Diabetes mellitus is a growing worldwide health challenge especially in sub-Saharan Africa. While the use and effectiveness of diabetes self-management interventions is well documented in high-income countries, little information exists in sub-Saharan Africa. Therefore, this study attempted to synthesize information in the literature on the use and efficacy of peer support and social networking in diabetes self-management in Kenya and Uganda.The purpose of this scoping review is to summarize research on the extent of use and efficacy of peer support and social networking interventions in diabetes self-management in Kenya and Uganda.We searched PubMed, ScienceDirect and Cochrane Library databases for articles reporting peer support and social networking interventions in Kenya and Uganda published in English between 2000 and September 2021. Key words encapsulated three major themes: peer support, social networking and self-management. Hand searches were also conducted to select eligible papers. Data was extracted using a form prepared and piloted in line with PRISMA-ScR guidelines.Thirteen peer reviewed articles were selected for analysis. Eleven studies reported peer support interventions while two focused on social networks in diabetes self-management. Peer support and social networking interventions incorporated microfinance and group medical visits, diabetes self-management education, telephone support and Medication Adherence Clubs. Most interventions were delivered by multidisciplinary teams comprising nurses and other professionals, peer educators, peer leaders and community health workers. Most interventions were effective and led to improvements in HbA1c and blood pressure, eating behaviors and physical activity and social support.The limited studies available show that peer support and social networking interventions have mixed results on health and other outcomes. Importantly, most studies reported significant improvements in clinical outcomes. Further research is needed on the nature and mechanisms through which peer support and social network characteristics affect health outcomes. Diabetes is a growing worldwide health challenge especially in sub-Saharan Africa. By the end of 2019, an estimated 19.4 million adults aged 20–79 years were living with diabetes in the International Diabetes Federation (IDF) Africa region, representing a regional prevalence of 3.9% . Peer anThere are wide variations of content and structure, roles and interactions, and settings and activities of peer support, ranging from structured and unstructured models . HoweverDSME interventions are associated with improvements in self-care behaviors , diabetes knowledge, coping and stress relief –36; signWhereas the use and efficacy of peer support interventions has been established in high income countries (HIC), limited data restricts drawing similar conclusions in SSA. It remains unclear what kind of peer support and social networking interventions are used in Kenya and Uganda. Therefore, a scoping study was conducted to systematically map literature in this area and identify gaps in research and practice. The following research question was formulated: What is known from existing literature about the use of peer support and social networking interventions in diabetes self-management in Kenya and Uganda?Ethical approval was provided by the Kenya Medical Research Institute (KEMRI) Protocol No. 4295. Research approval was provided by the National Commission for Science, Technology and Innovation (NACOSTI) Permit number: NACOSTI/P/21/13911.We employed a scoping design to carry out an overview of research evidence on the use of peer support and social networking interventions for diabetes management in Kenya and Uganda. These interventions are relatively new in sub-Saharan Africa, and to the best of our knowledge, this study is the first attempt to systematically examine the breadth of research on the use of peer support and social networking interventions in the East African region. With little research evidence available and negligible randomized controlled trials done, it is difficult to undertake a systematic review, hence making this study exploratory , 43. ConWe searched PubMed, Sciencedirect and Cochrane Library using key terms and Boolean operators related to 1) diabetes/diabetes mellitus; 2) peer support/social support/peer group*/social group*/peer support group*; 3) peer network*/social network*/support network*/social support network*. The search strategies were drafted by a Librarian from Makerere University and refined by the research team. The final search strategy for PubMed can be found in Two researchers independently screened titles and abstracts for relevance based on the inclusion and exclusion criteria established a priori and refined in a pilot using the first 20 studies identified. Records were then consolidated in an Excel sheet where duplicates were removed. Two researchers verified the screening for accuracy. Any disagreements on study selection and data extraction were resolved by discussion. Citations were excluded if they did not appear to be relevant to the topic of peer support and social networking in diabetes management. Following the initial title/abstract screening and removal of duplicates, two investigators screened the full texts and articles that met the inclusion criteria qualified for data extraction while those that failed to meet the criteria were tagged indicating the reason for exclusion.The following inclusion criteria were used in study selection: 1) published peer reviewed papers describing peer support and/or social networking interventions in diabetes self-management; 2) examined peer support and/or social networking intervention outcomes on diabetes self-management; 3) available in English; 4) interventions described were carried out in Kenya or Uganda only. Articles were also included if the peer/social networking intervention targeted more than a single non communicable disease (NCD) in one setting. Qualitative, quantitative and mixed methods articles were included to capture characteristics of peer support and social networking interventions, outcomes, efficacy and challenges. Articles were excluded if they were commentaries, conference presentations, reviews, protocols, studies describing an intervention carried out in multiple countries including Kenya or Uganda, studies whose full-text article was unavailable, and studies that reported PHC-based interventions without any peer dimension. The most recent reviews were used for reference list search.One researcher used a detailed charting form to extract data from each eligible article. One researcher verified the data charted and any disagreements were resolved by consensus of the four researchers. The form captured the following key information: article characteristics , study characteristics  and intervention characteristics .To present an overview of all material reviewed a narrative account of existing literature was preferred in line with the recommendations of Arksey & O’Malley. First, a numerical analysis of the nature and distribution of interventions, populations and outcomes was summarized in a table  under thThe search identified 624 articles. 26 articles were added from hand searches. 234 duplicate articles were removed, yielding 416 articles for title and abstract screening . After sn = 11) and two in Uganda. Their designs were as follows: randomized controlled trials or studies with a pre-post design (n = 4), retrospective comparisons and cohort (n = 4), mixed methods (n = 1), cross-sectional (n = 1) and qualitative (n = 3). Eleven studies [A total of 13 studies were reviewed. Majority of the studies were conducted in Kenya , community settings (n = 5); and distributed in urban (n = 2), rural (n = 7) and peri-urban and rural (n = 4) settings.The interventions varied in length from 3 months to 12 months. Patients receiving “routine care” or “usual care” were designated as control groups. Care services were provided as follows: diabetes clinics in PHC facilities  , 56, micTwo studies assessed diabetes knowledge of patients as an indicator of learning outcomes. One study  reportedDiabetes-related behavioral outcomes reported were medication adherence and compliance with protocols, eating behaviors, physical activity and acceptability and loss to follow up (LTFU).Medication adherence and compliance with protocols were reported in a single study  which reTwo studies reported on physical activity. One  reportedEating behaviours were reported in three studies. Two , 55 repoAcceptability was reported in 10 studies; two , 48 repoRetention rate/loss to follow up was reported in eight studies –53. OnlyClinical outcome indicators assessed included: glycated hemoglobin (HbA1c), body mass index (BMI)/weight, systolic/diastolic blood pressure (SBP/DBP), blood sugar/glucose and hip circumference (HC) and waist circumference (WC). HbA1c was measured in four studies , 52, 55 BMI was reported in three studies; two , 58 founBlood pressure was assessed in five studies; four , 53, 55 Blood glucose or sugar was an outcome measure of three studies. Two studies , 53 repoOther clinical outcomes including lipid profiles, cholesterol and high-density lipoprotein and overall metabolic syndrome (MetS), were the outcome measures of one study  which reSocial support was reported by four studies. One  reportedThe efficacy of reviewed interventions was assessed using established benchmarks  where peSome studies reviewed demonstrate evidence of more practical aspects of diabetes self-management. For instance, patient groups supported each other in acquiring medicines, food and transport , and parFace-to-face meetings were complemented by telephone support , 53, 55 Peer supporters also provided specific services that encouraged daily self-management. In one study  peer supAn intervention using a reciprocal model  ensured Belonging to groups provided opportunities for social support and resolution of emotional issues. In one intervention  peer supReviewed interventions connected peer supporters with healthcare professionals as well as patients to clinical care beginning from screening. First, being based in diabetes clinics in primary healthcare facilities, or in local diabetes support groups increased linkage to clinical care and increased retention rates. For instance, one study  reportedCertain features of reviewed interventions show evidence of feasibility and sustainability. In one intervention , group mInterventions focusing on microfinance emphasize community-based recruitment approaches and leverage on CHWs who are part of the healthcare system on a long-term basis using them as group liaisons , 54. FurIn primary healthcare that is grappling with huge patient numbers requiring follow up, majority of whom are stable, MACs provide an opportunity to offload single provider clinic visits by coping with appointments that would ordinarily be included in the regular clinic. MACs therefore reduce the burden of regular follow up among stable patients hence allowing clinicians to deal with other pressing cases, save time, provide support and increase patient satisfaction and flexibility of care delivery , 56.The efficacy of assessed interventions is hampered by recruitment processes. In two studies assessing MACs , 56, theInterventions assessed reported that the lack of meeting places resulted in group members holding meetings in clinics which also serve other healthcare needs. On their part, MACs are constrained by clinic settings and opening hours in line with legal limitations of drug dispensing by non-medical professionals . FurtherReviewed studies reported that the efficacy of interventions is hampered by lack of homogeneity in methods of delivery, duration, frequency and content of interventions and training of peer supporters. For instance, the duration of interventions varied from 3 months to 12 months and training of peer supporters varied from one day to 4 weeks, with or without a trainers’ manual. Supervision of peer educators to assess the extent of fidelity to objectives was not consistent across interventions yet contributed to success/failure. In one study , two diaOne major impediment to NCD management is poverty as it limits the ability of social networks. As an emerging innovation, the microfinance model reviewed , 54 seekThe twin challenges of low literacy and poor eyesight hamper the dissemination of DSME. Some interventions reviewed managed the challenge by reading educational materials translated into local languages loudly in group meetings .We used a scoping review to identify 13 studies published between 2000 and 2021 addressing the use of peer support and social networking in the management of diabetes in Kenya and Uganda. Our findings show the existence of different forms and contexts of group-based peer support models. This supports existing literature on the increased use of cost-effective group-based models in sub-Saharan Africa in provision of DSME , 59–61.In line with literature from SSA, peer supporters were trained for short durations, often ranging from one day to four weeks , 28, 29.Though very few studies focused on social networks, available evidence points to the important role of SNCs including family and friends and other linkages to social capital in daily management of diabetes which supports existing literature , 64–66. The review also revealed challenges that hamper the efficacy of interventions including recruitment processes, duration and frequency of intervention, training of peer supporters, poverty, limited literacy and unavailability of meeting places among others. These factors were found to be responsible for differences in retention rates and effectiveness of interventions. Interventions that employed interactive peer-to-peer communication , 49, 50 In MACs, the flexibility in scheduling allowed judicious use of time for people living in urban areas who must juggle between earning economic livelihoods and seeking health care. This is especially important since literature  suggestsFinally, some interventions demonstrated evidence of sustainability by involving diverse stakeholders in conceptualization and execution; and by working within existing healthcare systems and networks, including community health workers, diabetes support groups, administrators and chronic disease networks. By leveraging on existing networks, such interventions cut costs, reduce stigma for NCDs and gain from synergy.First, our search was limited to articles published in English and indexed in three databases–PubMed, ScienceDirect and Cochrane Library. We may have missed important articles written in other languages and in other databases or other informal sources not reviewed, or not publicly available. Second, included studies employed diverse designs which were not subjected to methodological quality assessment. Third, the review is based on 13 studies majorly from Kenya which may limit the strength of conclusions derived. Fourth, the inability to determine which kinds of interventions were found to be effective draws from the broad aim of this scoping review to rapidly map evidence supporting peer support and social networking interventions.The limited number of studies provide insufficient evidence to make concrete conclusions on the efficacy of interventions. However, findings shed light on the formats and strategies used, and provide some evidence for the acceptability, feasibility and scalability of peer support and social networking in diabetes care. Although further research should identify the specific activities, processes and interventions that were highly successful, these findings provide a basis for debate among stakeholders in NCD care. As emerging evidence suggests, peer support and social networking may be promising approaches to NCD self-management.S1 Checklist(DOCX)Click here for additional data file.S1 Appendix(PDF)Click here for additional data file.


African Americans chronically managing their diabetes benefit from receiving support from peers with shared experiences. Peer support is known to improve the well-being of individuals receiving support, however, there is limited literature on the experiences of those providing the support. The Peers Supporting Health Literacy, Self-efficacy, Self-Advocacy, and Adherence (Peers LEAD) program pairs Peer Ambassadors who are adherent to their diabetes medication, with Peer Buddies who need support with their medication adherence. Peer Ambassadors engage with Peer Buddies as they receive diabetes information, develop the skills and motivation to address identified psychosocial/sociocultural issues to enhance their diabetes medication adherence. This study qualitatively explores the experiences of African Americans who provided peer support in the Peers LEAD medication adherence intervention.Two focus groups were conducted with twelve Peer Ambassadors to explore their experiences of providing peer support in the Peers LEAD medication adherence intervention. Qualitative content analysis was conducted using an inductive open coding approach.Emergent themes provided insight into Peer Ambassador’ rationale for providing peer support and the benefits and challenges they experienced in their roles. Themes regarding their rationale included: their desire to receive support for their diabetes self-management as well as to contribute to their communities in reducing the stigma associated with diabetes. The perceived benefits they gained centered on creating interpersonal connections, experiencing personal growth as they adapted to their roles, and experiencing opportunities to contribute to an intervention regardless of professional training. Peer Ambassadors reflected on the challenges which included difficulties on coming to terms with their role as Peer Ambassadors, seeing African Americans experience complications associated with diabetes, and navigating supporting Peer Buddies who are also burdened with the challenges their family members are experiencing with managing their diabetes.This study provides unique insight to what motivates individuals to provide peer support and what they gain from these experiences despite the challenges. Understanding the experiences of peers participating in such interventions may help inform the structure and content of programs that use peer support to focus on the benefits of and the motivation for participating in the program. An estimated 30.2 million people in the United States have diabetes, and the total annual cost associated with diagnosed diabetes is approximately $245 billion . ChronicPeer support interventions are cost-effective means of improving and sustaining the self-management of chronic diseases such as diabetes –10. PeerIncreasing attention is being given to racial and ethnic minority groups—including African-Americans--and development of diabetes self-management peer support programs that are culturally-adapted . Peers SPeer support is shown to be beneficial for those who need to improve on their diabetes self-management, as well as for peer leaders who provide the support , 21. DesThe objective of this paper is to qualitatively explore the experiences of African Americans who provided peer support in the Peers LEAD medication adherence intervention.Details about the Peers LEAD intervention can be found in a protocol paper that describes the theoretical and conceptual frameworks that informed the study design, the participant recruitment/training procedure, and the intervention outcomes . As suchPurposeful sampling was used to recruit Peer Ambassadors. The research team asked community stakeholders and individuals who were Peer Ambassadors in previous studies to help identify Peer Ambassador candidates , 18. TheProspective Peer Ambassadors were screened via a phone conversation or face-to-face to assess their eligibility. During the screening, the research team assessed a candidate’s interest in serving on an advisory board, offering peer support, and their personal diabetes experiences.Peer Ambassadors attested to completion of human subjects ethics training by signing an investigator responsibility form approved by the University’s Institutional Review Board and consented to participate in a focus group by reviewing a consent information sheet approved by the University’s Institutional Review Board.The training of Peer Ambassadors was facilitated by the research team and consultants from the Wisconsin Network for Research Support (WINRS), a patient and community engagement group with experience in facilitating stakeholder engagement meetings and training since 2010 .Peer Ambassadors attended an orientation session 3 weeks before the start of the eight-week intervention. The orientation lasted two-and-half hours. Peer Ambassadors were informed about the project goals and the roles of all project stakeholders. During the orientation, PAs also participated in a demonstration of a Peer Ambassador actively listening and providing support to their peer buddies. Then, 1 week before the eight-week intervention, Peer Ambassadors participated in a two-hour training session where they prepared for phone calls with Buddies, were provided with detailed phone call suggestions, and discussed a telephone call guide that the Peer Ambassadors adjusted to their conversation styles.Fifteen peer ambassadors were paired with 21 Peer Buddies to provide support throughout the intervention. Peer Ambassadors were paired with one or two Buddies. Peer ambassadors attended 8 h of education with their peer buddies, including a separate Peer Ambassador/Buddy orientation and three group education sessions. Peer Ambassadors worked with their Buddies for 11 weeks, during which they attended the education sessions and completed five phone calls with their Peer Buddies  years. Of the Peer Ambassadors that were trained and participated in the Peers LEAD program, 12 consented to participate in the focus group.When asked about their roles as Peer Ambassadors, three main topics emerged regarding the Peer Ambassador experiences: the benefits of being a Peer Ambassador, the challenges of being a Peer Ambassador, and the rationale for being a Peer Ambassador.Qualitative analysis of the focus groups revealed several personal benefits that the PAs attributed to serving in this role. Most PAs reported that serving as a PA offered an opportunity to make meaningful connections by opening up, building trust, and listening to their Buddies. The themes and subthemes are described below with verbatim quotes from the PAs. Table PAs felt a strong connection to their buddies in having a shared experience. The PAs perceived Peers LEAD as an opportunity for them to connect with their buddies and listen to the buddies share their own experiences of living with diabetes.“I would have to say the contact, speaking with them [Peer Buddies], letting them share their journey. That’s what was really beneficial to me” – PA2.Peer Ambassadors benefited from the growth they experienced in the Peers LEAD program. They identified how the program helped them contribute to participants’ experiences, adapt to their roles as Peer Ambassadors, and self-reflect on their own journey of living with and managing their type 2 diabetes.Some Peer Ambassadors who were also nurses shared that regardless of their professional training, being a Peer Ambassador was an opportunity for them to learn from others in the program.“Beneficial, I would have to say the contact, speaking with them, letting them share their journey. That’s what was really beneficial to me, and I agreed with [PA 1] I didn’t have to be a nurse.” – PA7.Peer Ambassadors shared about their experience with their buddy which in some instances started with conflicts. However, by participating in the program, Peer Ambassadors reflected upon how those conflicts led them to open up more and share about their own frustrating challenges of living with diabetes. By adapting to their role and providing support they benefited in building meaningful relationships.“But as time went on, I had a peer buddy who actually was, we just kept bumping heads. It just was not working. But as time went on, the peer buddy I had this time, was like a whole 360. You know, personally, myself, I opened more, and I’ve shared a lot, and I received a lot.” – PA12.Peer Ambassadors shared how the program allowed them to reflect on their own journey of living with diabetes.“I’m just going to say that being a Peer Ambassador helped me to think about how many years I’ve actually been a diabetic. And beginning when things were not. .. that first year, and I worked, you know, to be where I am right now. So it’s been an experience. It’s just been an experience. It’s something different, and I’ve enjoyed it.” – PA7.Peer Ambassadors described several challenges of providing peer support as: 1) Seeing Peer Buddies experience complications associated with diabetes, 2) Buddies want to share the burden of their family member’s experiences with diabetes, 3) Coming to terms with the responsibilities of being a Peer Ambassador and, 4) Building a relationship and sense of trust with their buddies.“You know, it was hard to see people suffer. It’s difficult to see, I mean, to see how some people have such, both of my Buddies have suffered. They were ill, very ill. Like one is post-stroke. Another one, she has lung disease along with her diabetes, and they’re young. And it was just hard for me to see such guilt in people of that age.” – PA6.Some Peer Ambassadors described that it was difficult to hear their PBs describe the medical effects associated with their poorly controlled diabetes.“And then my Peer Buddy, he had amputated legs, and he has cancer. “– PA8.Peer Ambassadors shared in detail the diabetes-related complications their buddies were experiencing. The Peer Ambassadors were concerned about their buddy’s blood glucose level and poor management of diabetes.“You know, to me, it’s unfathomable as far as how one could allow themselves, I’ve heard people say that they had an A1C of 15. I just can’t, for me, that’s hard for me to imagine. You know, I’m not saying that it’s not, I know it’s possible. You know, just to hear that someone has allowed themselves to get to that level, for whatever reason.” – PA8“He has a sister that was struggling with a lot of things, and a lot of times he would want to talk about his sister, and the things that she was going through, because she likewise was a diabetic and had gangrene. You just wouldn’t think that people would allow themselves to get to a certain level, but it happens. That was. .. hard, just hearing some of the stories.” – PA8.Peer Ambassadors expressed the uneasiness they felt after their buddy described the complications associated with a family member’s uncontrolled diabetes.“It was, in the very beginning when I started doing this [Being a Peer Ambassador], it was really difficult for me to start asking questions or saying stuff, because I would feel that I’m saying something stupid or something didn’t make sense. – PA7.Participants mentioned that adjusting to the role of a Peer Ambassador was more difficult than they had anticipated.“I feel, for me, the hardest part was the first couple of conversations with my peer buddy, to get him to buy in to trusting me. And then after he did that, it just took off from there. But getting him to put trust in what we were talking about that I would keep the confidentiality, and we went from there.” – PA3.Another PA found that forging a bond with their buddy was challenging at first, but it provided them with an opportunity to cultivate a meaningful relationship.The Peer Ambassadors described their rationale for participating in the Peers LEAD program. These reasons ranged from their desire to receive support for their diabetes self-management as well as to contribute to their communities and to reduce the stigma associated with diabetes. Table “The reason why I wanted to become an ambassador is, because, I wanted to educate myself on diabetes, and then, at the same time, be able to reach out and help someone in the community.” – PA8.Most of the participants agreed that being a Peer Ambassador allowed them to educate themselves about their diabetes in order to help their Peer Buddies, their family members, and/or their communities struggling with diabetes management. Several Peer Ambassadors highlighted that they wanted to gain personal knowledge about diabetes prior to assisting others with the disease.The reason I wanted to be an ambassador was because when I was approached about it. .. diabetes, something that was not exactly talked about in our community. So, therefore, I wanted to learn more, and I wanted to give out more to other people, be able to give it out to other peoples who have diabetes. Then they don’t have to be ashamed of it, and that, you know, we can talk freely about it. I wanted to be so that we can just talk so freely about it, you know, instead of hiding it.” – PA10.Some Peer Ambassadors described the lack of dialogue about diabetes in the African American community and their desire to make a difference.Other Peer Ambassadors indicated that they wanted to share their experiences and offer support to others with diabetes in a safe and welcoming environment. Similarly, to learn more about their diabetes, Peer Ambassadors saw their role as an opportunity for them to personally open up about their own experiences and receive the support they also needed.“I am a diabetic. I’m a nurse as well. And the reason why I agreed to do it is because I think that a lot of people, they have a lot of questions and a lot of concern. And I thought that maybe I could answer some of them on a personal level, you know, share my experiences, and let them know that they’re not alone. We all struggled in the beginning to get hold. I didn’t always have perfect A1Cs either, you know, so that’s why I decided to do it.” – PA7.Peer Ambassador who were nurses, identified how their role as Peer Ambassador differed from their profession and gave them the opportunity to receive support.The study results showed that peer supporters in diabetes self-management programs aim to provide encouragement for other people with diabetes and to receive support for themselves. They view providing peer support as a responsibility, and they also benefit from their peer support role. These benefits include creating interpersonal connections, experiencing opportunities for growth through self-awareness and self-reflection, and finding reward in the commitment that comes with supporting others. Notwithstanding the benefits, African Americans described some challenges associated with peer support, especially when supporting peers who were seriously ill or who struggled with medication management despite the education provided during the program. One initial challenge for some of peers was creating a trusting relationship. Others struggled with accepting the terms of their roles as trained supporters. Nonetheless, the reasons African Americans partake in peer support consist of educating themselves to help others, decreasing diabetes-related stigma in African American communities, and receiving support themselves.Our study adds to the existing literature on peer support in several ways. First, our study adds a new dimension to the benefits of providing peer support. Prior studies of peer support only emphasize the clinical benefits of the programs to the peers involved , 30, 31.Second, existing literature recognizes peer support as a mutually beneficial relationship where individuals give and receive support from each other . Our PeeThird, trust has been associated with reasons why African Americans living with type 2 diabetes do not seek out support from their peers. A study revealed that African Americans were distrustful about disclosing their type 2 diabetes status to their peers and seeking out support . One of Familial relationships are ingrained in cultural beliefs that impact medication adherence among African Americans . For AfrOur Peer Ambassadors discussed how the knowledge they gained about their diabetes is to help themselves as well as their families and their communities. Individuals’ rationale for participating in a peer support program to help their communities can be further explored especially in under-resourced communities. Studies evaluating the benefits of diabetes self-management programs to individuals and their families show that families may benefit directly from attending health education programs , 43. HowPeer Ambassadors had difficulties seeing their peers suffer from diabetes-related complications. Peer support programs can provide emotional support to peers in their roles of supporting individuals struggling with type 2 diabetes. Other studies can further explore in-depth the challenges peers face when providing support and design interventions to equip them with the necessary tools to cope and be efficient in their roles. These roles do not require professional expertise, and although two peers in our study identified as nurses, their professional training was not necessary to provide peer support.While African Americans experience challenges in their roles as peer ambassadors, they participate in peer support programs to benefit themselves and their communities. A study of peer support in low-income African Americans found that sharing illness experiences in the group setting gave participants practical ideas on how to manage their illness . Peer AmThere are several limitations to our study. Focus groups have the advantage of eliciting the views, feelings, and perceptions of a group , 46. HowThe study findings were based on perceptions of middle-aged African American adults with diabetes in one Midwestern state. Experiences of ambassadors providing peer support might differ among age groups and regional locations. Future studies should consider exploring these experiences among other age groups of African Americans in different geographic locations. It is important to note that the sample size was 12 participants, which is consistent with the acceptable sample size in qualitative research for focus groups. However, two Peer Ambassadors that participated in the program did not participate in the focus group due to time constraints. Despite these limitations, the findings of this study can inform future research, as well as peer support training and programs.As the number of people with diabetes grows exponentially, particularly in low-resource communities, the evidence continues to grow for peer support as a viable and compelling approach to lifelong diabetes self-management. African Americans providing peer support perceive their roles as beneficial to them and their peers. The challenges they experience in their roles are linked to the emotional difficulties of seeing peers experience diabetes-related complications. Peer support programs in African American communities should consider the benefits and rationale for participants’ involvement in their programs and address the challenges they face when providing support.


Current observational and interventional studies in nutritional psychiatry suggest that healthy dietary patterns rich in fresh whole foods could protect against depressive symptoms, and that unhealthy dietary patterns high in ultra-processed and refined foods could contribute to depressive symptoms. However, no studies have explored detailed subjective accounts behind the food and mood relationship. This study aimed to uncover unknown factors in the human experience with food and mood. Using a phenomenological framework, this focus group study applied thematic template analysis to accounts of over 50 Australians aged between 18 and 72. Three themes were identified from the transcript of the focus groups: (i) reactive and proactive relationships with food, (ii) acknowledgement of individual diversity relating to eating and mental health, and (iii) improving mood by removing food restriction and eating intuitively. The data highlights the complexity of the relationship between food and mood that extends beyond biological mechanisms which could be used to extend current epidemiological and intervention studies in the field of dietary patterns and depression. Nutritional psychiatry is an emerging field in mental health . The impDue to these inconsistent findings, it is important to seek more nuanced information regarding the interplay of diet and depression, which may be achieved by exploring individuals’ experiences with food and mood. Experiences of depression and depressive symptoms have been extensively reported within qualitative contexts ,13,14, ySome published qualitative papers focus on food intake and mood but explore consumer perspectives of functional foods—those specifically designed to prevent chronic disease . Others It has been well documented that individuals have a socially constructed idea of how food, and diet influence mental health ,18,19. IPhenomenology is the philosophical enquiry of the structure of human experience and consciousness; it details how individuals’ experience a specific phenomenon from their perspective, context and interpretation . A phenoThe extent to which individuals assign meaning to food and the impact on mood needs further research. A phenomenological perspective may assist such examination in a broader context, considering strong social representations about certain foods exist and have done so for many years . ConsideThis qualitative focus group study explores individuals’ experiences with food and mood using the consolidated criteria for reporting qualitative studies, the (COREQ) 32-item checklist  can be fNine focus groups, each of approximately 60 min duration, were conducted in regional Australian locations. The regional locations have a wide range of ethnic and cultural communities. Focus groups were conducted in seven face-to-face and two online formats (via Zoom). All students and staff at a multi-campus university in Australia received an invitation email to participate. Additionally, participation invitations were shared on social media platforms Facebook, Twitter, Instagram, and LinkedIn. Individuals interested in participating were asked to provide their telephone number and a preferred time to call to discuss the study’s details. A follow-up email was then sent which contained an information sheet that outlined the study and a consent form. The study protocol was approved by Southern Cross University Research Ethics Committee #19-083.Eighty-three emails were received from interested individuals; 50 were able to attend the arranged timeslots for one of the nine focus groups. No compensation apart from refreshments was offered for participation. The focus groups were facilitated by the lead researcher (ML), a female PhD candidate and psychology tutor at Southern Cross University. The first focus group was also attended by the primary PhD supervisor (Assoc Prof SS) as part of the qualitative training within the PhD program, while the following eight were attended solely by ML and the participants. All focus groups were audio-recorded and transcribed verbatim. Field notes were taken directly after each focus group discussion and a reflexive journal was kept, including thoughts, issues, concerns, feelings attitudes, beliefs, values, expectations, ideas, experiences, and potential biases to account for why certain elements were identified during data collection ,27.Before each focus group, the facilitator established rapport, explained the personal interests and potential biases that she brought to the research, and described that the purpose of the focus groups was to explore individuals’ experiences with food and mood. The facilitator then prompted group discussion, using questions such as ‘Can you describe how something you ate resulted in changing the way you felt?’, and ‘Can you describe how your feelings and emotions have influenced your eating?’. Participants were not given the list of questions prior, in order to the focus group discussion. A full list of semi-structured questions and prompts used in the focus groups can be found in the Of the 50 participants who attended the discussions, 36 were female (72%), and 14 were male (28%). Further demographic information was not collected to ensure minimal intrusiveness of the research and potentially increased information sharing during the discussions ). Some (https://otter.ai/ (accessed on 12 September 2019)) to upload audio recordings into text. Transcriptions were then read line by line against the audio, and corrections made to the text by the lead researcher. All participants were de-identified at this stage in the transcription. An email was sent offering participants the opportunity to read and return feedback on the transcripts. One participant reviewed the transcripts and returned no comments. The remainder of participants were happy not to review the transcripts. Each transcript was then read in its entirety by the lead researcher. During the initial reading, patterns in the text and initial participant quotes of interest were noted. The lead researcher continued to keep account of any thoughts, issues, concerns, feelings attitudes, beliefs, values, expectations, ideas, experiences, and potential biases that could influence data analysis in the reflexive journal.A six-stage thematic template analysis was used to explore the data . During During stage two, an iterative and inductive coding process was conducted. It began with open coding, in which all transcriptions were reread line by line. Codes—a short word or phrase assigned to label a portion of the data )—were orAn inductive thematic template analysis revealed three themes, (i) reactive and proactive relationships with food, (ii) acknowledgement of individual diversity relating to eating and mental health, and (iii) improving mood by removing food restriction and eating intuitively. These themes were found across all focus groups and included descriptions of participants’ relationships with food, the meaning they attached to food choices, the social context in which food choices were made and the overall relationship between mood and mental health.This theme explores participants’ knowledge of how different ways of eating influenced their mood. The theme has two subthemes: (i) values assigned to food, and (ii) agency and direction of choice.In this subtheme, participants explored the values that they assigned to food and how this influenced their mood. Discussions were not limited to mood as a result of food consumption or intention to shift mood. On several occasions, participants suggested that their mood was influenced by values assigned to the food before it is eaten. Josephine describes how the values she assigns to the foods she eats directly influence her mood:It’s about what you’ve assigned to the salad. If you’ve assigned to the salad, this is healthy, and I’m doing this because I haven’t done this much, then it’s a good thing. However, if I’ve assigned to salad, I’m doing this because I’m restricting, then a salad is the worst thing like for me it will ruin my mood.(Josephine)Josephine suggests that if she believes that she is eating a salad because it is good for her health and what she wants to eat, this enhances her mood. However, if she eats a salad because she is restricting food to lose weight and eating it under duress, this worsens her mood. Josephine describes that fluctuations in mood are less about the food components and more about the value ascribed to the things eaten, possibly inferring that the biological mechanisms of food are secondary to the psychological value placed on what she eats.Negative values assigned to food were reported across the focus groups. One participant suggests a fear of food learned from childhood. In this extract, Mary describes the fear of food she developed as a young ballerina:Well, I think possibly, I am terrified of food from the early ballet years. I’m never just going to eat carelessly unless I’m madly drunk. One time I did cry eating some chocolate mousse at a big meeting in _____, a long, long, long time ago. Other than that, it’s a decision driven occupation. Sometimes it’s good. Sometimes it’s great. Sometimes it’s not quite as good as you thought it might be. The creme brulee that you had to have. I guess. Terrified. I think we’re coming from a position of terror. However, then perhaps in an extremely different way., I’m just not going to put it in my mouth If I’m going to gain weight.(Mary)Strict food restrictions imposed by parents and trainers lead to an unhealthy relationship with food; Mary uses the word ‘terrified’ more than once in her extract to emphasise this. Mary explains that she continues to restrict food in the same way that she was forced to when she was a child, and believes this is entrenched in her adult behaviour. Her description of these behaviours as an ‘occupation’ further highlights the seriousness of the value she assigns to food and its influence on her mood. Another factor is that she strongly controls her food intake unless she is under the influence of alcohol. She suggests that drinking alcohol may help her loosen her food inhibitions. Mary explains that the terror surrounding her relationship with food is deeply entrenched in her fear of gaining weight, which seems to be a side-effect of childhood eating habits. Elizabeth shares a similar view to Mary regarding a negative relationship with food:I went on an alkalising diet last year, and it was very strict. I lost way too much weight really quickly. It was too strict. However, you find, food is company, and when you cut it out, you have no comfort anymore. So, all these emotions come out…. I think that’s why things like chocolate and cakes and all the yummy things are quite comforting. I know through years of sort of struggling with weight, that eating is to push the emotions down. If you remove all of that, the emotions are coming out.(Elizabeth)Elizabeth considers a recent diet she tried, and due to the strictness of the food restriction, she had adverse symptoms such as excessive weight loss. Elizabeth suggests the diet impacted her mood because she finds comfort and solace in the foods she enjoys. When she could no longer have these foods, she was deprived of the comfort and company that food would normally provide for her. Elizabeth then acknowledges that this deprivation would increase her negative emotions. Like Mary, Elizabeth also describes that the guilt she experiences with food and her food relationship relates to a societal thin ideal and that she must always be trying to lose weight, which lowers her mood.Participants described how low mood could make them turn to unhealthy food options, making their mood worse. The interconnection between mood, mental health and food intake was commonly discussed across the focus groups. For example, Amy describes how she feels when eating refined and processed grains, and how this influences her mood:If I eat bread in any form, whether it be organic or mass-produced grain that has no nutrition, then I start to get feelings of lethargy, and I start to lose the impulse to have anything energetic happen. I will perpetuate more and more reasons to not get up and do anything in a hurry. It will make me feel like I’ve been less accomplished. Therefore, contributing to more feelings about low worth because I haven’t achieved anything. If I compound the wheat intake with dairy (and I love ice cream), then I know that that also helps get me into a downward spiral of low energy, lethargy, lack of enthusiasm towards the things I need to do, which makes me feel guilt. We totally are affected by what we put into our bodies.(Amy)A vicious cycle is reported between eating what is considered unhealthy food, lack of motivation, energy, lowered mood and feelings of insignificance and lowered self-esteem. Amy describes being stuck in a negative cycle and how difficult it is to stop once it begins. However, Amy also uses the word ‘accomplished’ when describing food intake, indicating that she may link food to a sense of achievement. Although she only describes the negative cycle of unhealthy food intake, it suggests that she may also be aware of what foods to eat that help maintain a positive mood and lead to feeling more accomplished.Much of the discussion about reactive relationships with food focused on reward, comfort, or commiseration. Many participants commented that no matter what their mood, reasons always existed to use food to either elevate mood or comfort negative mood. Jesse describes food as a constant reward or commiseration:It’s like an excuse in my brain. You’ve done really well. You should go and treat yourself to something nice. Or you’re upset. I should eat something. Whatever mood, I have an excuse to eat, and I use food as my emotional crutch.(Jesse)When Jesse does well, she rewards herself with food. Conversely, when she is upset, she turns to food for comfort and solace. This implies that there is always time to use food to celebrate or commiserate. She acknowledges needing to give herself a reason or an excuse to use food as a reward or comfort. The relationship between food and mood is not always a conscious choice to elevate mood. Food may also be used to wallow, grieve, commiserate, or when bored, despite the health implications of eating that food.Sugary and convenient snack foods were commonly associated with lowered mood. However, while participants acknowledged this, they disclosed eating them frequently. This cognitive dissonance is acknowledged by Alexa, who describes how her way of dealing with low mood and swings in emotion is by eating more chocolate than she considers wise:There would be times where I would hit like an emotional low, and my way of coping with that was going and buying a block of chocolate and just eating it. Like the whole thing. However, then I feel guilt and shame for eating more than I should, and this makes me feel worse than I was feeling before.(Alexa)Alexa suggests that she overindulges when feeling emotional by eating a whole chocolate block rather than a square or row. The consequence of this is that she is not choosing healthy foods to improve her mood but making an unhealthy choice that negatively influences her mood. Despite her knowing that her pattern of chocolate consumption lowers her mood, she seems unable to control her intake, which may be a negative coping mechanism for dealing with her emotions.Discussions of the bidirectional association between food and mood were common among the participants. Most suggested that their food choices influenced their mood, but their mood also influenced food choices. On several occasions, participants suggested that feeling lazy or tired made them turn to unhealthier, convenient options which they knew would lower their mood.Participants in each focus group described that the values assigned to the foods they consumed contributed to their mood and overall mental health. They articulated how these values signified rewards, comforts or commiserations, alongside reasons to treat themselves with foods of lower nutritional value. The discussions also included aspects of the role of food guilt. Assigning the value that a portion of food was detrimental to health led to guilt, blame and shame for eating these foods, which in turn was described as lowering mood.In theme two, participants suggested that every person is different physiologically and psychologically, which influences food and mood experiences. Participants discussed how there should not be one uniform set of guidelines for food and mood recommendations. Matilda suggests that each person’s food and mood experiences differ:It’s very individualistic. Everybody’s body processes are different. Some people react to one food in one way, and other people react to that same food in a different way. So, what is considered to be healthy, and what’s considered to be unhealthy may not be the same for every single person.(Matilda)Matilda wrestles with the idea that health may mean different things to different people because of the various ways that food impacts people physically and mentally.In the following extract, Su describes how her individual reactions to food contribute to guilt due to not eating the way deemed healthy or acceptable by society:I think it’s also hard not to beat yourself up if you’re doing something that is not working. Like, what is the best? Is it the food pyramid? Is it Paleo? Is it primal? Is it no grains? Not beating yourself up that you’re eating something different than everyone else. Recognising that everyone has their own types of food that works best for their body. I think everyone needs to come to that conclusion. It’s not a one shop fits all for everyone. To me, it’s just confusion, even though I know sort of what works best for me. Sometimes I eat well. Sometimes I don’t. You just do the best you can and not trying to realise you’ve got to understand it all.(Su)Su acknowledges that individual differences in food consumption and mood are common in society. However, Su explains she does not feel guilty about relinquishing a style of eating that does not work for her. The implication of this is that the acceptance of societal diversity enables contentment with her individual choices. She illustrates a catalogue of different media messages regarding changing dietary advice, fad diets, and government guidelines, but finds it important to recognise that food choice and what works for each person are different. She suggests it is difficult to determine what foods to choose on an individual level because uniform guidelines for everyone may not suit one person.The perception that uniform guidelines are not suitable for whole populations of people of different sizes, shapes, genders, physical activity levels and food tolerances was commonly addressed. Emma agrees with Su that the current population-based dietary guidelines in Australia may not be useful advice for everyone but are the default from most health professionals:I know when I’ve been like to see a dietitian in the past, and you’re going there because you’re wanting to get some healthy assistance. It is very much the dietary guidelines and diet pyramid. In the end, you just stop going because this is not what I want. Even with doctors in a way you feel like you aren’t being heard. I don’t want the grains, I don’t want the dairy, I’m looking at an alternative, you know, healthier. It’s frustrating, sometimes you go to the doctor about feeling sad. They don’t know about nutrition, they offer you a pill, you try and do something a little bit different. Go see a dietitian, it’s still that food pyramid and it seems that everyone’s still very behind the eight ball with all of this.(Emma)Emma describes frustrations with health professionals who always provide advice in line with dietary guidelines. Emma describes not feeling heard by health professionals in that she does not want the same advice that has not worked for her in the past, and ultimately, she chooses not to engage with health services because she feels their nutrition advice is outdated and not supported by evidence or a lack of individualised nutrition advice. Emma implies that medication may not be the only option for the treatment of mental ill-health symptoms, and that diet and nutrition could be a lifestyle factor that may be used as an alternative to current treatments for low mood.Throughout the focus groups, participants described how individuals have different eating patterns and consume different foods. They also suggested that each person’s biological system is different and that foods may react differently for each person. Descriptions of food intolerances and individual dietary needs were discussed, which presented specific physiological and psychological reactions.Participants reflected on the influence of food restriction and dieting compared to eating intuitively and the influence that such consumption patterns had on mood. In this theme, participants discussed intuitive eating and its association with mood—Intuitive eating is defined as an eating pattern that removes food restriction, weight focused thinking and promotes listening to internal hunger and satiety cues, accepting the body’s natural size and shape, eating mindfully, removing food guilt and ending food preoccupation . ParticiThe detrimental impacts of dieting and food restriction were commonly acknowledged across the focus groups. In the following extract, Shae describes her struggle in the past with food restriction:I had orthorexia for a while, without realising it. Because I wanted to be healthy, and then, you know, like, no that food’s good, that food’s bad…….However, I was really anxious and panicky around food. I was protective around food, if I’m cooking, don’t come and pick at it when I’m eating, because that’s less food for me, this may be my only chance to eat. It did change my mood and my mindset, and I still am struggling with myself to try and eat intuitively.(Shae)Shae describes her experience with orthorexia nervosa. Orthorexia nervosa is defined as a disordered obsession with eating only foods that are considered to be healthy. People who experience symptoms of orthorexia avoid any foods they deem as unhealthy, which can create disordered eating patterns over the long term . Shae deAs the mother of a newborn, Katie describes the urgency to lose the weight she gained during pregnancy and how food restriction lowered her mood:I went through postnatal depression. I had a huge period that I didn’t realise was disordered eating, like very disordered. Going on the diet bandwagon, lose the baby weight while having postnatal depression. I went on that food restriction, and I felt good losing weight. Then, it’s not sustainable. So, then the binge happens; and then I’m already low mood with the depression, and dealing with the baby, and then adding to it, because food was the coping mechanism or the control factor, I suppose. And then that body image stuff came into play.(Katie)The consequences of restrictive food behaviours during the onset of postnatal depression contributed to Katie’s negative eating patterns and exacerbated her symptoms. She explains that despite this, she continued dieting throughout this time which she believed helped her lose weight, but the weight loss was only for a short time and her deprivation mindset ultimately led to bingeing on the foods she loves. This cycle of dieting and bingeing resulted in an even lower mood, exacerbating her already compromised psychological well-being and the added pressures of parental caretaking responsibilities.The cycle of dieting and restricting foods is also described by Jane, who suggests that she finds it very hard to stop such a pattern:Because without having a good relationship with food and seeing food as like the enemy, or bad or feel guilty about it. You feel bad about yourself because you’re gaining weight. It can really affect my mental health and then the whole dieting cycle begins, which I think is really a big part of like the whole food and mood thing as well. However, when I eat the foods that I like, that my body tells me are good for me, and that I want without restriction—intuitively—when I’m not on a diet that makes me feel good.(Jane)Jane describes the impacts of the cycle of dieting and food restriction as a contributing factor to mood and mental health levels. She explains that viewing particular foods as restricted make her feel more negatively about herself. She implicates food guilt with weight gain and body image problems leading to lowered mood and negative mental health. She also describes that when she is not restricting foods and eating intuitively her mood and mental health improves.Intuitive eating was a term that was discussed across the focus groups. Participants suggested that dieting and restricting foods was detrimental to positive mood and increased negative mental health. They described eating the foods they enjoyed without guilt and listening to their bodies about which foods made them feel good. This intuitive way of eating was described as elevating mood for many of the focus group participants. They suggested that removing weight-focused thinking and focusing instead on the health foods brought to their body was uplifting for their mood, and that focusing on food guilt, losing weight, and dieting worsened their mood.A recurring theme across the focus groups was reactive and proactive relationships with food. Within this theme, many participants suggested a bidirectional link between food choices and mood. It was acknowledged that food choices influenced mood, but mood also influenced food choices. These findings suggest that reverse causality could be a factor in the food and mood relationship. For example, ultra-processed, refined and sugary foods are correlated with lowered mood and increased mood disorder symptoms  (but it values assigned to food, participants described that although the nutritional components of the food they ate were important for their mood, their relationships with, and the values they assigned to food were of greater importance than the nutrients consumed in the diet. These findings suggest that “there is more to food than just nutrition” [In the subtheme of trition” . There atrition” ,44, and trition” . Researctrition” . Mood hatrition” .acknowledgement of individual diversity relating to eating and mental health suggests that participants did not support a uniform approach to food and mood guidelines and health promotion. These findings support epigenetic studies that emphasise flexible and integrative approaches to nutrition, with recent recommendations for the future direction of nutrition advice to be personalised to diet type, genes and phenotype [Participants also perceived that individual differences determined the efficacy of recommended dietary patterns. This finding in the theme of henotype . Recent henotype . It is phenotype ’s asserthenotype .Participants also reported frustrations of not knowing which foods were good or bad for physical and mental health due to being surrounded by many different media messages, advertising, and population-based guidelines, such as the national dietary guidelines. This aligns with previous research exploring individuals’ knowledge of dietary guidelines, sources of nutrition information, and factors influencing food choices , which fImproving mood by removing food restriction and eating intuitively, there was a consensus among the groups that intuitive eating and food restriction were important elements in the food and mood relationship. Intuitive eating is a non-diet approach to eating known to positively influence body image, self-esteem and psychological well-being and reduce disordered eating behaviours [In the final theme of haviours . Intuitihaviours . The fochaviours ,55,56. Ohaviours ,58,59. TThis is the first study that has explored individuals’ experiences with food and mood in depth, specifically focusing on mental health. This is also the only paper that has applied a phenomenological lens to individual food and mood experiences and socially constructed representational contexts. There were also limitations of the study that should be addressed. Most of the participants were observed to be health or diet conscious. The participants’ dietary needs were acknowledged before the focus groups took place when asked if there were any dietary restrictions for the provided refreshments. Most participants discussed health-related dietary restrictions such as vegetarianism, veganism, paleolithic or ketogenic diets, or that they adhered to gluten or dairy-free dietary patterns. Future focus group research could ensure the voices of participants who were not as diet-conscious are included. Other limitations common to focus group studies may also have influenced the findings .Overall, the data from the focus groups point to the diversity of experience related by participants in their consideration of the bidirectional relationship between food intake and mood. More specifically, the data emphasise the need for more detailed phenomenological and social representational research in this area. The prevalence of depression is widespread, and the importance of good mental health maintenance is now greatly emphasised. If dietary patterns are to be promoted to influence and improve mental health, research must extend beyond a positivist paradigm. Despite growing statistical evidence supporting the role of nutrition in mental health, high levels of heterogeneity raise more questions relating to subjective perceptions of the links between nutrition and mental health. The demand for more experiential inquiry to fully explore the nuanced relationships between food and mood must continue.


Participants suggested that nutrients, food components or food patterns may not be the only way that food impacts mood. Rather, they described the social context of who, with, and where food is eaten, and that time, finances, and access to healthy fresh foods and bittersweet memories of foods shared with loved ones all impacted their mood. Findings suggest that quantitative studies examining the links between diet and mood should look beyond nutritional factors and give increased attention to the cultural, social, economic, and identity aspects of diet.Epidemiological and intervention studies in nutritional psychiatry suggest that the risk of mood disorders is associated with what we eat. However, few studies use a person-centred approach to explore the food and mood relationship. In this qualitative study of 50 Australian participants, we explored individuals’ experiences with food and mood as revealed during focus group discussions. Using a thematic template analysis, we identified three themes in the food and mood relationship: (i)  Over 350 million people annually experience symptoms of mood disorders such as depression . AlthougAlthough several qualitative studies have explored food and mood relationships, these focused on consumer preferences, rather than impacts on individuals’ mental health ,19. For A phenomenological viewpoint may provide broader insight on social contexts within which the food and mood relationships exist . PhenomeThe concepts of healthy/unhealthy eating are shaped by individuals’ unique perceptions and meanings assigned to food choices . LikewisNine focus groups, seven face-to-face and two online via Zoom, were conducted to explore individuals’ experiences with food choices and mood/mental health using the Consolidated criteria for Reporting Qualitative research (COREQ) . See theParticipants (N = 50) from Australian regional locations attended one of nine 60 min discussions. Excluding gender and age range—which were revealed during the group discussions—participant demographic information was not collected to facilitate comfort and promote open discussion. Participants consisted of 36 females (72%) and 14 males (28%). During the discussion, ages were revealed to be between 18 and 72 years of age, and all participants identified as either holding a current academic qualification or working towards a university degree. Participants were provided refreshments but no further compensation for participation. At this stage, participants self-disclosed dietary requirements for the refreshments. Most participants identified as being vegan, vegetarian, gluten-free, pescatarian, ketogenic or dairy-free. A total of 83 participants were recruited by email invitations circulated throughout a multicampus Australian university, or by social media advertisements. Participants responded by nominating their telephone number and preferred time to call. All respondents were called and informed of the study’s context. Thirty-three participants were unable to make the available times. A follow-up email was sent to the remaining 50 participants, including an information sheet and a consent form to participate.a priori semi-structured questions were asked, including “Can you describe how your feelings and emotions have influenced your eating” and “How do you think food and mood are related?” , a female PhD candidate and psychology tutor. The first focus group was supervised by the primary PhD supervisor as part of qualitative PhD training (Assoc. Prof. SS). The lead researcher jotted field notes directly after the commencement of each focus group and kept a reflexive journal noting thoughts, ideas, feelings, values, concerns, attitudes, beliefs, and any biases throughout the data collection and analysis stages .https://otter.ai/, accessed on 10 January 2022), cross-checking for accuracy, deidentifying participant information, and making corrections as necessary. Initial notes were made on first reading. Of the 50 participants invited to review the transcripts, one returned no adjustments, and the remainder declined the invitation.Data were explored utilising a six-stage thematic template analysis, as demonstrated in During the second stage, the lead researcher utilised NVIVO software, version 12  to condusocial context: familial and cultural influences in food and mood, (ii) social economics: time, finance, and food security, and (iii) food nostalgia: unlocking memories that impact mood. These themes identified the importance of social context, life experiences, beliefs, expectations, and values in the food and mood relationship.Three themes were identified during thematic template analysis: (i) In this theme, participants acknowledged their childhood, upbringing, family structures, and food culture as essential parts of the social context surrounding food and the connection to mood. Most of the recollections of family and food highlighted the importance of social context for mood. Mary suggests that her mood may not be impacted by the components in her food but that her mood is more highly influenced by the social context or environment within which she eats:Maybe it’s not just the food? There’s a whole environment and the context in which you’re in. I think it really makes a difference if you’re in some kind of a family system, or you’re not. I think part of mood, if I’m not being too analytical, is, maybe with feeling ready, feeling prepared, feeling organised. To me, that’s where the comfort level is. Way beyond my own personal tastes for food. Eating with my family makes me happy, despite what foods are being served. Preparing and sharing meals together is a way we express our love and gratitude towards each other.(Mary)Much of the extract describes the social context of family systems, the preparation and consumption of food, and how this is linked to feelings of comfort and security. A possible consequence of this is that Mary may eat foods that she does not like or does not think are healthy but are preferred /shared by her family. She has a sense of family duty and the role that food plays in this, knowing her family is organised and prepared with food makes her feel positive. She suggests that creating a loving family environment when eating influences her mood positively, and for her, food and mood relationships centre around social environments and context rather than the specific foods or nutrients eaten.Similarly, Vicki describes that eating a healthy meal in solitude may not provide the psychological benefits of eating in an environment that supports social connection. She describes eating lunch at her work desk and the resultant isolation impacting her mood negatively, compared with the feelings of wellbeing she receives eating lunch outside or with her co-workers:As far as mood is concerned, I can eat the healthiest diet in the world, in complete isolation. Say if I pack myself this beautiful organic lunch, and it’s got probiotics from the kefir and sauerkraut and all my organic greens, and I go to work in a cubicle, and I don’t talk to anyone. I just sit down at my desk all day and eat lunch at my computer. I just think I’m going to get sick. I don’t think. I’m going to be well. When I eat away from my desk surrounded by others, even if the food itself is not as healthy, I tend to feel more uplifted once I return to my desk.(Vicki)Vicki suggests that eating healthily while on her own may not benefit her psychologically as when eating in a less healthy manner with others. A potential implication of this is that her work lunchtime routine, eating without stopping or moving away from her workstation, could adversely influence her mood negatively compared with eating in the lunchroom (or away from the workplace) with co-workers. The value Vicki ascribes to eating in isolation suggests that her mood may benefit from eating in a social context with friends or co-workers and may not necessarily come from components of the food she eats.Another way that family and cultural influences were addressed during the focus group discussions was how current moods manifest by historical eating attitudes linked to childhood, upbringing, and parental eating exemplars. Amy reflects on her mother’s role modelling and the relationship between emotion and food:Every time I come into a situation that’s highly emotional. I just stuff my face. My Mum doesn’t deal with emotions. If you’re upset, she’ll bring around a cheesecake (laughs) and two spoons. I think a lot of times they don’t know how to comfort and that’s where my Mum brings a cake…... She won’t even give you a hug, so uncomfortable. But she will eat a cake with you. That’s her hug. We know where it’s coming from, a place of love. But it was the way she was raised as well.(Amy)This extract describes the use of food as a mechanism for emotional expression in a family, where conventional emotional displays were less favoured. Amy suggests a physical and emotional disconnection from her mother, which her mother tries to compensate by using food in times of trouble or sadness. She reflects that this method of using food to show love may have been learned from her grandparents. Amy acknowledges that these learned behaviours passed down from generation to generation are reflected in her adult relationship with food and its link to comfort eating and using food for emotional regulation in her adult life.Participants reflected on childhood eating and how foods eaten with friends and family increased or decreased mood. The discussions also included descriptions of how eating in a social context with family and friends impacted mood and wellbeing either positively or negatively. Participants discussed the importance of preparing and eating foods in the social environment on mood rather than the nutrients or components in the food providing mental wellbeing. Participants also referred to how families used food to show love towards each other, particularly if this emotion was difficult to express within the family.In this theme, participants reflected on how time constraints and other food security issues—such as cost—influenced their food choices and mood. They expressed that organisation, foresight in preparation, and planning helped them make healthier food decisions, which elevated their mood. Others described lack of time, tight finances, feelings of procrastination, lethargy, and decision fatigue as responsible for making less healthier choices, and this lowered their mood. Katherine acknowledges her frustrations with a lack of time to create healthy meals for her family:I’d make homemade pizzas, we did the base, and we could all put what we liked on them. But that would take me like an hour and a half of making the dough and rolling it out. It’s about time restraints as well, families who work and then pick up kids and then get home, and it’s not just about cost, it’s about the cost of time.(Katherine)In this extract, Katherine reflects the positive social context of cooking together as a family, but that this was not achievable every night. Time constraints from work and school make it difficult for her family to get together and cook in this way. An implication of this lies in that eating healthily and in a social way that elevates her family’s mood may not always be about the financial cost of the ingredients, but that lack of time and other priorities are also a significant contributor.Time constraints were a commonly discussed barrier to healthy eating, and having time to prepare food was seen as a luxury to improving mood and health. This acknowledgement of time as a luxury is reflected in Sarah’s description of how food preparation is an important part of her day that helps her limit unhealthy, convenient food options:I wouldn’t say I’m a food prepper…… sometimes I try, but I find that too boring and too overwhelming. I tend to make lunch at the same time as dinner. If I’m making dinner for my boyfriend. I’m going to make our lunches……… If I’m making this now, I’m just gonna do it double. I always make sure there’s leftovers, put it in the lunch boxes, ready to go. I found that if I didn’t, it would be too hard in the morning. I wouldn’t even be able to stomach the idea of lunch at that time. I would just end up wasting all this money buying stuff out and not feeling that good about it.(Sarah)Feelings of preparedness were a mediating factor in the food and mood relationship. Sarah reveals high levels of preparation that compensate for her mood. She feels that preparing food in advance helps her control her eating habits. Her mood is elevated by feeling prepared and being in control. Sarah reflects that a lack of preparation would leave her feeling low and lazy, and she fears a lack of control over the types of foods that would end up in her lunch if she was not well prepared. A potential positive consequence of this is that Sarah does not have to waste money buying lunch or being left to deal with food preparation in the morning. Sarah uses the words “overwhelming” and “boring” to describe traditional meal preparation, but she describes how her way of preparing lunches from dinners makes her feel ready and organised for the next day, and this feeling of preparedness elevates her mood.Participants across the focus group concurred that substantial time, effort, and preparation translated into eating well, but that this investment in time and health delivers rewards in heightened mood levels and greater wellbeing. Mary compares the differences between planning and being prepared and choosing fast, convenient options and their role in her mood:It takes extra time if you’re going to eat well and prepare well and plan well. I think we all know; if you’re tired or fatigued, it’s too hard to think, you can’t be bothered. You just go and grab whatever, which keeps you in that cycle, and when you’re feeling down, and then you’re tired, you’re like, “I’ll just grab something else.” Now you’re more tired and down. I’ve made all these decisions during the day. I think that’s the hardest part. The whole day like, tick, tick, tick, tick, tick, tick and then you just get to the night and you’re like—well I just had to eat the whole packet of chips.(Mary)When Mary describes “eating well” in this context, it appears that she means eating healthily. She suggests that, for her, preparation and planning are important aspects of healthy eating. As with Sarah, Mary finds it difficult to be well-planned and prepared when feeling exhausted at the end of the day. She acknowledges the role of decision fatigue at the end of a hard day—after making many healthy decisions throughout the day her ability to make healthy choices in the evening is diminished. Potential implications of her fatigue could result in it being easier to eat an unhealthier, more convenient option, promoting a cycle of unhealthier choices. It is possible that the cognitive dissonance of wanting to eat healthily but instead choosing an unhealthy option lowers her mood and exacerbates her weariness.In the following extract, Sophie highlights her frustrations with balancing work, study, personal, and family responsibilities and explains that time is an important factor in her and her family’s food choices:When do you find time to cook? To go shopping, get your whole foods and then go home and cook them and participate in some social activity like soccer? It’s hard, working full time, studying full time, being a parent, and managing time. It’s not so much an emotional thing. It’s more like, I just am spread thin. I’ve got the kids, and I’m like okay, you want frozen pizza for dinner? Hey, let’s just have frozen pizza for dinner. It’s the time thing for me. I would love if I had the energy to always walk into a perfectly clean kitchen. I would love to cook a healthy meal and have healthy snacks around for the kids, me, and everybody, but it’s the time really.(Sophie)Time constraints negatively impact Sophie’s energy and emotions. She illustrates maintaining a difficult balance between competing responsibilities that detract from her ability to think about, cook, and prepare healthy meals. Sophie discusses how succumbing to unhealthier food choices is sometimes the easiest option due to her time constraints and visualises what a perfect world would look like for her to provide her family with healthy meals, if only she had the time.Descriptions of social economic stressors for busy, working families included both financial and time pressures. Participants recounted that they did not always provide the healthy, nutritious meals for families as intended to because of these constraints. A common narrative was the influence of decision fatigue. Participants reflected on the many decisions made throughout the day, making it difficult to make healthy choices in the evening, where it is easier to turn to convenient, less healthy choices.In this theme, lines of discussion within the focus groups turned towards the role that food and nostalgic memories had in the experience of happy and bittersweet mood. The following extracts explore how certain foods connected participants with fond memories of loved ones who had passed on, creating feelings of nostalgia, and this reconnected them to happy times through the consumption of common foods eaten in their past:I think there are certain things that are comfort, whether it’s a particular food group, or it’s a memory of a food. If you had something that was wonderful when you were a kid, and you associate food with a wonderful time and you just want to go back there. My Mum always loved jam and cream. You’d have a slice of bread, no butter, jam, and then whipped cream on top, and that was her go-to. I lost her 18 months ago, so I’ve been having this periodically, because it’s what Mum wanted. So that’s the other element of food and mood—because it is memory that connects you to those you love.(Sarah)Sarah comments on how she can transport herself back to these feelings of her late mother through the food they would eat together. She uses the emotive word “wonderful” when reminiscing about the foods she shared with her mother when she was a child. Sarah recalls her mother’s love for comfort foods and how these foods now instil comfort in her. Food provides her with a connection to memories that inspire a positive mood and help her remember happy times. Similarly, Layla reminisces about food memories from her childhood that bring back nostalgic memories and impact her mood:Growing up, my mother, who has now passed, cooked desserts. I have strong feelings associated with these foods, and they take me back to my childhood and make me feel comforted. I just need cream. If I have any sort of cake even if it’s cheesecake creamy, I’ll have to have a big glob of cream. This was my mother as well. She was the same.(Layla)Layla reflects on how she now chooses the same foods she witnessed her late mother eating as a child in an attempt to reconnect with those memories and feelings of comfort and solace. In another discussion, the role of food and nostalgia in mood was addressed by the male participant Jonas. He describes how he developed a love for cooking and preparing food, which ties him to his family who live overseas:I love cooking. So, I get really excited when I start cooking …. Because my father lives in Greece and I cook there with my Mum and my Dad. It brings me in touch with those moments. So that’s really motivating. I get really happy when I’m cooking. I love having a glass of wine and chuck on the music and there’s a great atmosphere. It’s a big event for me every time I cook, because it makes me feel like I am there with them.(Jonas)The process of cooking food and being absorbed in the experience of cooking connects Jonas with his family, who all live abroad. The physical act reminds him of cooking with his family and connects him with happy memories. He finds that his family does not need to be directly in the room where he is cooking and eating. Rather, he benefits from the social context through actions, smells, texture, sound, and sights of the food; this connects him with his family when they are not physically present and contributes to elevated mood.Participants recollected and shared bittersweet memories of their childhood, families, and loved ones both passed and still alive which were inspired by certain types of foods they remember their loved ones eating. Food provided an instant connection and portal to past feelings and emotions which elevated mood. Participants shared that they would consciously seek out specific foods to help with a reconnection to memories of the past and happy times with their loved ones.social context: familial and cultural influences in food and mood, participants expressed that the social context in which they consumed food had a greater influence on their mood than the nutrients in or components of the food itself. They also considered how family circumstances and cultural upbringing influenced the relationship between food and mood. In the second theme, social economics: time, finance and food security, participants described how financial and time restraints influenced food choices that subsequently impacted mood. In the third theme, food nostalgia: unlocking memories that impact mood, participants suggested that they could reconnect with bittersweet memories from the past by choosing to eat specific foods from their childhood or that loved ones preferred.A thematic template analysis of participants’ accounts of food and mood experiences highlighted three themes. In the first theme, The focus group findings highlight the influence of social context and social economics on food choices and mood. Participants suggested that the social context of how food is eaten influenced mood positively and negatively, and past and present familial and cultural factors influenced the relationship between food and mood. It has been proposed that there is a social influence on individuals’ eating behaviours . People’Individuals experiencing mental ill-health are more likely to encounter social disconnect, stigma, and loneliness ,45, whicfamilial and cultural influences in food and mood was supported by research on the psychosocial benefits of cooking interventions, which found that cooking had positive effects on quality of life, social function, self-esteem, and influence [Participants who identified that they noticed a positive mood increase when they prepared meals at home suggested this was due to the deep connection with their family, culture, and the origins of the food they sourced and consumed. The finding within the focus groups of preparing and cooking elevating participants’ mood in the theme nfluence .social economics: time, finance, and food security, participants suggested that food insecurity, time, and financial constraints influenced their food choices, indirectly impacting their mood and mental wellbeing. Food insecurity is defined as the limited availability of nutritional foods and is linked to the stress and uncertainty of not knowing where the next healthy meal comes from [In the theme mes from . Food inmes from . Furthermes from . Those wmes from ,51. Ultimes from , which imes from . People mes from . This limes from ,16,55,56food nostalgia: unlocking memories that impact mood, participants described a recollection of memories prompted by the consumption of foods from their past or that loved ones’ preferred. Nostalgia is described as a bittersweet recollection of memories and sentimental longing for the past [In the novel and surprising theme the past . Food nothe past . Howeverthe past . Additiothe past  describethe past . The resIn the current study, participants described social context, food security, and nostalgia as important constructs that impacted their food and mood relationship. These three constructs are tightly coupled: there is a direct link between social connection and nostalgia, and food enhances this connection . There iThis study was the first of its kind to explore food and mood in a group of Australian participants. However, it is noted that, due to recruitment through a multicampus Australian university, all participants were well-educated and self-identified as being health conscious during the discussions and when nominating dietary requirements for refreshments. Selection bias may have influenced the discussion, as the voices of those who are less health-conscious were not explored . AdditioThis study aimed to explore individuals’ experiences with the food and mood relationship by conducting focus groups with Australian participants. Using thematic template analysis, three themes were identified that suggested that social context, food security, and food nostalgia were elements that impacted the food and mood relationship outside the food components or nutrients that are consumed. This research expands on the current quantitative nutritional psychiatry research and suggests that quantitative studies examining the links between diet and mood should look beyond the nutritional factors and give increased attention to the cultural, social, economic, and identity aspects of diet. This type of inquiry could broaden the current field of nutritional psychiatry and expand the context and understanding surrounding the diet and depression relationship.


Zingiber officinale Roscoe (ginger) has long been used as an herbal medicine to treat various diseases, and its main sub-components, [6]-gingerol and [6]-shogaol, were also reported to have anti-inflammatory, anti-oxidant, and anti-tumor effects. However, their effects on various types of pain and their underlying mechanisms of action have not been clearly analyzed and understood yet. Thus, in this review, by analyzing 16 studies that used Z. officinale, [6]-gingerol, and [6]-shogaol on mechanical, spontaneous and thermal pain, their effects and mechanisms of action have been analyzed. Pain was induced by either nerve injury or chemical injections in rodents. Nine studies analyzed the analgesic effect of Z. officinale, and four and three studies focused on [6]-gingerol and [6]-shogaol, respectively. Seven papers have demonstrated the underlying mechanism of action of their analgesic effects. Studies have focused on the spinal cord and one on the dorsal root ganglion (DRG) neurons. Involvement and change in the function of serotonergic receptors , transient receptor potential vanilloid 1 (TRPV1), N-methyl-D-aspartate (NMDA) receptors, phosphorylated extracellular signal-regulated kinase 1/2 (pERK1/2), histone deacetylase 1 (HDAC1), voltage-gated sodium channel 1.8 (Nav1.8), substance P (SP), and sciatic nerve’s morphology have been observed. Zingiber officinale Roscoe is a perennial herb from a member of the Zingiberaceae family -gingerol and [6]-shogaol are the main compounds -gingerol, and [6]-shogaol has been summarized and analyzed along with the underlying mechanisms of action. This review study includes a total of 16 studies.Thus, in this review, the effect of Z. officinale -shogaol. In addition, in their study, intrathecal pre-treatment of nonselective nitric oxide (NO) synthase inhibitor, inhibitor of guanylate cyclase, and ATP-sensitive K+ channels channel blocker also inhibited the [6]-gingerol-induced anti-allodynic effect.Gauthier et al.  has repoZ. officinale. First, the acute oral administration of Z. officinale significantly increased the threshold to mechanical stimuli, which was reduced after surgery. In their second experiment, the repeated oral administration of Z.officinale for 7 days starting from 3 days after surgery significantly decreased the pain induced by mechanical stimuli. Among the three doses used in the study , the anti-allodynia effect of 200 mg/kg was greater, which was similar to 30 mg/kg of pregabalin. The increase in histone deacetylase 1 (HDAC1) in BV2 cell and spinal cord after nerve injury were not shown in single and repeated Z. officinale treated rodents. Moreover, acute Z. officinale application decreased both phosphorylated extracellular signal-regulated kinase 1/2 (pERK1/2) activation in BV2 cell and spinal cord, respectively; however, repeated Z. officinale treatments decreased pERK2 activation in the spinal cord. Montserrat-de la Paz et al. -shogaol increased spinal GABA and glutamate decarboxylase 65 (GAD65) protein concentration in the spinal dorsal horn of L4–5 segments. Altogether, these results suggest that Z. officinale and its sub-components use spinal serotonergic pathways to induce an analgesic effect.Contrasting to the above-mentioned studies, Lee et al.  demonstrm et al.  also repm et al. . In thisZ. officinale and [6]-shogaol significantly attenuated mechanical pain induced by 110 mg/kg of STZ injection. Moreover, both Z. officinale and [6]-shogaol demonstrated less damage in the sciatic nerve’s morphology compared to the STZ group. In their second study [Z. officinale and [6]-shogaol significantly decreased mechanical pain induced by STZ injection. They reported that both Z. officinale and [6]-shogaol could significantly reduce upregulated spinal TRPV1 and N-methyl D-aspartate receptor subtype 2B (NMDAR2B) mRNA expression after STZ treatment.In two studies conducted by Fajrin et al. ,44, STZ-v1.8 currents and decreased substance P (SP) release induced by KCL and veratridine in CHO cells.Hitomi et al.  assessedZ.officinale and its main physiological active indicators, [6]-gingerol and [6]-shogaol, could significantly attenuate mechanical pain that has been induced by various animal models of pain. In summary, the above-mentioned studies demonstrate that Spontaneous pain includes sensations of stabbing, shooting, burning and paroxysmal pain associated with dysesthesia or paresthesia . ParesthIn this section, various types of chemicals, such as acetic acid ,32,39, fZ. officinale could prevent acetic acid-induced spontaneous pain in mice. Spontaneous pain was induced by intraperitoneal injection of 3% acetic acid (i.p.), and increase in the number of abdominal constrictions (writhing) and stretching with a jerk of the hind limb were shown after the injection. Z. officinale was intraperitoneally injected 1 h before acetic acid administration, and it significantly prevented acetic acid-induced writhing. The effect of Z. officinale was similar to the effect of 150 mg/kg of aspirin, which was used as a positive control. In the work of Ojewole -gingerol could be used to attenuate the spontaneous pain induced with acetic acid and formalin injection as the writhing and licking the affected limb decreased as much as the conventionally used drugs, such as aspirin -shogaol were evaluated through a tail-flick test in the STZ-induced heat pain in mice. Oral and intraperitoneal administration of Z. officinale and [6]-shogaol, decreased thermal hyperalgesia, respectively. In their subsequent study [Z. officinale and [6]-shogaol. The results show that both Z. officinale and [6]-shogaol treated group mice showed significantly longer latency time toward thermal stimulus compared to the diabetic control group.Chemotherapy treatment is also known to induce thermal pain both in humans and rodents ,76. In tm et al.  also repm et al. , the effnt study , STZ wasZ. officinale in electrical and radiant heat-induced thermal pain using a hot plate test and a tail flick test, respectively. In the study of Ojewole, Z. officinale was intraperitoneally administrated 20 min before the hot-plate test, and jumping-out of the beaker was considered a response to heat-induced pain. Z. officinale treatment significantly delayed the reaction time induced by electrical heat. Sepahvand et al. -gingerol and [6]-shogaol can effectively attenuate thermal pain  induced by nerve injury and chemotherapy treatment.Altogether, the results demonstrated in the included studies clearly show that Z. officinale, [6]-gingerol and [6]-shogaol on different types of pain have been summarized. A total of 16 studies that focused on Z.officinale -gingerol and [6]-shogaol have been analyzed on mechanical, spontaneous, and thermal allodynia or hyperalgesia , Mata-Bermudez et al. have also focused on spinal 5-HT1A, B, D, and 5A receptors and demonstrated that the analgesic effect of intrathecal injection of [6]-gingerol is mediated by these receptors. In addition, in the study of Kim et al. -shogaol act on spinal 5-HT1A and 5-HT3 receptors and [6]-gingerol on spinal 5-HT1A, B, D, and 5A receptors. Seven families of serotonin recipients are divided into 15 subtypes -shorneurons . Altogetsubtypes , and aresubtypes . Among t (GPCRs) . 5-HT1, tivation ,95,96. AZ. officinale and [6]-shogaol modulate the expression of spinal TRPV1 to induce analgesia. They reported that both Z. officinale and [6]-shogaol decrease the expression of TRPV1 in the spinal cord. Compared to the relatively well understood role of the TRPV1 present on the peripheral nervous system, the role of spinal TRPV1 has not been clearly understood yet -Shogaol”, “[6]-Gingerol”, “Allodynia” and “Hyperalgesia” “Pain”. After the initial search, duplicates, bibliographies, study protocols, clinical trials, and non-English studies were excluded. Sixteen animal studies were included in this study.A search was conducted on all studies on the effect of  Scholar . Extensi