling Diet: Major Diet ChangeFour men perceived making comprehensive diet changes after being diagnosed withprostate cancer and began ‘overhauling’ their diets.  The changes described included becomingvegetarian, eating organic and whole foods, increasing consumption of what they consideredhealthy foods including vegetables and decreasing consumption of unhealthy foods includingprocessed or fast foods, and following popular diet trends including the Pritikin diet or pHbalanced eating.a) Perception of pre-prostate cancer diet: Diet needs radical change.  Participants inthis group differed from those who made no changes or minor changes, by perceiving their dietsas deficient and in need of radical change to aid their recovery and healing.  This involved re-evaluating previous dietary beliefs and habits and (re)engaging in self-care.  One man talkedabout the importance of not hindering healing by eating what he perceived to be unhealthy foodsand described a moment of self-discovery as he committed to cutting out unhealthy foods toassist his healing from treatment as well as recovery from prostate cancer.  “Now that I’vefinished my prostate treatment, it’s like okay, now we’re going to get smart about what we’redoing about diet to be sure that we don’t adversely influence the healing by something we’reeating.” (P1).  He further acknowledged that eating healthy foods as a means to maintaininghealth was considerably more important than eating for pleasure since his diagnosis with prostatecancer.  Another participant emphasized how important and extreme his dietary beliefs and foodchoice modifications were by exclaiming, “If you said to me a year ago, ‘It’s a better idea to eatorganic’, then I would have told you to go to hell!” (P11).76b) Diet and health understandings:  Diet affects health.  Although these diet changesmight have been precipitated by their prostate cancer diagnosis, they were framed as moreimportant for general health rather than specifically for prostate cancer.  One man described howhis diet improvements were intended to increase his overall health and survival: “I want to live alonger life and I want to live it well in the absence of disease.  And diet is one of the few things Ican do that would help” (P1).  Although some changes were designed specifically for prostatecancer, the men didn’t abstract them from general health but rather described how general healthimprovements might aid their cancer recovery.  The youngest participant, a 48-year-old man onactive surveillance, enthusiastically described his self-health activities and was hopeful thatchanges to his diet and lifestyle would enhance his immune system, help manage his cancer andincrease his chances of avoiding treatment:So what I’ve tried to do is a combination of the recommendations for diet orspecifically for prostate cancer and some are just for cancer in general.  And someof it just has to do with the fact that it’s supposed to help your immune system, tomake it better because there’s a belief … that if your immune system is in tiptopshape then you can beat cancer just like you can heal from anything else. (P3)Most of the general diet changes were designed to help participants avoid or combat otherillnesses, live longer and have generally healthier lives.c) Orientation towards prostate cancer: “That was then, this is now”.  Whetherparticipants developed new understandings of the role of diet in health, or returned to previouslyheld healthy-eating beliefs, ‘overhauling diet’ represented increased engagement with self-carethat the men perceived as significantly changing their eating behaviours.  Although participantsmight have missed some aspects of their old diets including eating more meat or fast food, theyoften minimized this.  They perceived having prostate cancer as a turning point in their lives, and77their diet changes as marking a new way of life.  When asked if he was happy with his newvegetarian diet, one participant replied: “Absolutely, yeah, yeah, I’ve got no complaints.  Thequestion I continually get asked is ‘Well gee don’t you just miss that great big fat steak?’ Orwhatever the case may be. Nah, under the circumstances that was then and this is now … no, Idon’t” (P10).  These men were devoted to healthier diets and planned on maintaining themindefinitely.  This represented a lifelong commitment to healthy eating that extended beyondprostate cancer to encompass general health.d) Need for doing something: “Taking custody” of health.  Like other men who madediet changes, ‘overhauling diet’ became a way of ‘doing something’ for self-health or as one manexplained, having a healthy diet was “my way of being able to take some custody over the issuesthat I’m confronted with” (P10).  ‘Overhauling diet’ was framed as a major and vital endeavourthat could enhance recovery from prostate cancer and treatment-induced morbidities.  One mandescribed how he eliminated fast, processed and junk foods, which had been major parts of hisdiet and began choosing foods on the basis of their alkalizing effect on his body pH.  Althoughonerous and requiring much attention, he considered this vital to his survival and when asked ifthese changes were difficult to maintain replied emphatically:Well, no, because you’ve got two choices - to live or die, okay?!  To be healthy orto be unhealthy.  So like I’m a very - if I make my mind up, that’s what’s going tohappen, come hell or high water.  I get on that case and I stay on that case. (P11)In addition to nutritional health, these diet changes were also perceived as importantpsychological boosts to the men’s self-care:78Because the mind-body connection is really important.  Being positive about yourtreatment and etcetera, etcetera has a huge influence on how well your healing isgoing to take place.  So having something, knowing that you have something youcan do can have a big influence, I think.  (P1)DiscussionFindings drawn from this data add to a growing body of knowledge about food choiceand diet change processes by describing a diet change model specifically addressing theexperiences of men with prostate cancer.  Several other models have presented overviews offood choice processes for healthy adults (Falk, Bisogni, & Sobal, 1996; Furst et al., 1996; Sobal& Bisogni, 2009; Wetter et al., 2001) and diet change processes for adults faced with diet-relatedhealth crises (Falk, Bisogni, & Sobal, 2000; Janas & Bisogni, 1993); the ‘Constructing rationalesfor perceived diet change’ model presented here complements and expands these by focusingspecifically on men’s food choices and how prostate cancer influences their dietary decisionmaking.The Cornell food choice research group (Furst et al., 1996; Sobal & Bisogni, 2009)conceptualized food choice as a complex process whereby life course influences shapes aperson’s personal food system, which in turn helps them develop strategies to guide individualfood choice events.  Comprehensive and broad in scope, this model provides a useful frameworkfor conceptualizing food choice processes of distinct groups of adults.  The study findings detailhow food ideals and understandings of health and nutrition were important influences on men’sfood choices, and in a similar vein to Falk et al. (1996) and Sellaeg & Chapman (2008) I wasable to locate a discrete sub-population using this food choice model.Although popular and professional discourses about general benefits of diet change exist,there is a lack of standard dietary guidelines for men with prostate cancer.  In the absence of79medical certainty, men interested in diet must therefore interpret and evaluate multiple dietarydiscourses as they contemplate their diets and potential diet changes.  Consequently, this allowedme to examine the process study participants went through as they considered the possibility andnecessity of diet change, and the nature and degree of any changes they were willing to make.Other diet change models have focused on people experiencing diet-related health crises,but who had already decided to change their diets and enrolled in diet change programs.  Thesemodels consequently described how, but not why, diet changes were created, managed andmaintained by participants.  One such model described the ‘game plans’ thathypercholesterolemic adults constructed to help them achieve their dietary goals to lower theircholesterol (Janas & Bisogni, 1993).  Likewise the stages of change health behaviour frameworkwas used to create a model that described the stages that participants in an intensive heartrehabilitation program went through as they attempted diet change (Falk et al., 2000).Participants in both of these studies differed from the current study because they were alreadycommitted to changing their diets and believed that such changes would reduce their disease risk.Consequently, the processes and rationales that they used to justify diet changes were notexplored and rationales justifying not changing diets were excluded since only people whochanged their diets were included in these studies.Study findings reported here show that diet change decision making for men withprostate cancer is a complex process.  Involved were multiple considerations, which were used toconstruct rationales for not changing or changing their diet and if warranted, to determine howany changes would be made.  These considerations included participants’ pre-cancer dietperceptions, diet and health understandings, orientation towards prostate cancer, and their needto ‘do something’ for self-care.  These considerations can be interpreted in view of recent80knowledge developments in the role of masculinity in men’s health behaviours, which are oftenin stark contrast to women’s health behaviours (Courtenay, 2000).  For example, the currentfindings contrasted with those from a study on breast cancer survivors, which showed thatalthough women’s perspectives on healthy eating were related to their beliefs about relationshipsbetween diet and breast cancer (Chapman & Beagan, 2003), whether or not women changed theirdiets after breast cancer did not consistently relate to these beliefs (Beagan & Chapman, 2004).Unlike the men in the current study, these women did not rationalize their dietary (in)actionswith cognitive beliefs.  Instead, they described intricate considerations of their social, cultural,and economic context.  These social, relational and contextual issues were not salientconsiderations for men in the current study, which suggests that gender influenced the men’srationales for diet change.  This reflects individualistic and autonomous characteristics ofmasculinity, as well as the more self-controlled or pragmatic approach characteristic of men withregards to food (Roos & Wandel, 2005; Smart & Bisogni, 2001).Study findings demonstrate how gender is implicated in constructing rationales for dietchange (or lack thereof) through men’s perceptions of relationships between food, health andprostate cancer.  Varying perceptions and practices around diet, health, prostate cancer and self-care shaped participants’ dietary habits, to reveal distinct dietary patterns.  Differences in thesepatterns illustrate the complex and sometimes contradictory meanings of eating for men as theyexperienced prostate cancer.  How participants aligned themselves with masculine dietary idealswas a salient contributor to the nature and degree of their diet changes, reflecting re-framedmasculine ideals around diet and self-care and demonstrating the plurality of masculinities(Connell, 1995) implicated in how men ‘do’ diet.81All study participants demonstrated an interest and knowledge of healthy eating, whichcontrasts with traditional masculine lack of concern over diet and health promotion (Courtenay,2000).  They also articulated confidence in the importance of healthy eating for general healthand well-being; however, each expressed uncertainty about the role of diet in prostate cancerrecovery, regardless of perceived diet changes made (or lack thereof).  This positioning reflectscontradictory public discourses about the inconclusive evidence around diet, prostate cancer andsurvival rates (Dennis, Snetselaar, Smith, Stewart, & Robbins, 2004; Simon, 2005), conflicting‘best evidence’ interim dietary guidelines (Moyad, 2006a, 2006b) and calls for more researchbefore making specific prostate cancer diet recommendations (Meyer & Gillatt, 2002; VanPatten, de Boer, & Tomlinson Guns, 2008).  Likewise, their uncertainty also reveals masculineautonomy and reflects men’s disconnections from food preparation, diet and perhaps self-health,all of which limited some participants’ interest in diet change activities.  Despite this uncertaintysome men made diet changes, the nature and degree of which depending on their pre-prostatecancer diet perceptions, orientation towards prostate cancer and need for ‘doing something’ forself-care.Men who continued ‘eating as usual’ perceived their pre-prostate cancer diets as alreadyhealthy enough and therefore dismissed the need for diet change.  Despite an interest in healthyeating, these men drew on other traditional masculine ideals of rational self-management relatedto their diet and health understandings, orientation towards prostate cancer and lack of need for‘doing something’.  They cited a lack of evidence concerning the efficacy of diet changes forprostate cancer survival, which prevented them from considering diet changes.  Linkagesbetween diet and prostate cancer were consequently positioned by participants as tentative andfragile, and strong scepticism and cynicism emerged, similar to that identified in a study of82British men (Gough & Conner, 2006).  Eating as usual and the lack of need for ‘doingsomething’ was also positioned as an informed and rational choice closely linked to participants’perceptions of having ‘won the war’ against prostate cancer and a desire to return to a normallife.  Similarly, a study of men undertaking active surveillance for prostate cancer revealed men’spropensity for  ‘living a normal life’ as a means to avoid further stress (Oliffe, Davison, Pickles,& Mroz, 2009).  The desire to return to a pre-cancer lifestyle (including diet) might explain whymany men who experience prostate cancer resist long-term diet changes (Patterson et al., 2003)or are willing to sacrifice potential increased survival time rather than change their diet(Hopfgarten et al., 2006).In contrast, the other study participants engaged in varying degrees of diet change thatdemonstrated varying alignment to dominant masculine ideals and the complexity andcontradictions found in food related masculinities.  Similar to men who did not change theirdiets, participants who made minor changes perceived their diets as already healthy and werealso uncertain if diet changes could directly influence prostate cancer recovery, despite perceivedgeneral health benefits.  However, they differed by managing their uncertainty by positioningtheir prostate cancer as a chronic condition requiring ongoing management and thereforeexpressing a need to ‘do something’ about it.  They confided that they “should” improve theirdiets revealing both a need to ‘do something’ more for their recovery and a perceived moralresponsibility for healthier eating.  The ‘should syndrome’ is used to describe tension createdwhen someone’s beliefs about healthy eating do not correspond with their actual, but lesshealthy, practices (Paisley, Sheeshka, & Daly, 2001).  This tension is exacerbated by thecontradictions between masculine norms and personal practices that emphasize healthy diets.Using Robertson’s (2007) schema this equates to a ‘don’t care/should care’ dichotomy whereby83the men struggle with masculine ideals, which expect a ‘don’t care’ attitude about what men eat.The ‘don’t care’ ideals disrupt the ‘healthy citizen’ ideals embedded in men’s health promotion(Robertson, 2007).  Participants resolved these competing and somewhat contradictory positionsby making minor diet changes, suggesting some reformulation of masculine ideals to both enableand limit healthy eating.  This positioning was reinforced by participants’ perceptions of theirprostate cancer as a chronic condition, which required minor but ongoing management.  Thestudy findings support and extend the work of Sloan, Gough, & Conner (2009) who similarlyfound that healthy men framed their concern for and investment in self-health activities asaction-oriented and autonomous, and therefore, distinctly different to ‘feminine’ concerns abouthealth.In contrast to ‘intensifying efforts,’ the minor diet change practice of ‘adding-on’ wasframed as therapeutic, a form of complementary and alternative medicine (CAM) to maximiserecovery.  Taking nutritional or natural health supplements was acceptable because it was aconvenient form of insurance disengaged from domestic eating.  An autonomous and perhapspragmatic practice that was also disconnected from feminine ideals as an action-orientedmasculine activity, CAM usage for men with cancer has previously been described as a type ofhopeful insurance used to fight cancer and prolong life, an action-oriented and pragmaticmasculine approach that, similar to diet changes found in this study, did not require completebelief in its efficacy (Evans, Shaw, Sharp, Thompson, Falk, Turton et al., 2007).Several participants perceived their diets as requiring radical improvement and despitetheir uncertainty of its efficacy, strongly believed in the importance of healthy eating andengaged in major changes of ‘overhauling diet’.  These men positioned prostate cancer as animportant turning point (Devine, 2005) in their lives, which required significant self-84management as part of coping with cancer.  Their strong desire for ‘doing something’ about theircancer to improve their health and survival influenced the extent of subsequent changes.  Suchmajor changes including adopting vegetarian diets would be necessary to match diets shown toreduce markers of prostate cancer progression in recent diet trial studies (Ornish et al., 2005) andwould probably require major shifts in dietary beliefs and practices for most men.  Similaradoption of significant self-care activities was previously identified as an opportunity for somemen to manage the uncertainty of having untreated prostate cancer (Bailey, Wallace, & Mishel,2007; Oliffe et al., 2009).  The concern and urgency participants expressed about their cancerpermitted men to justify adopting dramatic self-care activities as their personal responsibility andbest operating under their control.  Participants framed diet change activities as important,masculine, action-oriented and autonomous endeavours, which suggested that they reformulatedmasculine ideals to position diet change as the wise and rational choice.Strengths and LimitationsThe small number and demographic homogeneity of the participants in this qualitativestudy limits the transferability of findings.  Most participants were Caucasian, middle class, welleducated and attended PCSGs.  All participants were self-selected and therefore may have beenmore interested in discussing diet, health and prostate cancer than most men.  Despite this, avariety of ages, treatments and differing grades and stages of prostate cancer provided somediversity in the men’s experiences.  This permitted a deep understanding of participants’perceptions around diet and prostate cancer and allowed me to reach data saturation for thissmall group.However, future research might assess the diet and health understandings of men fromother socio-demographic groups and from men who do not attend PCSGs.  As well, longitudinal85studies that incorporate objective measures of dietary intake would allow for comparison withmen’s subjective assessments of their diets.  Researchers could also assess relationships betweenparticipant characteristics such as age, disease risk or treatment type and diet change response.I also acknowledge that the research context might have influenced these findings andthat participants might have talked differently about health and eating to me as a ‘nutritionstudent’ than to other interviewers.  However the men were eager to relay their opinions,perceptions and knowledge about nutrition and food and appeared to use the interview as anopportunity to express their agreement or disagreement with current nutrition discourses, confirmtheir eating practices as healthy or to seek nutrition advice.  All of the participants expressedgenuine interest in presenting their personal accounts of their dietary understandings and foodpractices with comfort and ease.  This was recorded in field notes, which described participants’non-verbal signals indicating their degree of comfort.  For example a typical observation wasthat men appeared relaxed and assumed comfortable seating positions and typically smiled andlaughed while speaking with enthusiasm.ConclusionsThe diet change model for men with prostate cancer presented in this chapter expandsexisting food choice models by exploring men’s perceptions of diet in the context of a significanthealth event and through a gender lens.  Study findings also provide directions for ways in whichdietary interventions might be developed for men with prostate cancer by considering theirvarying perceptions of diet, health, prostate cancer recovery and need for self-care.  Findingssuggest informed discussion of the healthfulness of current and previous diets is an importantaspect of counselling men with prostate cancer.  Given men’s uncertainty about the evidencerelating diet and prostate cancer in contrast to their acceptance to other diet-health connections,86diet change promotion in prostate cancer care should target overall health rather than prostatehealth (Jayachandran & Freedland, 2008).  Because many diet changes that are prostate friendlyare also heart healthy, they might be promoted as best practice models (Moyad, 2004).Motivational messages for diet change might be needed for some men, rather than (or prior to)‘how-to’ action-oriented dietary advice.  Being diagnosed with prostate cancer has beenproposed as a teachable moment for evaluating dietary practices and, if necessary, making dietchange (Demark-Wahnefried, Aziz, Rowland, & Pinto, 2005).  This might benefit from anunderstanding of men’s orientation towards their prostate cancer and if they express a need to‘do something’ more or different around diet for their self-care.  Positioning diet change as aform of adaptive coping and important, action-oriented and autonomous enterprise would bestmobilize men’s masculine ideals to take up prostate cancer protective diets.87ReferencesBailey, D. E., Wallace, M., & Mishel, M. H. (2007). Watching, waiting and uncertainty inprostate cancer. Journal of Clinical Nursing, 16(4), 734-741.Beagan, B. L., & Chapman, G. E. (2004). Eating after breast cancer: Influences on women'sactions. Journal of Nutrition Education and Behavior, 36(4), 181-188.Berkow, S. E., Barnard, N. D., Saxe, G. A., & Ankerberg-Nobis, T. (2007). 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C., Sigman-Grant, M., Baer, R., Crayton, E., et al.(2001). How and why do individuals make food and physical activity choices? NutritionReviews, 59(3), S11-S20.92CHAPTER 4.GENDER RELATIONS, PROSTATE CANCER AND DIET: RE-INSCRIBING HETERO-NORMATIVE FOOD PRACTICES3IntroductionDiet might influence the growth of low-risk prostate cancer and could be a valuableadjunct to patient care (Ornish, Magbanua, Weidner, Weinberg, Kemp, Green et al., 2008; Saxe,Major, Nguyen, Freeman, Downs, & Salem, 2006); however, men do not typically change theirdiets following diagnosis (Blanchard, Courneya, & Stein, 2008).  This might partly reflect men’slack of interest in self-care and typically poorer diets compared to women (Wardle, Haase,Steptoe, Nillapun, Jonwutiwes, & Bellisle, 2004).  Health behaviours like diet change arecomplex and shaped by multiple determinants including gender, and an emergent body ofresearch has described how masculinities shape men’s health practices (Gough, 2006).Masculinity theory (Connell, 1995) offers a framework for conceptualising howadherence to dominant masculine ideals might shape men’s health and food practices(Courtenay, 2000); however, the roles that men’s female partners play are poorly understood.Food choice is shaped by social relationships and women often take diet leadership roles(Schafer, Schafer, Dunbar, & Keith, 1999).  This is especially salient to heterosexual men whooften rely on female partners for nutrition and primary health care, and in the context of prostatecancer these practices are normalised as a key part of what is often referred to as a ‘couples’disease (Gray, Fitch, Phillips, Labrecque, & Fergus, 2000).                                                  3 A version of this chapter has been submitted for publication. Mróz, L.W., Chapman, G.E., Oliffe, J.L. and Bottorff,J.L. (2010) Gender relations, prostate cancer and diet: Re-inscribing hetero-normative food practices93Complex gender interactions between men and women contribute to men’s healthpractices and explicit use of gender-relations frameworks are key to unravelling these linkages(Schofield, Connell, Walker, Wood, & Butland, 2000).  In the context of prostate cancer, agender-relations approach can illuminate how gender and diet are negotiated and co-constructedby couples.  These analyses afford insights to how couples’ performances of masculinity andfemininity interact to shape men’s diets and nutritional health.  In this chapter the genderrelations framework outlined below was used to examine how interactions between men andwomen shape the food practices of men who experience prostate cancer.Background: Masculinity, Femininity and Men’s HealthMen in Western countries are more likely than women to suffer and die from manyleading causes of death (Dodson, 2007).  These health disparities are attributed in part to men’spoor health behaviours, including poor uptake of health promotion messages, avoiding helpseeking and engaging in risky behaviours.  In men’s health studies, hegemonic masculinity andthe plurality of masculinities emerge and illuminate health disparities within and between menand women from a social constructionist perspective whereby gender is produced andreproduced through daily practices.  Hegemonic masculinity is defined as having specificcharacteristics including self-reliance and stoicism as well as power differentials in whichwomen and some men are subordinate.  Men’s behaviours as masculine performances can alsobe constructed in opposition to what women ordinarily do.  Embedded here is male privilege andpatriarchal power yet men might ‘pay’ for this power by experiencing ill health (Connell, 1995).Masculinity is implicated in men’s experiences with prostate cancer, and men have often beenforced to reformulate their masculine ideals as a result of losses (e.g., impotence andincontinence) invoked by prostate cancer and its treatments (Oliffe, 2005).  Men might cope with94such challenges by bolstering other aspects of their masculine identity including ideals of controland self-reliance as compensatory measures (Oliffe, Davison, Pickles, & Mroz, 2009).There is, however, significant variation in how men experience and express masculinity.Hegemonic masculinity ascends as a set of dominant ideals and practices supported by multiplealternative masculinities and shaped by social context.  Although few men embody hegemonicmasculinity, most are complicit in maintaining this hierarchy (Connell & Messerschmidt, 2005).Femininity is positioned as opposing and subordinate to masculinity and many women areguided by dominant feminine ideals or ‘emphasised’ femininity as a counterpart or complementto hegemonic masculinity (Howson, 2006).  Just as men usually perform alternative rather thanhegemonic masculinities, most women perform alternative or ‘ambivalent’ femininities, whichrepresent varying degrees of compliance or resistance to male dominance.  Masculinity theoryhinges on relationality between idealized gender performances to maintain gender hegemony;consequently, expressions of masculinity and femininity cannot be fully understood withoutknowledge of, or reference to, one another (Robertson, 2007).Gender is an important determinant of nutritional health as evidenced by men’s typicallypoorer diets and higher risk for chronic disease compared to women (Millen, Quatromoni,Pencina, Kimokoti, Nam, Cobain et al., 2005).  Specific foods and eating styles that contribute togender inequality in health, including meat consumption and consuming large heavy meals, areoften positioned as masculine (Bourdieu, 1984).  Yet most aspects of food and diet, includingshopping, cooking, healthy eating and being concerned about nutrition and health aretraditionally feminine domains (Vartanian, Herman, & Polivy, 2007).  A small but growingliterature focused on masculinity and men’s food practices shows that men’s perceptions ofhealthy eating reflect societal masculine food ideals, and are typically positioned as contradictory95to healthy eating guidelines.  Domestic food provision, cooking and attention to healthy eatingare often framed as feminine endeavours and therefore to be avoided by men unless necessary(Sellaeg & Chapman, 2008; Sobal, 2005).  Cynicism towards government directed nutritionmessages and perceptions of healthy foods as ‘unsatisfying’ are barriers to some men’s healthyeating practices and are interpreted as reflecting masculine ideals of strength, rationality andautonomy (Gough & Conner, 2006).  These findings suggest that many men’s food practices arepartly shaped by masculine food ideals.Although masculinity theory offers a way of conceptualising men’s health and foodpractices, Lohan (2007) suggests that men’s health studies would benefit from integratingresearch on gender inequality in health with masculinity and men's health research in order todevelop a ‘critical studies on men’ approach.  Promised within this critical approach are morenuanced understandings of men’s health in relation to women, which would build on feministresearch that has examined how gender shapes women’s lives.  Feminist perspectives oftenframe gender inequality in food work as constituting patriarchy whereby women are subordinateto men (DeVault, 1991).  Women might also position family food work as an expression oftraditional feminine ideals of nurturing and caring (Lupton, 2000) and/or means for maintainingpower or control within the ‘domestic sphere’ (Furst, 1997).Linkages between masculinities and femininities are theoretically and empirically under-developed, especially in the context of masculinity and men’s health research, which has lackedgender relations analyses (Lyons, 2009).  This is problematic because men’s experiences aroundhealth issues such as prostate cancer are often influenced by female partners, with both positiveand negative effects on men’s health behaviours (Bottorff, Oliffe, Halpin, Phillips, McLean, &Mroz, 2008; Gray et al., 2000; Helgeson, Novak, Lepore, & Eton, 2004; Soloway, Soloway,96Kim, & Kava, 2005).  These findings suggest complex interactions between men and womencontribute to both health opportunities and constraints for men, and underscore the need fordeveloping gender relational approaches.Intersections between masculinity and femininity in food practice research are alsopoorly understood.  Compartmentalizing men’s and women’s ‘food worlds’ offers littleunderstanding of how masculinity and femininity interact in shaping couple food dynamics andmen’s nutritional health.  Lyons (2009) recommends that food and health research incorporate agender relations perspective that examines how performances of masculinity and femininitymaintain traditional power dynamics or ‘gender order’ between men and women, and thus shapemen’s health behaviours.  With this in mind I addressed the following question in this chapter:How do heterosexual gender relations shape couples’ food practices when the man experiencesprostate cancer?MethodsQualitative grounded theory methodology employed in this study included concurrentdata collection and analysis and development of emergent themes through inductive reasoningand constant comparison (Charmaz, 2006).  Institutional ethics approval was obtained andfollowed (see Appendix 2 – ethics approval certificate).  Study participants were recruited from aurology clinic in a western Canadian city hospital and nearby prostate cancer support groups (seeAppendix 3 and 4 - recruitment materials).  Although primarily a convenience sample, purposivesampling was employed when possible to provide a variety of prostate cancer experiences andsocial backgrounds.  Eligible participants were all fluent in English including men who had beendiagnosed with prostate cancer within the previous five years and their cohabiting femalepartners who lived together in non-institutional settings with independent household food97provision.  Informed consent was obtained and participants were given a $30 honorarium (seeAppendices 5 and 11 – consent forms).Data were collected by the candidate (LWM) through individual in-depth, semi-structured interviews of 60-90 minutes duration held in participants’ homes (see Appendices 6and 12 – interview guides).  Interviews were conducted privately, with men interviewedseparately from women.  Field notes and demographic information were collected at theinterview (see Appendix 9 - field note form; Appendices 8 and 13 - demographic forms).Individual, private interviews allowed participants freedom to express themselves and to avoidinterruptions, differences of opinion and power dynamics that conducting joint couple interviewsmight have permitted (Morris, 2001).  Open-ended interview questions were used to solicitparticipants’ understandings about diet and food practices in the context of prostate cancer, andtheir roles in the men’s diets.  Questions were adjusted as data collection progressed to test anddevelop emerging themes.  Interviews were digitally recorded, transcribed verbatim, and checkedfor accuracy.  Atlas/ti™ software was used to facilitate coding of the transcripts, wherebyconcepts were labelled with identifying codes (see Appendix 10 - sample coding schedule).Using constant comparison, initial open codes were grouped under descriptive abstract categoriesfrom which emerging themes were described in memos.  Themes and major concepts werecompared to newly collected data and discussed at research team meetings.  Dyad summarymemos were prepared for each couple that described influences on household diets, the roles thateach partner assumed in food provision and how food work was negotiated and conducted (seeAppendix 14 – dyad summary template).  These memos helped organise analysis of emergentcodes, categories and themes that focused on performances of masculinity and femininitythrough couples’ accounts of food practices.  Themes derived from coding were organized,98compared and described in memos and were interpreted using a gender relations framework(Lyons, 2009).Fourteen married heterosexual couples were recruited (see Appendix 15 – participantcharacteristics).  Participants were between 45 and 78 years old and most self-identified asCanadian-European heritage except for two women who were of Canadian-Asian heritage.  Mostparticipants were college-educated, middle-class and retired.  Most men were diagnosed withlow-risk prostate cancer for which a variety of treatments were used.  The terms ‘husband’ and‘wife’ are used to describe participants because each couple was married and participantsroutinely used these terms.  Findings from the 28-interview data set are presented withillustrative quotes and labelled by gender (i.e., M = men or W = women) and couple ‘C1’ to‘C14’.FindingsAccounts of the participants’ food practices revealed that although men became moreinterested in their diets following prostate cancer, couples tended to mutually constrain the natureand extent of men’s engagement in food work.  Participants depicted women as natural foodleaders, often positioning them as ‘mothers’ in control of men’s ‘child-like’ dietary practices.Doing so sustained hetero-normative food roles, whereby women controlled the domestic foodsphere but also carefully negotiated support for men’s diet changes through deference to men’sfood preferences and maintenance of hegemonic power dynamics.  These themes are illustratedbelow using the gender relations framework previously described.Men Increase Diet InvolvementMost men reported developing interest in nutrition and becoming more involved in theirdiets following their prostate cancer diagnosis.  They researched and collected prostate cancer99specific nutrition information and/or recipes, often sharing these findings with their wives.Although a few men described making substantial healthy eating changes, the majority reportedminor diet changes, which most often involved eating certain foods or taking supplements.  Themost common prostate cancer associated changes included eating less red meat, replacing it withfish and poultry.  Other changes included eating more tomato products, broccoli and othervegetables, usually framed as additions to men’s regular eating habits rather than integralcomponents of their daily diets.  Many men also reported increasing shopping and/or assistingtheir wife in food preparation.  One man perceived his new interest in gathering food as asignificant change brought about by prostate cancer:It (having prostate cancer) really did make a difference on how I perceived foodbecause I would go to [grocery store] and then I’d start looking around for what’sgood and I’d come home with more stuff and things than she might have bought… and I was kind of proud that I was doing that.  (C14M)Other researchers have identified how masculinity is often associated with consuming redmeat and disinterest in healthy eating, while femininity is associated with preferences forvegetables, seeking nutrition information, cooking, and doing the bulk of domestic food work(Jensen & Holm, 1999; Roos, Lahelma, Virtanen, Prattala, & Pietinen, 1998).  The ways the menin this study became more involved with diet suggest shifting masculine practices that departfrom idealised hegemonic masculine performances.  This ‘feminization’ of being interested orinvested in a healthy diet is also representative of an atypical masculinity.  Correspondingly,men’s increased involvement in family food work might disrupt some women’s feminine foodideals, as Furst (1997) found in women who framed food provision as a form of nurturing andexpression of femininity.  Related to this study findings reveal how men and women negotiateddiet and food work by mutually constraining men’s engagement with diet, maintaining women’s100food leadership amid sustaining hetero-normative gender power relations.  Each of thesestrategies is described below.Men as “Sous Chefs”Men reported continuing with the typically masculine food work they had done prior totheir cancer diagnosis, including preparing special dishes (e.g., chili), making their own breakfastor lunch (e.g., granola or sandwiches), reheating leftovers and barbequing.  Although most menbecame more interested in diet after their diagnosis, couples typically limited the extent of theirincreased involvement, framing men’s food work as ‘helping out’ their wives rather thanassuming responsibility for diet.Men who reported shopping often did so at their wife’s request or with the guidance of ashopping list: “I mean I go out and help her sometimes, or if we need something and I’m comingback from somewhere I’ll stop at the market and get it.”(C11M)  One man described thisrelationship by referring to his wife, as the “head chef” while his role was that of “sous chef.”(C7M)  In accordance, wives were typically positioned as household food leaders and theindispensable conduit for men’s healthy diets.Participants’ rationales for men being less involved in diet reflected and preserved whatDeVault (1991) previously described as traditional gendered food ‘roles’.  Most couplesdescribed men’s shopping and cooking skills as inadequate compared to women’s.  One womancommented: “Stuff that comes into the house that’s probably not healthy is when [my husband]goes shopping, he throws things into the cart. … Typical guy, I guess.” (C9W)  Her husbandagreed with her assessment, further clarifying that he did not prepare food because: “She doesn’ttrust my culinary skills.” (C9M).  In contrast men often praised and affirmed their wife’s foodwork skills.101Participants also indicated that they left health and dietary considerations to womenbecause of women’s superior nutrition knowledge and concern about healthy eating.  Womenwere described as “more fussy” or “more health conscious” than men who were converselyframed as “useless” or “more relaxed” about healthy eating.  Women confirmed the perspectivethat men were less concerned about nutrition than them.  One woman was sceptical about herhusband’s new interest in healthy eating, suggesting: “I just don’t think that’s ever been hispriority. I think he eats when he’s hungry.”(C9W).Overall, comments about men’s lack of skills and interest in food and nutrition wereoften invoked to support the limited extent to which they engaged in their diets.  These findingsare reflected in other research where women’s disproportionate contributions to family foodwork have been rationalised in terms of women’s expertise, enjoyment and fairness (Lupton,2000) or the notion that it is ‘just easier’ for women to do family food work than men (Beagan,Chapman, D'Sylva, & Bassett, 2008).Women as Leaders in Food and HealthParticipants’ accounts of men’s limited diet involvement and skills were supported byseveral themes apparent in their descriptions of women’s food leadership, including assumptionsthat food work is women’s domain, that their attention to healthy eating is essential andsufficient, and that their husbands are like children who need to be supervised and directed.Food and health work as feminine. The assumption that nutrition, food work and thekitchen are women’s domain was reflected in men’s comments about how “gladly” their wivescooked for them and that their food work was not to be interfered with:102My attitude is that [my wife] is such a good cook and she takes such good care ofme in general and is so nice about all of this stuff that it would be inconsiderate ofme to pressure her to cook differently than she feels like cooking. And it’s reallyher business. (C6M)When another man was asked about the division of food-related work in his home, hisjustification for not cooking indicated not only appreciation for his wife’s skills, but also that hewas careful not to disrupt a convenient and well established arrangement anchored in atraditional gendered division of labour:She does a great job and doesn’t seem to mind it. I’m not dumb, I’m not gonna[laughs] … I’ll, you know, do some dishes and clean some things and [laughs] …we divide up everything, like I do all the finances and everything else. … I’m justspoiled really. (C14M)Positioning women this way as natural leaders in family food work reflects longstandinggender norms and confirms previous research which frames this as a way for women to expresstheir femininity as a ‘proper’ socially affirmed wife or mother through nurturing their husbandand family (Charles & Kerr, 1988; DeVault, 1991; Sidenvall, Nydahl, & Fjellstrom, 2000).Similar to these previous findings, most women in this study were complicit with women’s‘natural’ leadership in household diet.Some women appeared uncomfortable with their husband’s new interest in diet anddescribed how they ‘permitted’ their husbands’ to help out, although only with supervision: “I’lllet him go out and he buys the vegetables and the fruits.”(C4W) or “I let him use thekitchen.”(C5W)  Framing men’s help as provisional and based on granting permission revealshow women positioned themselves to control and oversee family food work.  Careful regulationof men’s involvement in family food provision displayed here supports other researchers’103suggestions that maintaining gender food roles allows women to maintain control of householddiet and their domestic sphere (Furst, 1997; Lupton, 2000).Women’s leadership in diet changes is essential and sufficient.  Women’s foodresponsibilities extended beyond provision of meals to encompass primary responsibility fornutritional health, a role that often took on increased importance following their husbands’prostate cancer diagnosis.  This was linked to broader expectations that men’s health was oftenwomen’s responsibility.  Explicit about the importance of wives’ health management role, wasone man who affirmed the practice as normative:If it wouldn’t be for her I wouldn’t be alive today. I have always said that, and alot of the men I’ve talked to, different men that are married, they always say thatit’s their wives that either pushed them to get the tests done or pushed them tokeep their diet on track… I can just sit there and say, yeah, that woman isresponsible for keeping him going, you know.  (C13M)This man’s wife confirmed his assessment, describing in detail how she convinced herhusband to seek medical care and the importance of her presence at doctor appointments toaccurately take direction and ask the “hard” questions.  These findings are confirmed by medicalprofessionals who have also noted the centrality women in men’s help-seeking and compliancewith medical advice (Seymour-Smith, Wetherell, & Phoenix, 2002).For some participants, nutrition was framed as a couple’s collaborative project, as oneman said: “When I was diagnosed, [my wife] and I began thinking about. ‘What do we need todo diet-wise to support my treatment  [and] my healing?’” (C1M).  For another couple, when thehusband became interested in healthy eating after his prostate cancer diagnosis and decided tobecome vegetarian, the feasibility of doing that was heavily reliant on his wife’s willingness towork toward that change:104She’s approached this as a, we’re in it together…. She’s found herself in asituation, right, here is it me with prostate cancer and so she’s, I see that she’simmersed herself in a healthy way like in a sense there’s something I can do to, toassist with this difficult time etc., etc., so she spends an awful lot of the, or she’smore vigilant about extracting recipes and ideas and things like that than I am.(C10M)Findings that women were significant in men’s care were consistent with other reportswhich frame prostate cancer as a couple’s disease, and women instrumental in prostate cancerrecovery (Gray et al., 2000; Maliski, Heilemann, & McCorkle, 2002).  Several women describedthat any diet changes they made were designed to increase the couple’s overall health rather thanspecifically for his prostate cancer.  A woman clarified: “I’m not thinking just of his prostate,I’m just thinking of both of us just trying to eat better”(C14W).  Consequently, while manywomen were aware of the diet information that their husbands found and brought home, theytended to disregard it.One justification for ignoring this information was that this research was seen as theman’s personal project and irrelevant to women’s longstanding expertise in family foodprovision.  This was demonstrated by a woman who ignored her husband’s supplement usagebecause she was too busy to include it in her food work:I hate to say it but I’m sort of listening, but I’m not really. I have to deal enoughwith my own stuff that I don’t really – if he wants to take it (supplements) and it’sbeen recommended and he’s heard at the support group that that’s what he shouldbe taking. (C7W)This finding supports previous work by Miller & Brown (2005) that suggested somecouples became disengaged in dietary change management after one spouse was diagnosed withtype 2 diabetes.  In contrast a desire to maintain a normal life led other families to assimilate diet105changes into daily family practices when one member of a couple was diagnosed with celiacdisease or heart disease (Gregory, 2005).  Gray et al (2000) also found that couples attempted toprevent prostate cancer from interfering with maintaining a normal life, including preservingcouples’ existing relationships.  Findings in this study suggest an explanation for some of thedifferences between findings in these other studies, demonstrating how couples’ food practicescan be interpreted as preserving pre-existing gendered food relationships regardless of dietchanges made.Women as mothers, men as children.  Mutually framing men as incompetent aroundhealth and food work prompted some couples’ food relationships to become parental wherebywomen infantilized men and adopted mother roles.  Men were complicit with this arrangementby disclosing lack of self-control and a childish need for supervision.  Women reported hidingsnack foods and treats, portioning food to control overeating at meals, “nagging” and otherstrategies for monitoring and manipulating men’s diets.  As one woman explained: “I hidethings. (laughs) He’s terrible! He’s like a little kid. Because if I don’t he will completelydemolish something.”(C2W)  Despite describing his annoyance at her “nagging” and attempts tocontrol his eating, her husband agreed with her assessment: “Yeah. I mean if there’s cookies inthe house I’ll eat them. If there’s chocolate in the house I’ll eat it.”(C2M)Even men who became more involved in their diets recognised how important thismaternal role was in helping them curb their undisciplined practices.  One man described hischild-like taste preferences as a source of conflict with his wife and as barriers to healthier eatingsaying: “It’s like if you ask a kid if he wants. I want all the gooey yummy things and maybe Idon’t want to eat kale tonight.” (C10M)106The infantalization of men demonstrated by couples in this study echoes contemporarydiscourses regarding men’s health.  Lyons & Willott (1999) suggested that media portrayals ofmen being childish and unrealistic about their health care, while women were framed asresponsible for changing men’s health, represented a “man as infant” discourse.  Healthprofessionals can also invoke this discourse in their assessment of men’s poor help seekingbehaviours, as reported by Seymour-Smith et al. (2002) in a study revealing how men ignoredemergent health issues until their female partners “ordered” them to seek medical help.These findings suggest that a key aspect of gendered food practices in heterosexualcouples involves positioning men as incompetent around nutrition, and in reifying women’scontrol within the domestic food sphere and men’s health and diets.  In this sense, women in thisstudy devalued their husband’s attempts to engage in family food work to maintain their foodcontrol.  Furthermore, findings suggest that men were powerless (like children) in making foodchanges on their own because women dominated family food politics and practices.  However,power dynamics, which are scrutinized further in the next section, revealed women’s ‘control’ offood existed amid larger gender power structures.Maintaining Hetero-normative Gender Power Relations.As described above, participants’ accounts of food practices suggested that womencontrolled the domestic food sphere and consequently their husband’s diets.  Gender relationstheory, however, requires illuminating how gender performances are implicated in genderhegemony and patriarchal power structures (Schippers, 2007).  Consequently, further analysisdemonstrates the complexity of couples’ power dynamics around food, indicating women’sapparent control of food as ambiguous.  Most women also described deferring to their husbandsfood preferences and carefully negotiating how they supported men’s involvement in diet to107avoid disrupting men’s masculine identity.  Thus women demonstrated ‘emphasised’ femininity,which reduced conflict and supported men’s aspirations for hegemonic masculinity (Howson,2006).  These practices can be interpreted as reflections of traditional gender roles and relationsembedded within gender hegemony and as illustrated in the following section, these practicesmight reinforce patriarchal power structures (Bourdieu, 2001).Women deferred to husbands’ preferences.  Despite women’s apparent control of thefamily diet, men had notable influence on women’s shopping and cooking and there were manyexamples of women’s deference to their husbands’ food preferences.  One man jokingly referredto his wife as “my personal chef” because she prepared his favourite meals.  For another couplethe husband began directing his wife’s food provision; accordingly she planned and cookedfamily meals around his prostate cancer specific food preferences.  Although she recognised thathe was directing her efforts, she framed the family diet changes as jointly made because she wasthe main food provider:We work together, [my husband] and I, and he’s doing a lot of reading and heexplains things to me and I’ve been helping him in that way regarding eating,cooking the meals and changing our food.  (C3W)For most other couples this power dynamic was less explicit and women minimized theirhusbands’ influence on their food provision.  Food routines for these couples were developedover many years whereby women learned their husbands’ food likes and dislikes, and menexpected their wives to shop and cook with their preferences in mind.  One woman reported thatalthough she remained the final food decision maker, she often deferred to her husband’s tastesregardless of his prostate cancer:108Well, I mean I do the shopping and I’m not going to buy something that I knowhe doesn’t like, to cook. But normally speaking, I might say, “What would youlike for dinner between this, this and this that I’ve got?”  (C11W)Men supported this arrangement and described how although day-to-day cooking wastheir wife’s responsibility, overall food decisions were tacitly understood to consider hispreferences and prostate cancer, and were thus jointly made.  These findings support early worksthat demonstrate that women’s domestic food work is often done in deference to men’spreferences and might therefore constitute male dominance (Charles & Kerr, 1988; DeVault,1991).Men undervalued women’s food work.  Although appreciative of their food provision,men tended to undervalue, minimize and/or appeared unaware of the substantial amount of foodwork their wives did.  Planning, shopping and cooking meals was invisible work to many men asdemonstrated when several could not recall specific details about the diet changes their wivesmade for them.  This reflects traditional gendered food practices whereby men undervaluewomen’s unpaid domestic food work, and has been interpreted as a form of male dominance byother researchers (e.g., DeVault, 1991; Kemmer, 2000; Lupton, 2000).  For example, one manstated:  “She doesn’t (plan meals). There’s very little planning with my wife. (laughs) We’dcome home and she can have a meal ready in a half hour! … Well, she knows what’s in thefridge.” (C4M)One woman recognised that her husband undervalued her food work in comparison to his‘man’s work’ around the house.  She perceived that: “I think he has a little ‘lensing’ system,which is if what I’m doing is less important than what he’s doing then I should cook the meal.”(C1W)  Positioning men’s work as important and women’s food work as subordinate may have109allowed some couples to bolster men’s masculine identities amid men’s prostate cancer relatedemasculations by reinforcing traditional gender roles.Women’s support as “cheerleaders” not “bus drivers”.  Many women were pleasedthat their husbands were interested in healthy eating and glad to have help in shopping andcooking.   However, women were careful to avoid forcing their husbands into food work anddescribed their roles as supportive and feminine, or as one woman referred to herself, a“cheerleader” (C1W) of her husband’s diet changes.  Several women described cautiouslysupporting rather than leading their husband’s diet changes.  They acted as ‘backgroundsupporters’ similar to the supportive style of women who attended prostate cancer supportgroups (Bottorff et al., 2008).  One woman described how she balanced her role as nurturer withher husband’s preferences through careful negotiation of power dynamics whereby she remainedsubmissive to his wishes around food provision.  In her opinion, he would resist diet changes shemade unless he thought that he had some control over decision-making.  This demonstrated thedelicate balance between her performance of ambivalent femininity as nurturer and supporter ofhis interest in healthy eating with his dominance and need for autonomy:I felt that I was probably taking more responsibility for [my husband’s] diet thanhe was sometimes, and I realize it was partly me feeling like he should do thevery best here, you know, with your diet. And then I realized well, I just had toback off with that outlook. It’s his life, right? He has to make decisions for whathe wants, and I can cook things that are healthy and that’s the part I can do but Ididn’t want to get into saying, “Oh, I think you should be eating that.”(C1W)Another woman agreed that despite her main role as food provider, diet change decisionshad to be jointly made because he needed to have ownership over any changes he made:110We’re kind of taking control a bit more, we’re taking [laughing] control well itsounds like I’m driving the bus, I’m not really but, you know, I support [myhusband] with what he wants to do and then sometimes I remind him when I, Ithink, you know, “Did you go for your walk today?” You know, that kind ofthing. (C10W)Camouflaging her food control was important to directing his diet and health changes.She carefully supported and helped him to make healthy changes.  Evaluated together, thefinding that women appear to control domestic food, yet do so in deference to men illustrateshow gender hegemony shapes, and is supported by, couples’ performances and co-constructionsof masculinity and femininity.Discussion and ConclusionsOverall, the findings demonstrate the interplay of performances of femininity andmasculinity in shaping household food practices of men with prostate cancer.  Together, men andwomen limited men’s deeper engagement in their diets by mutually positioning women asnatural household food leaders and men as unskilled in such matters.  By re-inscribing hetero-normative gender roles, couples bolstered men’s alignment to hegemonic masculinity byallowing them to maintain distance from feminine concerns about healthy eating whilereinforcing women’s emphasised femininity through nurturing food practices.Using a gender relations framework illuminated how these performances of gender helpmaintain gender hegemony.  This has implications for improving our understanding of men’snutritional health by exposing unseen links between genders in the context of food, men’snutritional health and prostate cancer.  Previous food practice research has focused on eithermasculinity and food or femininity.  For example, masculine food ideals have typically beenlinked to athleticism or performance whereas feminine concerns about nutrition embrace health111and well-being (Roos & Wandel, 2005; Sloan, Gough, & Conner, 2009; Smart & Bisogni, 2001).These previous findings demonstrate that masculinities are implicated in men’s food choices inmany ways and because these choices are often seen as unhealthy, must be considered in men’sfood practices research.Similarly, research on femininity and food has shown how most aspects of family foodprovision and attention to healthy eating are framed as feminine.  Feminist writing on womenand food has interpreted this as constituting patriarchy (e.g., Charles & Kerr, 1988; DeVault,1991), although others have noted that women’s performance of femininity through food canallow women to maintain control of their domestic sphere (Furst, 1997; Lupton, 2000; Sidenvallet al., 2000).  However, despite the large amount of research on gender and food, there has beena notable lack of attention to the connections between men and women’s food worlds (Lyons,2009; Schofield et al., 2000).  Findings from this study illuminate such links and demonstratehow women and men can work in concert to maintain traditional gender roles and hetero-normative power dynamics that simultaneously put women in control of family food, but alsoposition them subordinate to men.These findings are novel in that they specifically address gender relations around foodand the nutritional health of men with prostate cancer.  Although masculinity has beenimplicated in the health of men with prostate cancer (e.g., Chapple & Ziebland, 2002; Oliffe,2009), their food practices are poorly understood.  Likewise, although men’s food practicesresearch has begun to examine masculinity and food it has not grappled with how to assist mento eat healthier diets when confronted with a health crisis.  Findings demonstrate thatunderstandings of masculinity and food are incomplete without corresponding understandings offemininity in the context of heterosexual couples, who have also been shown to strive to112maintain a sense of control and normalcy in their lives to help manage the impact of prostatecancer (Maliski et al., 2002).  Themes previously found in ‘prostate cancer couples’ including“stopping illness from interfering with everyday life” and “keeping relationships working”indicate that maintaining traditional gender food roles and hence power structures, might be animportant part of this management (Gray et al., 2000).  The current study findings suggest that toensure effectiveness, dietary interventions for men with prostate cancer must carefully considergender relations that support performance of hegemonic masculinity through men’s foodpractices.Limiting men’s diet involvement as found in the participants’ accounts of family foodpractices supports men’s masculinity but also prevents men from deeper engagement with theirdiets.  Although men might be instrumental in collecting prostate cancer related nutritioninformation and recipes, the findings suggest that women are often key to mobilising thatknowledge.  Furthermore, by ignoring men’s diet involvement women might inadvertently stiflemen’s investment in their diets, muting their responsibility for nutritional self-health.Although men might express interest in food many men are unlikely to independentlymake what they perceive as feminine changes such as eating less red meat or increasingvegetable consumption.  Likewise women seem unlikely to permit their husbands to assumesignificant control of family food provision since this would require relinquishing control of theirdomestic sphere and challenge feminine nurturing ideals.  This suggests that nutritioninterventions might work best for some couples within (rather than attempting to change) theirexisting gender relations.  Therefore, some nutrition programs for men with prostate cancermight work best to assist women with adopting acceptable, feasible and sustainable family dietchanges.113Alternatively, researchers and nutrition educators can acknowledge the significant role ofhetero-normative gender relations without reinforcing them.  Nutrition interventions for menwith prostate cancer might aim to change existing gendered food-related power structures byincreasing men’s diet engagement.  Challenging hetero-normative power dynamics is difficult;however, if we expect men to become deeply engaged with their own health and diets, then wemust consider how this disrupts men’s masculinity and women’s leadership roles in this arena.The study findings presented here illuminate men and women’s gendered foodways,suggesting we need to help couples to be aware of how gender is shaping their food practices andhealth.  Men’s perceptions of healthy eating might be considered in nutrition interventions inways that support their masculinity while simultaneously eliciting increased interest and agencyin food and eating.  Promoting alternative ‘insurance’ masculine healthy eating ideals thatsupport healthy eating might allow men to engage in diet while preserving masculine identity.Likewise, interventions might support women in fostering men’s increased engagement in theirdiets and family food work and create a ‘new couple norm’.The findings of this study are based on heterosexual couples living in a large WesternCanadian city and therefore are not espoused as generalisable to other settings and other familystructures including single living and/or same-sex partnered men where gender roles mightdiffer.  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Annalsof Behavioral Medicine, 27(2), 107-116.119CHAPTER 5.DISCUSSION AND INTEGRATION OF STUDY FINDINGSIt is clear that tastes in food cannot be considered in complete independence of theother dimensions of the relationship to the world, to others, and to one’s ownbody. (Bourdieu, 1984:193)Growing evidence demonstrates that gender is a determinant of men’s food perceptionsand practices and might therefore influence diet change or nutrition intervention uptake for menwho have been diagnosed with prostate cancer.  Consequently the objective of this study was toexplore how masculinity and gender relations are implicated in shaping dietary understandingsand food practices of men with prostate cancer.  Findings presented in this dissertationcontribute to these scholarly understandings.  In this chapter, I present an integrated discussion ofthe study findings, discuss the strengths and limitations of the research, some complexities ofdoing gender research, my role as researcher and describe how the findings can inform men’snutrition program development and future research in diet change practices of men with prostatecancer.Masculinities and Food after Prostate CancerThe research presented in this dissertation addresses gaps in understandings of how socialconstructions of masculinity are implicated in the food practices of men with prostate cancer.Findings reveal masculinities as an important influence on men’s perceptions of diet and dietchange.  As reviewed in Chapter 2, previous explorations of masculinity and food indicate that‘real’ (hegemonic) Western men are expected to perform masculine ideals by ignoring healthy120eating messages and typically (over)consuming meat or eating heavy high-fat, high calorie meals(Courtenay, 2000; Moynihan, 1998; Robertson, 2007; Sobal, 2005).  Other literature presented inChapter 2 suggests these expectations may be problematic for men with prostate cancer becausemasculine food ideals and practices designed to portray them as the “stronger sex” are contraryto prostate cancer primary and secondary protective dietary recommendations (Jensen & Holm,1999; Moyad, 2006a, 2006b).  Men with prostate cancer face a dilemma: although consuminglow-fat vegetarian diets might offer survival benefits, this requires reducing consumption of atraditionally male food (meat), consuming more feminine foods (vegetables) and adopting morefeminine eating patterns (low-fat, vegetarian).  The literature synthesis presented in Chapter 2further suggests that the combination of the feminized anti-prostate cancer diet andemasculations linked to prostate cancer experiences poses a threat to the men’s masculinity (e.g.,Oliffe, 2005) that may be at least partly responsible for men’s avoidance of diet changefollowing prostate cancer (e.g., Demark-Wahnefried, Aziz, Rowland, & Pinto, 2005).Empirical findings presented in this dissertation suggest that the role of masculinities inshaping food practices of men with prostate cancer is not straightforward.  All of the men whoparticipated in this study expressed interest in nutrition and healthy eating and most believedthey engaged in some, albeit minor, healthy eating changes after their prostate cancer diagnoses.However, men positioned these changes in ways that can be seen to reflect masculine ideals andconsequently de-linked from feminine healthy eating concerns.  They invoked multiplemasculine ideals of autonomy and self-control in constructing rationales for their diet changesrather than reporting more traditional feminine ideals linking diet and health.  These findings canbe interpreted within Connell’s (1995, 2005) conceptualisation of hegemonic masculinity theory,which allows and accounts for multiple masculinities as contextually shaped by interactions121between agency and social structures.  Experiencing chronic disease might therefore provide acontext for men to express alternative masculinities that justify them paying more attention totheir nutritional health than typical for men, as some participants did in this study.  Alternativemasculinities, similar to the ‘healthy’ or ‘strong man’ ideals described by Sobal (2005), wereinvoked by some participants to justify reduced, and therefore non-hegemonic, meatconsumption in the attainment of healthy and strong male bodies.Men in this study who described making diet changes rationalised these by citing theincreased need for self-care during cancer recovery and the importance of diet for continuedperformance as men.  This confirms findings reported in other masculinity and food studiesaddressing men’s food practices.  Like previous reports about male fire-fighters (Deutsch, 2005)and engineers (Roos & Wandel, 2005) who engaged in traditionally feminine eating practices,some men in this study described their food practices in ways that can be interpreted as emergingfrom ideals of autonomy, self-control and being action-oriented.  Although engaging in somefood practices traditionally seen as feminine, these practices were described by the men inmasculine ways, and typically distinct from womanly concerns about nutrition and healthyeating.Other participants acknowledged the significance of having cancer, but situated theirprostate cancer as a chronic and manageable condition, similar to men in another study whoframed their prostate cancer as a “good cancer” (Maliski, Heilemann, & McCorkle, 2002).Together these constructs allowed men some to leverage their interest in nutrition and diet butdid not warrant becoming engaged in nutrition in explicitly feminine ways.  These findingssupport the conceptual framework developed in Chapter 2, in that despite their increasedinterest/involvement in nutrition, the men might have been attempting to preserve their122threatened masculinity and compensate for a ‘crisis in masculinity’ presented by prostate cancerexperiences by reframing eating in masculine ways rather than invoking more traditionalfeminine healthy eating ideals to describe their perceived diet changes.Experiencing prostate cancer might therefore offer an occasion or turning point wheresome men can overlook expected masculine food practices and change their diets to improvetheir health and recovery.  However, the relationship between masculinities, diet and prostatecancer is more complex as evidenced by the degree and nature of diet changes reported byparticipants.  Although men in this study professed more ‘masculinised’ interest in nutrition andmade minor diet changes, most tended to avoid wide-ranging, extensive changes.  None of themen, even those who perceived themselves as making major diet changes, reported becomingdeeply engaged in or assumed control of their diets independent of their wives.  Some mensearched for diet information and began shopping and helping with food preparation but inavoiding ‘excessive’, feminine interest in nutrition or healthy eating, none became householdfood leaders.  Despite their assertions of autonomy and self-control all of the men in the currentstudy nonetheless relied on their female partners to guide and provide for their dietary needs,which restricted their personal, direct diet change engagement regardless of how they framedtheir perceived diet changes.  This demonstrated traditional or hetero-normative domestic genderperformativity that supports previous research on gender and food practices where women areleaders in household food provision (e.g., De Vault, 1991).In summary these findings are reflected within the framework in Chapter 2 bydemonstrating that masculine ideals shaped how men in the study perceived diet and dietchanges.  Although they became interested in nutrition they distanced their involvement fromtypically feminine nutrition concerns by reframing their food perceptions and practices in ways123that can be interpreted as reflecting masculine ideals.  But there was a limit to how far reframingof food ideals would permit the men to engage in their own diets suggesting that a threat tomasculinity prevented them from further involvement.  Because they did not become moredeeply engaged in their diets, (e.g., by assuming more traditional leadership feminine familyfood provision ideals and roles) there was a need to explore how the men’s actual diet changepractices occurred within a family context.  The need to include a family context was reflected inthe literature review and synthesis, which showed a lack of knowledge of the complexcontributions that gender relations plays in shaping many men’s health, food practices andprostate cancer experiences.  The empirical study presented in this dissertation demonstrates thatmasculinities did not solely account for the limits to the men’s diet changes and that genderrelations were also implicated.  How intricate gender relations linked to broader societalgendered power structures contributed to the men’s diet change practices are discussed in thenext section.Masculinities and Femininities: Gender Relations and Power DynamicsStudy findings presented in Chapter 4 of this dissertation provide a unique analysis of theintersection of expressions of gender through family food work.  Men performed masculinity bylimiting their dietary engagement and deferring responsibility for diet leadership to their wives.This was done in relation to women’s performances of femininity through nurturing foodpractices and control of household food provision.  Overall both men and women mutuallyworked to re-inscribe hetero-normative food roles that kept men out of the women’s domesticfood sphere.  Doing so maintained the men’s masculinity, the women’s femininity and a stablecouple power dynamic that ultimately shaped the men’s diets and nutritional health.  Although124couples were not asked how long they were married these relationships appeared to belongstanding and well established.These findings provide a new and important understanding of men’s food practices thatbuild on Bourdieu’s (1984) classic work where he recognised the complexity of gendered powerdynamics in food.  He suggested that despite male social dominance, when women avoidexcessive meat consumption, they derive a local power or “authority” over men from doing do,as evident by the disgust that they might experience through its over-consumption: Meat, the nourishing food par excellence, strong and strong-making, givingvigour, blood and health, is the dish for men, who take a second helping, whereasthe women are satisfied with a small portion. It is not that they are stintingthemselves; they really don’t want what others might need, especially the men,the natural meat eaters, and they derive a sort of authority from what they do notsee as a privation.  Besides, they don’t have a taste for men’s food, which isreputed to be harmful when eaten to excess (for example, a surfeit of meat can‘turn the blood’, over-excite, bring you out in spots etc.) and may even arouse asort of disgust. (Bourdieu, 1984:192)However, despite Bourdieu’s (1984) early work there has been little attention to genderrelations and food until recently.  The importance of power relations has been noted in gendertheory (Connell, 1995; Connell & Messerschmidt, 2005; Courtenay, 2000) but remainedtheoretically and empirically under-developed (Schippers, 2007).  This study adds to thisunderstanding by demonstrating how societal power structures are reproduced in coupleinteractions that prevent men from becoming more engaged in their diets.  Female partners areknown to play important roles in the health of men with prostate cancer and the findingspresented provide a unique perspective not previously seen in the literature: women’s accounts125of the men’s diets and diet changes.  Available here are new insights into how gender relationscan constrain and/or provide permission and affirmation for men’s food practices.Masculinity is performed in relation to femininity and therefore understanding men’sfood practices is contingent on exploring femininities and food.  Although Connell (1995)described gender relations as contextual and societal, she also noted that individual heterosexualrelationships could be framed as micro versions of larger societal interactions.  Thus genderrelations is not just how masculinity is defined in relation to femininity, but also exists on a dyadlevel for heterosexual couples as shown by how study couples’ expressions of genderinterrelated.  In the same way that social constructions of masculinity shape men’s perceptions offood, women are influenced by social ideals of appropriate feminine food practices.  Women inthis study performed traditional feminine framing of food provision practices by shopping andcooking for their husbands as a form of nurturing as previously reported (Furst, 1997; Lupton,2000).  Women (and their husbands) positioned femininity as embodied by ‘mothers’ and carers,and therefore, important ‘wifely’ contributors to their husband’s nutritional health.  In contrast,participants positioned men as at best uninterested and at worst ‘childish’ and inept in nutritionand food work demonstrating how couples’ interactions and gender relations were implicated inshaping the men’s diets.  Women maintained control of the couple’s domestic food sphere, andin doing so preserved feminine ideals while simultaneously bolstering their husbands’masculinity by allowing them to maintain a masculine ‘distance’ from feminine dietary concernsand domestic food provision practices.These findings demonstrate how gender relations maintain traditional power structureswithin the home and confirm Bourdieu’s (2001) observation in Male Domination, that it is the126sexual division of labour that shapes and is shaped by patriarchy and gender inequality; thus menand women have distinctly different domestic roles:The social order functions as an immense symbolic machine tending to ratify themasculine domination on which it is founded: it is the sexual division of labour, avery strict distribution of the activities assigned to each sex, of their place, timeand instruments; it is the structure of space, with the opposition between the placeof assembly or the market, reserved for men, and the house, reserved for women.(Bourdieu, 2001:9)These findings also validate Lyons’ (2009) admonition that taking into considerationgender relations provides a more complete picture of men’s food practices than masculinity andfood research currently offers and provides directions in reconstructing masculine food ideals.We need to bear in mind that a gender relations approach is essential, and wecannot afford to focus on reconstructing masculinity along more healthy linesindependently of femininity, or their interaction.  (Lyons, 2009:408)From this discussion it is apparent that exploring how men perceive diet and diet changeprovides important information on how masculinity helps shape their dietary perceptions andfood practices.  However, it is also evident that understanding men’s health requires anexploration of how masculinities interact with femininities within couple dyads to shape men’sfood practices.  This dissertation demonstrates that such understandings can be obtained byconsidering the relational intersections of masculine and feminine performances of foodpractices and how they sustain hetero-normative power dynamics and men’s hegemonicmasculine dietary ideals and ultimately their food practices.  This is especially important in thecontext of prostate cancer because of the idiosyncratic and emasculating nature of the disease127and treatment sequelae.  Women might attempt to bolster men’s hegemonic masculinity bypreventing them from experiencing further emasculations such as engaging in feminine self-carepractices, in this case engaging in diet change.  This research suggests that such attempts mightbe motivated by more than women’s concern for the men’s masculine identities but also toreinforce the women’s feminine identity and retain their control of the domestic sphere,(re)stabilise couple power dynamics and ultimately sustain gender hegemony.Intersectionality of Race, Class and AgeThese findings demonstrate how masculinities and gender relations can be interpreted ascontributors to men’s food perceptions and practices; however, the contributions of other healthdeterminants are also acknowledged.  Issues of ethnicity, race, age and class for example havenot been explored within this data set but are thought to intersect with gender in shaping healthbehaviours in complex ways (Schulz & Mullings, 2006).  In this sense, gender can beconceptualised as performed relative to social constructions of these determinants.  For example,as Bourdieu (1984) found, tastes in certain foods signified class distinctions that might also beinterpreted as class-based productions of alternative masculinities.  Likewise ethnic or racedifferences in performances of masculinities might be expected.Thus men from different classes might perform different masculine food ideals; howeverthis analysis was not conducted on this small data set with relatively upper-middle classparticipants.  There were no apparent class based patterns in men’s adherence to masculine idealsusing couple earnings as a marker for class.  Several of the lowest earning couples (C4, C8, C12and C13) made minor diet changes, although the highest earning couples  (C7, C14, C11, C10,C9, C3) were found in all diet change clusters (none, minor and major).  Likewise, age mightcontribute to differences in performances of gender, however, in this study the youngest couples128(C3 and C10) displayed similar gender relations patterns as the oldest couples (C1 and C2)where traditional gender roles were found.  These findings demonstrate that the intersections ofrace, age and class with gender although beyond the mandate of this research study, need furtherinvestigation (Schulz & Mullings, 2006).Reflections on the Research ProcessSome strengths and limitations of this qualitative research project are related to the natureof this approach to scientific enquiry and the goals of the research.  Because little is known inthis area, I sought to explore participants’ perceptions of diet and diet change to discover howmen with prostate cancer, and their female partners, perceive diet and food practices.  I wastherefore interested in exploring the participants’ subjective understandings of reality, whichhelped me explain and find meaning in their social behaviours around diet (Charmaz, 2006;Morse & Field, 1995).  In this section I outline some strengths and limitations of the research,discussed in relation to sampling characteristics, data collection, conducting separate interviews,my role as a researcher, and rigour and trustworthiness of the research.Sampling CharacteristicsThe small number of participants in this study can be viewed as a limitation becausefindings from this research cannot be generalised to other populations; however, that was not thegoal of this study.  The sample size of 28 allowed for in-depth explorations of the dietary issuesof each participant and consequently much richer detail than could be obtained from largersample sizes, and is considered adequate for qualitative studies of this nature (Sandelowski,1995).129Although primarily a convenience sample, purposive sampling was attempted to ensurethat the 14 couples recruited were able to provide relevant information to enhance the developingunderstanding of how gender and gender relations were implicated in their food choices.  Hencefor the purpose of this research, participants were heterosexual couples who were cohabiting,responsible for their own food provision and the men were interested in talking about diet.There were several challenges I experienced in recruiting a wide variety of men and theirfemale partners for this study.  To recruit participants, I attended prostate cancer support groupmeetings, information forums and clinics.  Recruitment was generally difficult because men withprostate cancer, their partners and caregivers were typically reluctant to discuss diet or becomeinvolved in research.  At some venues I was allowed to distribute notices and brochures while atothers I was permitted to directly approach men or couples.  I talked to potential recruits atlength to pre-screen them for eligibility before inviting them to participate.  Many of the menwho approached me with interest in this study had been long-term (more than 5 years) prostatecancer survivors and therefore ineligible for my study.  Similarly, single men and men who didnot wish their wife’s involvement in the research were also ineligible.Asking men to complete food journals was sometimes useful in eliciting the men’sengagement with their diets and involvement in this research.   Several men expressed interest inkeeping journals and were eager to comply with this part of the research.  However, completing afood journal was a deterrent for many other men who lost interest in this study when theyunderstood the time commitment in completing a journal, and then declined to participate.Similarly, some men declined when they realised that their wife was expected to participate aswell, citing that they did not think she would be interested.130For the majority of couples it was the man who initially approached or contacted me,except for one couple where a woman ‘volunteered’ her husband to me.  Because of this I alsoattempted to recruit men through their female partners, however, most of these attempts failed,and I re-focused my recruitment attempts on men who were willing to talk to me about diet.Consequently men in this study might not represent a majority of men who are typicallyexpected to be uninterested in diet and would not wish to participate in such a study.Although I attempted theoretical sampling to recruit a diverse group of participants thiswas not always possible with the time and resources available for a small pilot project of thiskind.  Consequently I relied primarily on available volunteers who tended to be well-educated,middle-class and of Euro-Canadian background and most men were diagnosed with low-riskcancer (see Appendix 15 – participant characteristics).  Thus the resulting participants reflectedthe characteristics of the majority of attendees at the recruitment venues.  Ideally, I would havepreferred a larger selection of couples to theoretically sample from but I did not have sufficientnumbers of volunteers to do this adequately.  Regardless, I was able to recruit a range of ages, acouple with co-habiting young children and two men with wives of Asian-Canadian heritage.Otherwise, this was a moderately homogeneous, convenience sample, thus diet perceptions ofmen with prostate cancer from other socio-economic groups or living situations were not well-represented.  Nevertheless, participants gave detailed and rich accounts of their dietaryperceptions and food practices that allowed me to develop an in-depth theoretical understandingof the diet and diet change understandings of this group of men and women.Data CollectionFindings from this research gave rich and deep insight into this particular context, whichcontributes to growing theoretical understandings of why men engage in certain food practices.131This was achieved by engaging the participants in in-depth interviews in their homes.  Open-ended questions allowed for maximum flexibility and participants were freely able to describetheir perceptions, feelings, beliefs, attitudes and practices in detail.  Because the interviews werenot restricted to specific questions I was able to explore new ideas as they arose for eachparticipant and tailor questions to each participant accordingly.The food journals that the men completed assisted in this by providing concrete examplesof eating events and allowed the men to think deeply about their diets.  Thus the interviews wererelaxed, informal and conversational, which provided relevant data with thick descriptions ofthese understandings from an ‘insiders’ perspective (Dilley, 2000).  The flexibility in researchdesign allowed for some aspects of theoretical sampling within the confines of conveniencesampling.  Accordingly I adjusted some participants’ interview questions about their foodpractices as data collection progressed and therefore was able to explore and saturate differentconcepts more fully as they emerged.Separate InterviewsInterviews were conducted individually and privately to allow the participants freedom toexpress themselves with candour and without censure from their partners.  This was especiallyimportant for interviewing the men who might have otherwise relied on their wives to answer forthem if couples were interviewed together.  This was reflected by the tendency of some men toask their wife to complete their food journals for them and for some of the women to offer to‘help out’ with the men’s interviews to ensure that the ‘proper’ account of family food practiceswas provided.  For example, even though they were instructed to fill out their food journalsindependently, two men relied on their wives to do it for them and another asked his wife to type132it for him and ensure that it was accurate.  Even so, a few men had difficulty in remembering ortalking about some healthy eating details and at times deferred questions to their wives’interviews rather than answer for themselves.  This suggested that for some men, if his wife hadattended the interview with him, the man would have asked for her input rather than provide hisown perceptions.In addition, food and eating can be contentious issues for some couples.  Severalparticipants were critical of their spouse’s food practices and some couples disagreed on thenature and extent of the men’s diet involvement.  For example, one man perceived that he mademajor diet changes, despite his wife’s assertions that she already provided him a healthy diet anddismissed his changes as minor and unimportant.  This is especially salient since the genderrelations framework used required examining gender power structures, which might also besources of couple contention.Generally, the men easily discussed their dietary practices, especially their less-healthyhabits, which they might not have felt free to do so if their wives were present.  Likewise, thewomen were free to describe their husbands’ eating habits with candour that might have beenhindered by the men’s presence.  Although conducting joint interviews might have provided adifferent, dyadic dimension to the data, the issues of intrusion, power dynamics and differencesof opinion persuaded me to conduct separate and private interviews (Morris, 2001).  Future andlarger studies might benefit from conducting both joint and separate interviews to explore theseissues more fully, however, this was beyond the scope of this project.  Therefore, to ensure thatgender relations was fully explored in the interviews, I probed each participant about theirpartner’s and their own roles in household food practices.  In this way I was able to expose133individual food roles and tacit power relations within couples that might not have beenuncovered in dyad interviews.My Role as ResearcherI recognise that as the researcher, I was a co-constructor of these interviews and that theresulting analyses emerged from my interpretations of the data.  Interviews were guided andenhanced by my training and experiences in interviewing men about prostate cancer and health(e.g., Oliffe, Davison, Pickles, & Mroz, 2009).  As a male researcher I felt prepared to interviewother men about topics men are often unable or unwilling to discuss: nutrition and prostate health(Oliffe & Mróz, 2005).As a man, power issues might have been at play in either men’s or women’s interviews.Women might have interpreted my interest in their food perceptions as a form of verification oftheir femininity and nurturing of their husbands.  Alternatively some might have felt threatenedby questions about their household food provision practices.  For example, a few of the womenseemed reluctant to be interviewed and only agreed to do so at their husband’s request.  It waschallenging for me to get some of them to talk in-depth about some of the issues and they werenot interested in long, deep discussions.  For some of these women, it was apparent thathousehold food was their domain and that their husband’s interest in food did not concern themor alter their usual food provision.  However, most of the women appeared eager to talk to meabout their husbands’ diets to ensure I understood the ‘truth’ and not just the men’s (incomplete)understandings of the women’s food provision.  Likewise men might have been threatened byquestions about their personal food perceptions because they might have interpreted my interest134as a ‘test’ of their masculinity.  However, since most of the men eagerly volunteered for thestudy, they were patient and willing participants.Having a women interviewer might have created a different interview interaction, but Iremained open and tried to maintain a ‘neutral’ demeanour to ensure participants were at ease tospeak freely.  Other than gender, my age and educational background might have been more ofan influence on the interview outcomes.  Because I identified myself as a nutrition student,participants tended to view me as ‘young’ and a ‘nutrition expert’ and they might have used theinterviews as a means to explain, justify and verify their beliefs and knowledge about diet andprostate cancer.  This was less apparent for a few of the younger participants who viewed memore as a peer than a ‘young’ student.  Likewise issues of class and education might haveinfluenced the interviews.  For example, two of the men were professors and one woman was adietitian, who might have viewed the interview as an opportunity for mentoring.  Alternatively,several of the participants were trades or service workers and might have been intimidated by myeducation.  I therefore strove to present myself as a competent and interested learner seeking theparticipants’ unique perceptions and beliefs about diet without judgement.I also acknowledge that my own background, education, class and theoretical sensitivitycontributed to all aspects of this research.  I was trained in molecular biology and nutritionalbiochemistry and approach diet and healthy eating from a traditional scientific stance.  My beliefin the efficacy of diet for prostate cancer survivorship influenced my attitudes towards diet andself-care and would have helped shape the design and delivery of interviews.  For example Iassumed that the men would be interested in making healthy diet changes specifically forprostate cancer and thus initially directed questions in that direction.135As a social science researcher embracing a constructionist understanding of masculinityand gender relations I was prepared to critically examine men and women’s performances ofgender through food, thus exposing those tacit assumptions often held by people as natural andunquestioned.  This presented a challenge during the interviews as I questioned the naturalnessof men’s and women’s food ‘roles’ as the participants described them.  I wished to understandtheir perspectives yet also not appear to contest their beliefs.  This was not always easy toaccomplish and there were questions that were not well received because they challengedparticipants’ beliefs.  For example when I asked some men about their roles in food provisionthey interpreted my questioning to imply that they should be more engaged in family food andconsequently defended their lack of food work involvement.  These tensions were negotiateddifferently with each participant and were part of the ‘messiness’ associated with this type ofresearch.Tacit understandings about food and gender extended into the data analysis where myown assumptions about men’s and women’s gender ideals sometimes delayed me gaining adeeper understanding of the data.  For example, I at first assumed that women’s control of thedomestic food signified a challenge to gender hierarchy rather than existing within patriarchy.This illustrates the challenges of examining social structures, which guide both the participants’and researcher’s beliefs and behaviours.  As a man questioning gender food roles I was keenlyaware of my own privileged interpretations of diet and food roles in society and in my ownmarriage.  Although a man, I felt that I could view and interpret gender issues from a uniqueposition as both a student of gender theory, and also as an ‘outsider’ from traditional hetero-normative couple roles because my spouse is also a man.  My position within a subordinatedmasculinity offered me a novel view of masculinity and gender relations that a more136‘hegemonic’ man might not have experienced thus allowing a different dimension to the analysisand research product.Rigour and Trustworthiness of the ResearchMy knowledge and experience helped shape the interviews and subsequent analysis;however, I strove to ensure that the findings were represented in the data and therefore left adetailed audit trail of codes, and memos to document how the analysis was conducted and toenhance the study rigour and trustworthiness (Morse & Field, 1995).  Several methods were usedto enhance trustworthiness of the findings.  In-depth interviews were conducted to ensure richand meaningful discussions with participants.  Both men with prostate cancer and their femalepartners were interviewed to provide alternate and sometimes diverse perspectives on the men’sfood practices.  Data triangulation was performed by using different sources of data including,food journals, field notes and dyad summaries.  Periodic team meetings were held with mysupervisory committee to discuss the data as coding, analysis and writing progressed to enhancethe credibility of the findings.Implications for Future ResearchBecause this study group was somewhat homogeneous, the dietary perceptions ofdifferent sub-groups of men, including single-living, institutionalised, younger men, men withcohabiting children, men living in same-sex relationships and men from other social class,cultures and ethnicities should be included in future research.  Findings from this project mighthelp inform future development of food habit survey instruments and health promotion programstargeting men with prostate cancer.  In addition these insights would assist oncology/nutritionresearchers to incorporate greater understandings of how gender influences men’s dietary137perceptions and practices in relation to health and disease.  For example, surveys might explorethe extent to which the rationales men provided for diet change (or lack thereof) are prevalent invarious groups of men.The food choice process model as presented by the Cornell food choice research group(Furst, Connors, Bisogni, Sobal, & Falk, 1996; Sobal & Bisogni, 2009) would benefit fromincorporating information on gender based food choice research.  These findings suggest thatmen’s food choices are shaped by gender in several ways that are different to women that couldinform model constructs.  Men’s food ideals and personal factors that influence food choice areshaped by masculine food ideals.  Masculinity might also shape men’s ‘value negotiations’,described in the model as necessary for developing personal food systems because men mighthave different value systems about food than women.  These findings also show that masculinityand femininity interact to influence men’s food choices.  Although men might perceive food andfood choices differently than women, their overall food practices also appear more heavilyinfluenced by such interactions in their social context.  Generally, men’s food interactions withwomen as described here, suggest that the context of food choices are important, especially thesocial context of gendered relations.  Further research is needed to determine how gender can beincorporated more fully into this model to illustrate the differences in men and women’s foodchoice processes.Implications for PracticeResearch findings from this project will contribute to ongoing research and developmentof nutrition education and support services for men with prostate cancer, enhancing the ability ofthese programs to meet the specific needs of their client population.  Increased understanding ofthe nutrition education and support needs of men with prostate cancer and their families will138have policy implications regarding the provision of nutrition services within cancer care.  Healthpromotion programs might consider how masculinity might influence the uptake of nutritionservices and how women might be appropriately involved.  Findings demonstrate that exploringmasculinity alone is necessary but insufficient for understanding men’s diets.  Nutritioneducation and program planning for men is complex and findings show how understandinggender relations and the role that women play in men’s diets is essential for success.Nutrition intervention program developers need to understand that reframing healthyeating as masculine might change men’s perceptions about food but might not necessarilychange their food practices.  Program developers must also consider how food practices areconstructed within couple dynamics and how interventions might disrupt or sustain these powerrelations.  Therefore nutritionists must consider how the women in the lives of men with prostatecancer will respond to nutrition programs and men’s increased interest in food.  Interventionsthat do not oppose hetero-normative gender food roles might work for some couples that areunlikely to change traditional food practices, and therefore the women should be targeted for dietchange.  Other approaches might encourage men and women to consider how these gender foodroles constrain men and their food practices, and then encourage men to become more involvedin their own diets.  Incorporating knowledge of how gender and gender relations shapes the dietperceptions and food practices of men with prostate cancer and their female partners will ensurethat these programs are comprehensible, efficacious and ultimately relevant to clinical practice(Davison, 2003).  As results of ongoing research clarify the biological relationships between dietand prostate cancer, the knowledge provided by this study will be critical for development ofprograms that will result in the behaviour changes needed to reduce prostate cancer morbidityand mortality.139ConclusionsThis project adds to the growing body of literature in men’s health and food practices,which seeks to explain why men eat what they eat and why men’s diets are often unhealthycompared to women.  Findings from this dissertation contribute to ongoing men’s health researchby showing how men’s food choice behaviour, and consequently their nutritional health, isshaped by psychosocial influences, including gender, masculinity and femininity, family andgender relations.  Furthermore, this study extends current understandings by examining foodchoices of a previously unstudied subgroup of men who have experienced prostate cancer, andincludes their female partners.Jean Anthelme Brillat-Savarin, the French philosopher and gastronome, associated foodand cuisine with a person’s character when he wrote in 1825: “Tell me what kind of food youeat, and I will tell you what kind of man you are” (Brillat-Savarin, 1825/1854).  Findings fromthis dissertation demonstrate how this is true for men with prostate cancer nearly two centurieslater: how food practices are linked to what it means to be a man in modern Western society, andhow experiencing prostate cancer creates a dilemma for men who must decide what kind of manthey want to embody through the kind of food they eat.  Hegemonic gender theory has beenuseful in showing how masculinity shapes constructions of food ideals and how they contributeto men’s perceptions of food and their actual food practices.  These findings address aknowledge gap by illuminating these constructions in previously unstudied contexts, prostatecancer, and framed with gender relations.  By responding to Lyon’s (2009) appeal for anintegration of gender relations to masculinity and men’s health research, I add a novel dimensionto understanding how interactions between men and women must also be better understood.Women are also influenced by hegemonic masculine ideals about how the men in their lives140should act around food, as well as feminine ideals guiding their own behaviours.  In the contextof prostate cancer, these findings demonstrate how couple’s expressions of masculinity andfemininity interact to shape and constrain men’s food practices.  These insights increase ourunderstanding of men’s food choice behaviour and inform future research in men’s nutritionalhealth practices and assist nutrition programmers in developing services for men with prostatecancer, and the women in their lives.141ReferencesBourdieu, P. (1984). Distinction: A social critique of the judgement of taste. Cambridge,Massachusetts: Harvard University Press.Bourdieu, P. (2001). Masculine domination. Stanford, California: Stanford University Press.Brillat-Savarin, J. A. (1825/1854). Physiologie du Gout, ou Meditations de GastronomieTranscendante (Fayette Robinson trans.). Philidelphia: Lindsay&Blakiston  p25(Original work published 1825).Charmaz, K. (2006). Constructing grounded theory. London; Thousand Oaks, California: SagePublications.Connell, R. W. (1995). Masculinities. Berkeley: University of California Press.Connell, R. W., & Messerschmidt, J. W. (2005). Hegemonic masculinity: Rethinking theconcept. Gender & Society, 19(6), 829-859.Courtenay, W. H. (2000). Constructions of masculinity and their influence on men's well-being:A theory of gender and health. Social Science & Medicine, 50(10), 1385-1401.Davison, B. J. (2003). Utilizing research to guide clinical practice in prostate cancer education.Oncology Nursing Forum, 30(3), 377-379.Demark-Wahnefried, W., Aziz, N. M., Rowland, J. H., & Pinto, B. M. (2005). Riding the crest ofthe teachable moment: Promoting long-term health after the diagnosis of cancer. Journalof Clinical Oncology, 23(24), 5814-5830.Deutsch, J. (2005). "Please pass the chicken tits": Rethinking men and cooking at an urbanfirehouse. Food & Foodways, 13(1/2), 91-114.DeVault, M. L. (1991). Feeding the family: The social organization of caring as gendered work.Chicago: University of Chicago Press.Dilley, P. (2000). Conducting successful interviews: Tips for intrepid research. Theory IntoPractice, 39(3), 131-137.142Furst, T., Connors, M., Bisogni, C. A., Sobal, J., & Falk, L. W. (1996). Food choice: Aconceptual model of the process. Appetite, 26(3), 247-265.Furst, E. L. (1997). Cooking and femininity. Women’s Studies International Forum, 20(3), 441-449.Jensen, K. O. D., & Holm, L. (1999). Preferences, quantities and concerns: Socio-culturalperspectives on the gendered consumption of foods. European Journal of ClinicalNutrition, 53(5), 351-359.Lupton, D. (2000). 'Where's me dinner?': Food preparation arrangements in rural Australianfamilies. Journal of Sociology, 36(2), 172-186.Lyons, A. C. (2009). Masculinities, femininities, behaviour and health. Social and PersonalityPsychology Compass, 3(4), 394-412.Maliski, S. L., Heilemann, M. V., & McCorkle, R. (2002). From "death sentence" to "goodcancer": Couples' transformation of a prostate cancer diagnosis. Nursing Research, 51(6),391-397.Morris, S. M. (2001). Joint and individual interviewing in the context of cancer. QualitativeHealth Research, 11(4), 553-567.Morse, J. M., & Field, P.-A. (1995). Qualitative research methods for health professionals (2nded.). Thousand Oaks: Sage Publications.Moyad, M. A. (2006a). Step-by-step lifestyle changes that can improve urologic health in men,Part I: What do I tell my patients? Primary Care: Clinics in Office Practice, 33(1), 139-163.Moyad, M. A. (2006b). Step-by-step lifestyle changes that can improve urologic health in men,Part II: What do I tell my patients? Primary Care: Clinics in Office Practice, 33(1), 165-185.Moynihan, C. (1998). Theories in health care and research - Theories of masculinity. BritishMedical Journal, 317(7165), 1072-1075.Oliffe, J. L. (2005). Constructions of masculinity following prostatectomy-induced impotence.Social Science & Medicine, 60(10), 2249-2259.143Oliffe, J. L., Davison, B. J., Pickles, T., & Mroz, L. (2009). The self-management of uncertaintyamong men undertaking active surveillance for low-risk prostate cancer. QualitativeHealth Research, 19(4), 432-443.Oliffe, J. L., & Mróz, L. (2005). Men interviewing men about health and illness: Ten lessonslearned. The Journal of Men's Health & Gender, 2(2), 257-260.Robertson, S. (2007). Understanding men and health: Masculinities, identity, and well-being.Maidenhead; New York: McGraw Hill/Open University Press.Roos, G., & Wandel, M. (2005). "I eat because I'm hungry, because it's good, and to becomefull": Everyday eating voiced by male carpenters, drivers, and engineers in contemporaryOslo. Food & Foodways, 13(1/2), 169-180.Sandelowski, M. (1995). Sample size in qualitative research. Research in Nursing & Health,18(2), 179-183.Schippers, M. (2007). Recovering the feminine other: Masculinity, femininity, and genderhegemony. Theory & Society, 36(1), 85-102.Schulz, A. J., & Mullings, L. Eds. (2006). Gender, Race, Class, and Health: IntersectionalApproaches. San Francisco, California: Jossey-Bass.Sobal, J. (2005). Men, meat and marriage: Models of masculinity. Food & Foodways, 13(1/2),135-158.Sobal, J., & Bisogni, C. (2009). Constructing food choice decisions. Annals of BehavioralMedicine, 38(0), 37-46.144APPENDICESAppendix 1.  Food for Thought  © Parkurst, 2003 (Used by permission fromOur Voice)145146147Appendix 2.  UBC Research Ethics Board's Certificate of Approval148Appendix 3.  Recruitment Advertisement149Appendix 4.  Recruitment Brochure150151Appendix 5.  Consent Form for Men with Prostate CancerTHE UNIVERSITY OF BRITISH COLUMBIAConsent Form (Men with prostate cancer)Project Title:DIETARY BELIEFS AND PRACTICES OF MEN WITH PROSTATE CANCERInvestigators:Dr. Gwen Chapman, Food, Nutrition and Health, UBC, Phone: (604) 822-6874Dr. Joan Bottorff  Health & Human Development, UBC-O, Phone: (250) 807-9901Dr John Oliffe, School of Nursing, UBC, Phone: (604) 822-7638Graduate Student:Lawrence (Larry) Mróz, Food, Nutrition, and Health, Phone: (604) 822-5057(Parts of this research will be used for a PhD thesis in Human Nutrition at the Universityof British Columbia)Introduction: Many men with prostate cancer and their families show interest in thepotential role of diet in prevention, treatment and recovery from prostate cancer.However, little is known about their actual dietary beliefs and practices. Furtherunderstanding of these issues is needed for development of effective educational andcounselling resources.(Note that although this study is about diet, it is important to consider that diet is onlyone aspect of prostate cancer prevention and treatment research and that many otherfactors are involved in the occurrence of prostate cancer.)You have been invited to participate in this study because you were diagnosed withlocalised prostate cancer and have completed definitive treatment within the past 5years, or are on a ‘watchful waiting’ protocol.Food, Nutrition and HealthFaculty of Land and Food Systems2205 East MallVancouver, BC, V6T 1Z4Phone:  (604) 822-6874Fax:  (604) 822-5143152Purpose: The purpose of this study is to examine how men with prostate cancer makedecisions about what they eat.Study Procedures: Your involvement in this study will include several components,involving a total of 2 to 4 hours of your time:1. Food Journal. You will be given a booklet to use as a Food Journal.  You will beasked to keep a record of everything that you eat and drink for one week.  Thisbooklet will be used by the interviewer to ask you questions about what you ate andthe reasons for doing so.2. Interview. In a private, tape-recorded interview, a researcher will ask you to talkabout what you eat and drink on a daily basis, and how those eating habits relate toyour health concerns and personal preferences. You will also be asked to talk abouthow food-related decisions are made in your family, including who makes thedecisions, how family members influence each other, and why you make the foodchoices that you do.  We will ask who shops for and prepares the food and whomakes these decisions.  We will ask you what your definition of healthy eating is andyour opinion of the role of diet in prostate cancer recovery. The interview will lastapproximately 1 to 1.5 hours.3. Follow up interviews. You may be asked to participate in an additional interview, tofollow up on issues raised during the initial interview and to review the findings ofthis study.Confidentiality: Your identity will be kept strictly confidential throughout the study andwhenever we report the findings of the study. Any tapes, notes and interview transcriptswill be labelled with a code number and/or false name, and stored in a locked filingcabinet. Your name will be recorded only on this consent form and on one master listthat links your name to your code number and/or false name. The consent form andmaster list will be stored in a separate locked filing cabinet, accessible only to membersof the research team.  Any computer files relating to this research will be stored onpassword protected computers that only members of the research team can access.When we report the findings of this study, we will not report details about you or yourpartner that would allow others to identify you.Remuneration/Compensation: In order to compensate you and your partner for thetime involved in participating in this project, each couple will receive a $30 gift certificatefor a bookstore.Risks: There is a possibility that differences of opinion between you and your partneraround food choice issues may become apparent through this research.Future use of data:   In addition to publications and presentations addressing theresearch questions identified above, data collected for this study might be used for:a) future comparative analyses in studies on similar topics but with a differentgroup of participantsb) teaching purposes in qualitative research methods courses.Your identity will be kept strictly confidential in any of these situations.153Contact for information about the study:  You are welcome to ask any questions, atany time, regarding any aspect of this study. You may ask questions of the researcherwho is interviewing you, and/or you may contact Dr. Gwen Chapman (604) 822-6874.Contact for concerns about rights of research subjects:  If you have any concernsabout your treatment or rights as a research subject, you may contact the ResearchSubject Information Line in the UBC Office of Research Services at (604) 822-8598.Consent:  Your participation in this study is entirely voluntary and you may refuse toparticipate or withdraw from the study at any time without any consequences to yourrelationship with the University, health care, or community services.Your signature below indicates that:1. You have received a copy of this consent form for your own records2. You consent to participate in this study.____________________________________________________Participant SignatureDate____________________________________________________Printed Name of the Participant signing above.____________________________________________________Witness SignatureDate____________________________________________________Printed Name of the Witness signing above.154Appendix 6.  Interview Guide for Men with Prostate CancerInterview Guide for Men with Prostate CancerNotes:  The goal of the interview is to uncover men’s understandings regarding the roleof diet and nutrition in health for men with prostate cancer.  Consequently, questions will bedirected towards the men’s understandings of diet in the context of prostate cancer.  Questionsregarding dietary practises will include the men’s partners to uncover how these family andsocial forces influence men’s behaviour. Probing will be added as needed to ensure full answersto the questions.1. Preamble:  Explanations regarding the nature of the study, informed consent andconfidentiality.  Additionally, participants will be advised that there are no “right” answers tothe questions, and that no one will judge them on their diet or lifestyle.2. Introductions:  Getting to know about the participant.a. Let’s begin by talking about your experiences with prostate cancer.  (probe: whendiagnosed, what it was like to be diagnosed, watchful waiting or treatment choice andhistory)b. How would you describe your overall health now? (probe for health history, healthconcerns, medications, diet related illnesses or conditions such as heart disease ordiabetes)Using the Food Journal: Prior to this interview, review the journal entries and make notes about the participant’s foodchoices. Use the Food Journal as a discussion starting point.c. What was it like to fill out this journal?  (probes: difficulties, surprises)d. Is this a reasonably accurate account of your usual diet?  (probes: any specialoccasions, unusual events in past week)Choose a few (2-3) specific contrasting events from the food journal to use as examples.Show participant the entries and ask him why he made those choices and in what context.e. Let’s talk about this (meal snack) How typical is it? (probe: if not typical, why not?)f. What influenced the things you ate here?  How did having (person) with you make adifference?  (probe for particular items and alcohol)Use this a starting point to discuss his daily dietary habits including typical or everydayand special occasions.  Ask him to choose a “typical” day from the journal.g. What makes this a typical day (weekend or weekday)? (probe: for vitamin andsupplement usage, eating out, junk food, organics, refined or whole foods, alcoholand other beverages).155h. I’m interested in learning about men’s eating habits.  How are decisions usually madeabout what you eat? When and where do you usually eat?  With whom? Why?(probe: eat out or in? social reasons)If he can’t choose a typical day then ask:i. How would a typical day look in your journal?Ask him to choose an unusual day:j. How is this an unusual day for you?  (probe: special occasions)General questions:k. What would you say are the biggest influences on what you eat? (probe: cost, taste,favourite meals/foods, convenience, partner, habits, prostate cancer or other illness)l. Are you currently on any special or restrictive diet?  If so why? How does it changethe way you eat? (probe: other health issues, losing weight, fad diets, “low-carb” diet)3. Prostate cancer and diet: The goal in this section is to explore how and why his diet haschanged during his specific prostate cancer illness trajectory.a. How is what you recorded in this journal different from what you might haverecorded if you had completed this journal some time in the year before you werediagnosed with prostate cancer?  (probe: why was your diet different then?)b. If you had completed this journal in the first month after your diagnosis, how would ithave differed then? (probe: why was your diet different then?)Depending on the participant’s prostate cancer history, probes will be made for otherdietary changes made over time in relation to his specific illness progression.c. Are there any other times since your diagnosis that your journal would have lookeddifferent?  Why? (probe for dietary changes during treatment decision making; whilewatchful waiting; before, during and after treatment(s); while in recovery; after being‘cured’ of cancer)  (For men who had treatments probe for treatment side effects onhunger or appetite.)d. What do you think was the most important change you’ve made in your diet sincehaving prostate cancer?  What were the main reasons for making these changes?e. Have you ever changed what you eat because of treatment side effects?f. Is there anything about your diet that you haven’t changed that you think you should?(probe why didn’t you make those changes?)(For men who have NOT made dietary changes skip questions f and g)g. Do you think you will be able to keep up the changes you have made in your dietsince you’ve had prostate cancer? What would help you?  What would hinder you?(probe: old versus new habits)h. Is there anything in your diet that you miss from before you had prostate cancer?156I’ve been asking you about your own diet, but I’d like to ask some general questions.i. What role do you think diet plays in prostate cancer recovery? (probe for how it caneffect your own health)j. What if anything, can you do to prevent prostate cancer recurrence? How might dietaffect your prostate cancer recurrence?k. How might diet affect a man’s PSA level?l. Among PCa patients, there seems to be a controversy (difference in opinions) aboutthe role of diet and lifestyle in PCa recovery – have you seen this?  What do you thinkabout it?m. Do you think the way men eat has influenced this controversy in any way – how?n. How do you make sense of the differences in opinion and all the nutritional advicethat you hear? How about other men?o. Some men treat their diagnosis as a ‘wake–up call’ for diet and lifestyle changes –what do you think about that?  Did that happen for you?  Tell me about it.p. Some men want to be doing something themselves- did you feel this way?  If so, whatdid you do?q. I’ve found that some men eat for prostate cancer, some eat for general health andsome eat as they always have – what do you think about that?  Where would youplace yourself?4. Role of Man’s Partner in diet:a. What would your (partner/wife) say about your diet?  (probe: how healthy would shethink it is? What changes would she think you’ve made)b. What would she say about her role in your diet?c. Who shops for food in your household?d. In your home how does meal preparation occur? What role do you play?e. How are decisions made about which foods/meals are bought, prepared or served inyour home? (probe: differences in taste, cooking skills)f. What things about food do you and your partner agree about?  What things aboutfood do you disagree about? (probe: differences in opinion between him and partner)g. Do you discuss healthy eating with your partner?  If so, what do you talk about?h. Did you/your partner change what you/she cooked or served after you werediagnosed?  What sort of plans do you have for making dietary changes? (probe forincorporating prostate healthy cooking information)i. What would she say about this?j. How does her diet influence yours? (probe: diet related illness, special diets, dieting)1575. Healthy Eating:a. What do you think a healthy diet would be like for you?b. What about for other men?  What kind of diet is important for a man to follow?  Isthis different from a healthy diet for a woman? How does being a man influence whatyou eat and drink? (probe: alcohol, meat, fruits and vegetables)c. Do you eat a healthy diet?  If so, what about your diet makes it healthy?d. How do you think your diet influences your health?e. Where do you get nutrition information? (probe, partner, friends, doctor)f. How do you incorporate new nutrition information into your diet? (probe: wife’s role)g. Do you have enough information about healthy diets? If not, what sort of informationdo you need or want?h. Is there anything that keeps you from eating a healthy diet?  If so, what?i. Is there anything that helps you eat a healthy diet? If so, what?6. Summary and closing:a. These are all the questions that I have but before we finish is there anything elseabout diet and prostate cancer that you want to tell me?b. Is there anything else about healthy eating for men with prostate cancer? Are thereany questions that I should have asked?Thanks for participating.  Invitation to learn about study results and to participate infuture research.  Ask permission to contact for follow-up interview.158Appendix 7.  Food Journal Booklet Templates (Cover, Instructions, Exampleof Completed Page, Blank Page)159FOOD JOURNAL INSTRUCTIONS:Dear Sir;In this notebook I would like you to record a diary of everything that you eat ordrink over a one-week period, including all beverages (such as coffee, tea or alcohol)and all meals and snacks.   Please include a weekend in this time period.  For every timeyou have something to eat or drink, please write it down in the appropriate spaces in thejournal.Please also include such details as who prepared the food, or where it waspurchased (for example from a restaurant or coffee shop) who you had it with and whereyou had it.  You don’t need to worry about exact amounts.You should also write down anything that you think is important about each mealor snack, such as your feelings about what you ate or drank and why you had thatparticular food or drink.Please write down:! What you ate or drank! When you ate or drank it! Who you ate or drank it with! Where this occurred! Preparation (or purchase) details! Your thoughts and feelings about this food choiceThe purpose of this journal is not to analyse or judge your diet, but rather torecord your general food and drink related choices over one week including meals,snacks, coffee breaks, beverages, alcohol drinks or anything else that you consume.  Wewill use this journal in our interview where we will discuss your diet.See the sample page for an example of how this should be done.  When you havecompleted the journal please call me at 604-822-5057 or email me atlwmroz@interchange.ubc.ca and I will come to pick it up from you and arrange for ourinterview.Thanks!Larry Mróz160Sample of completed page:When? Date/Time:March 2/06 morningWas it a Meal, Snack or Drink? (including alcohol)Snack – coffee breakWhere? Location of Meal, Snack, or Drink:At homeWith Whom?With my wife and sonWhat was Consumed? (Describe)Coffee (medium size mocha)  and 1 small piece of chocolate cakePreparation or purchase details: (made at home? who made it or where was it bought?)My wife made the cake- it was chocolate with chocolate icing- from a mix, the coffee which was a double café mocha for me and a soy latte for my wife came from starbucks that myson picked up on his way over to visit.Other Comments (reasons for choices, reflections/feelings, concerns…):Son drops by every week for coffee and a visit.  We usually have a treat of some kind and a nice visit.161(Blank Journal Page)When? Date/Time:Was it a Meal, Snack orDrink (including alcohol)?Where? Location of Meal,Snack, or Drink:With Whom?What was Consumed? (Describe)Preparation or purchase details: (made at home? whomade it or where was it bought?)162Dietary beliefs and practices of Men with Prostate CancerDemographic data form for men (to be completed by interviewer)Participant Code: _________________  Interview Date:                                       Age:                  Ethnicity:                              Marital Status:                                    Education Level:                                          What is/was your usual occupation?                                                                       Are you:Employed Ful time          Part time        Retired              On Disability              Unemployed             What was your approximate family income for the past year?                                       Who currently lives with you (eg. Children)? Please list                                                                                                                                                                                                 When was your prostate cancer diagnosis?                                                                       What was the site of your cancer (eg. Local)?                                                                   What was the stage of illness at diagnosis?                                                                        What prostate cancer treatment did you have?No treatment             Watchful waiting NoYes  Date:                                SurgeryNoYes  Date:                                Radiation (EBRT)NoYes  Date:                                Hormone NoYes  Date:                                Brachytherapy NoYes  Date:                                Other treatmentNoYes  Date:                                Type:                           Have you been diagnosed with, or had the following?Food Allergies NoYes  List:                                 High CholesterolNoYes  Date:                                Appendix 8.  Demographics Form for Men with Prostate Cancer163Heart DiseaseNoYes  Date:                                Heart attackNoYes  Date:                                StrokeNoYes  Date:                                DiabetesNoYes  Date:                                Other CancerNoYes  Date:                                Type:                           Others please list:                                                                                                                                                                                                                                                      Are you currently taking any treatments or medications?No  Yes  please list                                                                                                                                                                                                                                                            Are you currently on a restricted or special diet for a particular health concern?NoYes  please describe:                                                                                                                                                                                                                                                  Are you currently trying to lose weight?No YesWhat is your biggest health concern (if any)?                                                                                                                                                                                                                   What is your biggest dietary concern (if any)?                                                                                                                                                                                                                  Thank you!  Please use the following space for any other relevant information.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 164Appendix 9.  Field Notes FormField notes,  PCDate:Location:Contact notes:Notes on Man:Non-verbal:Content of Man’s Interview:Analysis of man’s interview:Notes on Partner:Non-verbal:Content of Partner’s interview:Analysis of Partner’s interview:Dyad notes:165Appendix 10.  Coding ScheduleCoding schedule for diet changes after prostate cancer diagnosis [39]Lawrence Mróz January 4, 2008Category:  Types of diet changes [6]• Adding foods [also experimenting with new foods and cooking styles]• Eating as usual [no change]• Eating less/more of• Overhauling diet [descriptions of major changes]• Revisiting healthy eating [general descriptions of improved eating,paying more attention, being more careful, eating better]• Taking supplementsCategory: Reasons for diet changes [5]• Changing for general health• Changing for other reasons• Changing for other specific health concerns• Changing for prostate cancer• Changing for treatmentsCategory: Reasons for no changes [3]• Already have a healthy diet• Eating for other reasons [specific influences used as reasons for notchanging]• Other reasons for not changingCategory: Dietary beliefs [6]• Could eat better• Definitions of healthy eating [general diet beliefs and practises]• Diet affects health• Diet affects prostate cancer• Diet doesn’t affect prostate cancer• Unsure about role of diet in prostate cancer166Category: Influences on diet [8]• Bariers to change• Eating for Health [general reasons for healthy eating, living longer]• Facilitators to change• Life history• Nutrition confusion• Other influences• Partner• Work/retirementCategory: Diet information or advice [7]• Expert advice• F to M advice• M to F advice• Other advice sources• Peer advice• Seking advice• Written informationCategory: Roles – doing food work [2]• Engaging in food [becoming involved with food work]• Food provisionCategory:  Commentary on men’s diets [2]• Men’s commentary• Women’s commentary167Appendix 11.  Consent Form for WomenTHE UNIVERSITY OF BRITISH COLUMBIAConsent Form (Spouse/partners of men with prostate cancer)Project Title:DIETARY BELIEFS AND PRACTICES OF MEN WITH PROSTATE CANCERInvestigators:Dr. Gwen Chapman, Food, Nutrition and Health, UBC, Phone: (604) 822-6874Dr. Joan Bottorff  Health & Human Development, UBC-O, Phone: (250) 807-9901Dr. John Oliffe, School of Nursing, UBC, Phone: (604) 822-7638Graduate Student:Lawrence (Larry) Mróz, Food, Nutrition, and Health, Phone: (604) 822-5057(Parts of this research will be used for a PhD thesis in Human Nutrition at the Universityof British Columbia)Introduction: Many men with prostate cancer and their families show interest in thepotential role of diet in prevention, treatment and recovery from prostate cancer.However, little is known about their actual dietary beliefs and practices. Furtherunderstanding of these issues is needed for development of effective educational andcounselling resources.(Note that although this study is about diet, it is important to consider that diet is onlyone aspect of prostate cancer prevention and treatment research and that many otherfactors are involved in the occurrence of prostate cancer.)You have been invited to participate in this study because your husband/partner wasdiagnosed with localised prostate cancer and completed definitive treatment within thepast 5 years or is on a ‘watchful waiting’ protocol.Food, Nutrition and HealthFaculty of Land and Food Systems2205 East MallVancouver, BC, V6T 1Z4Phone:  (604) 822-6874Fax:  (604) 822-5143168Purpose: The purpose of this study is to examine how men with prostate cancer makedecisions about what they eat.Study Procedures: Your involvement will occupy about an hour and a half of your time.4. Interview. In a private tape-recorded interview, a researcher will ask you to talkabout what your husband/partner eats and drinks on a daily basis, and how thoseeating habits relate to his health concerns and personal preferences as well as toyour eating habits. You will also be asked to talk about how food-related decisionsare made in your family, including who makes the decisions, how family membersinfluence each other, and why you and your partner make the food choices that youdo.  We will ask who shops for and prepares the food and who makes thesedecisions.  We will ask you what your definition of healthy eating is and your opinionof the role of diet in prostate cancer recovery. The interview will last approximately 1to 1.5 hours.5. Follow up interviews. You may be asked to participate in an additional interview, tofollow up on issues raised during the initial interview and to review the findings ofthis study.Confidentiality: Your identity will be kept strictly confidential throughout the study andwhenever we report the findings of the study. Any tapes, notes and interview transcriptswill be labelled with a code number and/or false name, and stored in a locked filingcabinet. Your name will be recorded only on this consent form and on one master listthat links your name to your code number and/or false name. The consent form andmaster list will be stored in a separate locked filing cabinet, accessible only to membersof the research team.  Any computer files relating to this research will be stored onpassword protected computers that only members of the research team can access.When we report the findings of this study, we will not report details about you or yourpartner that would allow others to identify you.Remuneration/Compensation: In order to compensate you and your partner for thetime involved in participating in this project, each couple will receive a $30 gift certificatefor a bookstore.Risks: There is a possibility that differences of opinion between you and your partneraround food choice issues may become apparent through this research.Future use of data:  In addition to publications and presentations addressing theresearch questions identified above, data collected for this study might be used for:a) future comparative analyses in studies on similar topics but with a differentgroup of participantsb) teaching purposes in qualitative research methods courses.Your identity will be kept strictly confidential in any of these situations.169Contact for information about the study:  You are welcome to ask any questions, atany time, regarding any aspect of this study. You may ask questions of the researcherwho is interviewing you, and/or you may contact Dr. Gwen Chapman (604) 822-6874.Contact for concerns about rights of research subjects:  If you have any concernsabout your treatment or rights as a research subject, you may contact the ResearchSubject Information Line in the UBC Office of Research Services at (604) 822-8598.Consent:  Your participation in this study is entirely voluntary and you may refuse toparticipate or withdraw from the study at any time without any consequences to yourrelationship with the University, health care, or community services.Your signature below indicates that:3. You have received a copy of this consent form for your own records4. You consent to participate in this study.____________________________________________________Participant SignatureDate____________________________________________________Printed Name of the Participant signing above.____________________________________________________Witness SignatureDate____________________________________________________Printed Name of the Witness signing above.170 Appendix 12.  Interview Guide for WomenInterview Guide for Partners of Men with Prostate CancerNotes:  The goal of the interview is to uncover men’s understandings regarding the role of dietand nutrition in health for men with prostate cancer.  Consequently, questions will be directedtowards the woman’s understandings of her partner’s diet in the context of prostate cancer.Questions regarding dietary practises are included to uncover how these family and social forcesinfluence men’s behaviour. Probing will be added as needed to ensure full answers to thequestions. The following topics will be covered:1. Preamble:Explanations regarding the nature of the study, informed consent and confidentiality.Additionally, participants will be advised that there are no “right” answers to the questions,and that no one will judge them on their diet or lifestyle.2. Introductions:  Getting to know about the participant.a. Let’s begin by talking about your partner’s experiences with prostate cancer andwhat that’s been like for your family.  (probe: when diagnosed, what it was likefor your family with his diagnosis, watchful waiting or treatment choice andhistory)b. How would you describe his overall health now? (probe for health history, healthconcerns, medications, diet related illnesses or conditions such as heart disease ordiabetes)  What is the impact of his health in your family now?c. How would you describe your own health? (probe for diet related conditions)Man’s diet:d. Now let’s talk about (partner’s) diet.  Please describe his eating and drinkinghabits to me.e. What does he eat during a typical day (weekend or weekday)?f. What about on special occasions? (probe: social events, junk food, alcohol andother beverages)g. When and where does he eat?  With whom?  (probe: eat out or in?)h. What is his favourite meal, least favourite? (probe: who cooks it?)i. What are the biggest influences on what he eats? (probe: cost, taste, favouritemeals/foods, convenience, her, habits, prostate cancer or other illness)j. Is he currently on any special or restrictive diet?  If so why?  How about you?(probe: other health issues, losing weight, fad diets, low-carb diet, vitamin andsupplement usage, organics, refined or whole foods).1713. Prostate cancer and diet:  The goal in this section is to explore how and why his diethas changed during the prostate cancer illness trajectory.a. In what ways, if any, has his diet changed since he was first diagnosed? (probewhy did he make those changes?)Depending on the participant’s prostate cancer history, probes will be made for other dietarychanges made over time in relation to their specific illness progression.(probe for dietary changesduring treatment decision making; while watchful waiting; before, during and after treatment(s);while in recovery; after being ‘cured’ of cancer)For men who have completed treatments probe for treatment side effects on hunger or appetite.(If they made no dietary changes, skip b and c.)b. Is there anything that he used to eat or drink from before he had prostate cancerthat he misses now?c. Do you think he will be able to keep up the changes he has made in his diet sincehe’s had prostate cancer? What would help him?  What would hinder him?(probe: old versus new habits)d. Is there anything about his diet that he hasn’t changed that you think he should?(probe: why didn’t he make those changes?)e. What role do you think diet plays in prostate cancer recovery? (probe: for how itcan effect his health)f. Has he ever changed what he eats because of treatment side effects?g. What if anything, can he do to prevent prostate cancer recurrence? Do you thinkthat diet can affect his prostate cancer recurrence?  If so, how?h. How might diet affect a man’s PSA level?i. Among PCa patients, there seems to be a controversy (difference in opinions)about the role of diet and lifestyle in PCa recovery – have you seen this?  What doyou think about it?j. Do you think the way men eat has influenced this controversy in any way – how?k. How do you make sense of the differences in opinion and all the nutritionaladvice that you hear? How about your partner?  Other men?l. Some men treat their diagnosis as a ‘wake–up call’ for diet and lifestyle changes –what do you think about that?  Did that happen for you?  Tell me about it.m. Some men want to be doing something themselves- did your partner feel thisway?  If so, what did he do?  What do you think about that?n. I’ve found that some men eat for prostate cancer, some eat for general health andsome eat as they always have – what do you think about that?  Where would youplace your partner?o. Do you think altering diet is important for other health reasons? How?1724. Role of Man’s Partner in diet:a. How do you think your partner would describe his diet? (probe: how healthywould he think it is? What changes would he say he’s made?)b. What would he say about your role in his diet?c. How would you describe your role in his diet?d. Who shops for food in your household?e. Who prepares the food that you eat?  How is he involved in meal preparation?f. How are decisions made on what foods/meals are bought, prepared or served inyour home? (probe: personal taste, cooking skills)g. What things about food do you and he agree about? What things about food doyou disagree about? (probe: differences in opinion between her and her partner)h. Do you discuss healthy eating with your partner? If so, what do you talk about?i. Did you/he change what you/he bought, cooked or served after he was diagnosed?(probe for incorporating prostate healthy cooking information)j. What goals or concerns do you have for your own diet?  How does this influencehis diet?5. Healthy Eating:a. What do you think a healthy diet would be like for you?b. What do you think a healthy diet would be like for a man like (partner) to follow?c. How is this different from a healthy diet for a woman?d. How does being a man influence the things (partner) eats and drinks? (probe:alcohol, meat, fruit and vegetables)e. Do you think your partner eats a healthy diet?  If so, what about his diet makes ithealthy?f. How do you think that diet influences your partner’s health? What about now thathe had prostate cancer?g. Where do you get nutrition information? (probe, partner, friends, doctor)h. How do you incorporate new nutrition information into your diet?  (probe forpartner’s role)  How does he?i. Do you have enough information about healthy diets? If not, what sort ofinformation do you need or want?  What sort of information does he need orwant?j. Is there anything that keeps you from eating a healthy diet?  If so, what?  Howabout him?k. Is there anything that helps you eat a healthy diet? If so, what? How about him?1736. Summary and closing:a. These are all the questions that I have but before we finish is there anything elseabout diet and prostate cancer that you want to tell me?b. Is there anything else about healthy eating for men with prostate cancer? Arethere any questions that I should have asked?Thanks for participating.  Invitation to learn about study results and to participate infuture research.  Ask permission to contact for follow-up interview.174Dietary beliefs and practices of Men with Prostate CancerDemographic data for partners (to be completed by interviewer)Participant Code: _________________  Interview Date:                                       Age:                  Ethnicity:                              Marital Status:                                    Education Level:                                          Who currently lives with you (eg child)? please list                                                                                                                                                                                                           What is/was your usual occupation?                                                                       Are you: (tick all that apply)Full-time homemaker            Employed full-time             Employed part-time             Retired              On Disability              Unemployed             What was your approximate family income for the past year?                                       Have you been diagnosed with, or had the following?Food AllergiesNoYes  List:                                High CholesterolNoYes  Date:                                Heart DiseaseNoYes  Date:                                Heart attackNoYes  Date:                                StrokeNoYes  Date:                                DiabetesNoYes  Date:                                Other CancerNoYes  Date:                                Type:                           Other illnesses or conditions please list:                                                                                                                                                                                                                                                                                                                                                                              Appendix 13.  Demographics Form for Women175Are you currently taking any treatments or medications?No  Yes  please list                                                                                                                                                                                                                                                            Are you currently on a restricted or special diet for a particular health concern?NoYes  please describe:                                                                                                                                                                                                                                                  Are you currently trying to lose weight?No YesWhat is your biggest health concern (if any)?                                                                                                                                                                                                       What is your biggest dietary concern (if any)?                                                                                                                                                                                                      Thank you!  Please record any other relevant information below.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                176Appendix 14.  Gender Relations Dyad Summary TemplateWho controls food in the house - Who calls the shots?What shots does she call?How does he influence the shots she calls?What shots does he call?How does she influence the shots he calls?What descriptive words or phases used to describe roles?1.  What priorities, goals, values, ideals shape what is eaten in the household?(e.g. weight, body image, illness, athletics, taste, convenience, money)He says he does:He says she does:She says he does:She says she does:2.  What food roles are taken on by whom, what does she say he does, what does he say shedoes?  (e.g. planning, information seeking, monitoring supplies, making shopping lists, cookingmeals, cleaning up)He says he does:He says she does:She says he does:She says she does:3.  How does prostate cancer fit it?  What difference has it made or not?  When, where andhow is it considered or ignored?He says he does:He says she does:She says he does:She says she does:4.  What masculinity or femininity scripts are being enacted?He says he does:He says she does:She says he does:She says she does:5.  How are gender relations within each dyad being played out?  How is her engagementwith performance of femininity through food supporting/ resisting/ transforming hisperformance of masculinity through food?177Appendix 15.  Participant CharacteristicsCode*AgeIncomeEducationWork statusProfessionCo-morbidityC1M75 DentistryRetiredDentistNoneC1W7480,000MA PsychologyPart-timeCounsellorSpinal chord injuryC2M78 PhDRetiredProfessorDiverticulosisC2W71DeclinedBA RetiredPublic relationsSkin cancer, arthritisC3M48 CommerceFull-timeAnalystNone/ mildhypertensionC3W45100,000Tourism diplomaNoneHomemakerNoneC4M68 CollegeRetiredIBM technicianHigh cholesterol/hypertensionC4W6745,000CollegeRetiredClerk NoneC5M65 Law schoolRetiredRCMP officerNoneC5W6470,000High schoolRetiredCustomer serviceDiabetes, highcholesterolC6M60 PhDFull-timeProfessorMelanoma, stressC6W57DeclinedHigh schoolRetiredProject coordinatorArthritis,hypertensionC7M56 DiplomaRetiredEngineerMild hypertensionC7W47180,000DiplomaFull-timeRadiology directorDiabetes, highcholesterolC8M73 DiplomaPart-timeTravel agentHigh cholesterolC8W7350,000DiplomaRetiredSecretaryNoneC9M68 AccountantSemi-retiredBusiness consultantBPH, melanomaC9W64100,000College diplomaFull-timeInterior designerNoneC10M55 High schoolFull-timeRCMP sergeantHypertension, highcholesterolC10W53160,000CollegeFull-timeLaboratory supervisorNoneC11M72 High schoolSemi-retiredMachine marketingNoneC11W70100,000High schoolRetiredOffice assistantNoneC12M74 Grade 11RetiredBank clerkNoneC12W6660,000DiplomaRetiredSecretaryNoneC13M64 Grade 10RetiredMill workerNoneC13W6160,000Nursing diplomaRetiredClerk NoneC14M63 BScRetiredCollege instructorNoneC14W56120,000DiplomaFull-timeMedical transcriptionistNone178Participant Characteristics continuedCode*Diagnosis DateSelf-Reported DiagnosisDetails (when available)**Treatment(s)***Treatment datesC1MApril 2005T3a ADT & EBRMay 2005 toJanuary 2006C2MJanuary 2002Early stage/LocalADT & EBR2003C3MNovember 2005T1b AS Not applicableC4MDecember 2003Early stage; Low gradeADT & EBR2003/2004C5MOctober 2006Early stage; Gleason 3+3AS Not applicableC6MFebruary 2003T3a; Gleason 7ADT & RPApril-October 2003C7MAugust 2006Early stage; High gradeADT & RPSeptember 2006,January 2007C8MMay 2006T1c;  Gleason 6AS (BT)PendingC9MJune 2005Early stage; Low gradeAS Not applicableC10MJanuary 2007Late stage (escaped capsule); Gleason 9ADT & RP & EBRRP May 2007C11MOctober 2006T3a; Gleason 7HIFUJanuary 2007C12MSeptember 2006Early stage; Gleason 6RP December 2006C13MJune 2006Late stage (escaped capsule);Gleason 7ADT & RP(EBR pending)RP December 2006,ADT July 2007C14MMarch 2003Early stage; low gradeRP July 2003*C = couple, M = Man, W = Woman**T1b & T1c = Early stages where tumour is contained (local) in prostate; T3a Later stage wheretumour has escaped the gland (capsule); Gleason = grade where 1 to 6 is low, 7 is moderate and8-10 is high grade cancer.***RP = radical prostatectomy;  EBT = external beam radiation;  AS = active surveillanceADT = androgen depravation therapy;  BT = brachytherapy; HIFU = high intensity focusedultrasound;

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