Leslie A. Lytle

Emerging adulthood and college-aged youth: an overlooked age for weight-related behavior change.

Emerging adulthood: a unique developmental stage Over the past 50 years, major population-level demographic shifts including increases in postsecondary education and delays in marriage and childbearing have occurred. These shifts have opened the door for a period of “emerging adulthood,” typically defined as 18–25 years of age (1). This period is marked by important transitions such as leaving home and increasing autonomy in decision-making; however at the same time, adult responsibilities such as financial independence and residential and employment stability are still in flux. This period of emerging adulthood may be an important, yet overlooked, age for establishing long-term health behavior patterns. Several factors differentiate emerging adulthood from other life stages and have specific relevance to the formation of health behavior patterns, including identity development and shifting interpersonal influences. One defining characteristic of this life stage is the development of a self identity. Emerging adulthood is a time for the exploration of new ideologies and behaviors which allow individuals to express their individuality. Given previous research showing that identity (e.g., incorporating healthy lifestyle characteristics in the concept of one’s self) is an important indicator of lasting health behavior change, emerging adulthood may be a particularly important time for establishing and intervening on long-term health behavior patterns (2,3). In addition, other psychosocial attributes associated with beneficial health behaviors (e.g., self-efficacy) develop or become established during this period of emerging adulthood (4), providing support for the unique importance of this life stage in long-term behavioral patterning. Emerging adulthood may also be a time for changing support systems and shifting interpersonal influences. Although the influence of parents and family is well established in the literature on childhood and, to a lesser extent, adolescent diet and physical activity patterns, little research has examined these issues among young adults. Young adults spend more leisure time alone compared to other age group (except retirees ≥55 years) (5) and are often assumed to be more disconnected from their family. However, some research suggests that closer relationships with parents (6,7) and siblings (8) may evolve as youth transition into college and adulthood (9,10). As youth become more independent, family and social network influences begin to shift and may serve different roles, as compared to that which they served in childhood and adolescence. Much additional research is needed to understand the evolving social influences in the emerging adult years and the extent to which this may influence health behavior patterns. Given the overall paucity of research in this area, more work is needed to understand better how the unique characteristics of emerging adulthood may contribute to establishing long-term behavioral patterns and the possible vulnerability of this life stage to various influences. Obesity is a major public health concern, and effective population-wide intervention strategies aimed at reducing obesity are needed. Although a growing body of literature has explored modifiable determinants of excess weight gain in adults and, to a lesser extent, in children, other important ages have been understudied. Though once considered to be an age of optimal health and well-being, the transition from adolescence to young adulthood is gaining recognition as an important time for health promotion and disease prevention. Not only is the presence of obesity and unhealthy lifestyle characteristics at this life stage associated with increased chronic disease risk, but this also may be a critical time during which young people establish independence and adopt lasting health behavior patterns. The objectives of this article are to: (i) describe emerging adulthood as a developmentally unique life stage, (ii) highlight epidemiologic evidence documenting adverse changes in diet, physical activity, and weight during this stage, (iii) discuss the influence of food and beverage marketing targeting emerging adults, and (iv) illustrate the need for health promotion and intervention efforts that could target young adults through settings such as postsecondary institutions. emerging Adulthood and Collegeaged youth: An overlooked Age for Weight-related behavior Change

Promoting Physical Activity in Middle School Girls Trial of Activity for Adolescent Girls

BACKGROUND Physical activity is important for weight control and good health; however, activity levels decline in the adolescent years, particularly in girls. DESIGN Group randomized controlled trial. SETTING/PARTICIPANTS Middle school girls with English-speaking skills and no conditions to prevent participation in physical activity in 36 schools in six geographically diverse areas of the United States. Random, cross-sectional samples were drawn within schools: 6th graders in 2003 (n=1721) and 8th graders in 2005 (n=3504) and 2006 (n=3502). INTERVENTION A 2-year study-directed intervention (fall 2003 to spring 2005) targeted schools, community agencies, and girls to increase opportunities, support, and incentives for increased physical activity. Components included programs linking schools and community agencies, physical education, health education, and social marketing. A third-year intervention used school and community personnel to direct intervention activities. MAIN OUTCOME MEASURES The primary outcome, daily MET-weighted minutes of moderate-to-vigorous physical activity (MET-weighted MVPA), was assessed using accelerometry. Percent body fat was assessed using anthropometry. RESULTS After the staff-directed intervention (pre-stated primary outcome), there were no differences (mean= -0.4, 95% CI= -8.2 to 7.4) in adjusted MET-weighted MVPA between 8th-grade girls in schools assigned to intervention or control. Following the Program Champion-directed intervention, girls in intervention schools were more physically active than girls in control schools (mean difference 10.9 MET-weighted minutes of MVPA, 95% CI=0.52-21.2). This difference is about 1.6 minutes of daily MVPA or 80 kcal per week. There were no differences in fitness or percent body fat at either 8th-grade timepoint. CONCLUSION A school-based, community-linked intervention modestly improved physical activity in girls.

A Randomized School Trial of Environmental Strategies to Encourage Fruit and Vegetable Consumption among Children

The Cafeteria Power Plus project examined whether a cafeteria-based intervention would increase the fruit and vegetable (FV) consumption of children. Twenty-six schools were randomly assigned to either an intervention or control condition. Baseline lunch observations of a sample (N = 1668) of first- and third-grade students occurred in the spring of 2000; follow-up was in the spring of 2002. The intervention took place during two consecutive school years beginning in the fall of 2000 and consisted of daily activities (increasing the availability, attractiveness, and encouragement for FV) and special events (kick-offs, samplings, challenge weeks, theater production, and finale meal). Training of food-service staff and cook managers was ongoing throughout the intervention phase. Students in the intervention schools significantly increased their total fruit intake. Process measures indicated that verbal encouragement by food-service staff was associated with outcomes. The outcomes suggest that multicomponent interventions are more powerful than cafeteria programs alone with this age group.

Measures of the Food Environment: A Compilation of the Literature, 1990–2007

BACKGROUND Valid and reliable measures are required to assess any effect of the food environment on individual dietary behavior, and form the foundation of research that may inform obesity-related policy. Although many methods of measuring the food environment exist, this area of research is still relatively new and there has been no systematic attempt to gather these measures, to compare and contrast them, or to report on their psychometric properties. EVIDENCE ACQUISITION A structured literature search was conducted to identify peer-reviewed articles published between January 1990 and August 2007 that measured the community-level food environment. These articles were categorized into the following environments: food stores, restaurants, schools, and worksites. The measurement strategies in these studies were categorized as instruments (checklists, market baskets, inventories, or interviews/questionnaires) or methodologies (geographic, sales, menu, or nutrient analyses). EVIDENCE SYNTHESIS A total of 137 articles were identified that included measures of the food environment. Researchers focused on assessing the accessibility, availability, affordability, and quality of the food environment. The most frequently used measure overall was some form of geographic analysis. Eighteen of the 137 articles (13.1%) tested for any psychometric properties, including inter-rater reliability, test-retest reliability, and/or validity. CONCLUSIONS A greater focus on testing for reliability and validity of measures of the food environment may increase rigor in research in this area. Robust measures of the food environment may strengthen research on the effects of the community-level food environment on individual dietary behavior, assist in the development and evaluation of interventions, and inform policymaking targeted at reducing the prevalence of obesity and improving diet.

Measuring the Food Environment: State of the Science

The past decades have seen an increased interest in understanding how the environment affects population health. In particular, public health practitioners and researchers alike are eager to know how the food environments of neighborhoods, schools, and worksites affect food choices and, ultimately, population risk for obesity and other diet-related chronic disease. However, the measurement tools for assessing the environment and the employed study designs have limited our ability to gain important ground. The field has not yet fully considered the psychometric properties of the environmental measurement tools, or how to deal with the copious amounts of data generated from many environmental measures. The field is dominated by research using unsophisticated study designs and has frequently failed to see the role of social and individual factors and how they interrelate with the physical environment. This paper examines some of the measurement issues to be considered as public health practitioners and researchers attempt to understand the impact of the food environment on the health of communities and takes a broad look at where the science currently is with regard to how the food environment is measured, thoughts on what issues may benefit from more deliberate inspection, and directions for future work.

Overweight and obesity among Norwegian schoolchildren: Changes from 1993 to 2000

Aim: The aim of the present study was to investigate the prevalence rate of overweight and obesity in a nationwide survey of fourth- and eighth-grade Norwegian schoolchildren, the changes in overweight rates among eighth graders from 1993 to 2000, and to investigate factors associated with overweight. Methods: Cross-sectional dietary surveys were conducted on nationally representative samples of eighth graders in 1993, and among fourth and eighth graders in 2000. Self-reported weight and height was available from 1,650 eighth graders in 1993, and from 664 fourth and 825 eighth graders in 2000. Data on dietary pattern, social class, and physical activity were also available. Results: In 2000 the prevalence of overweight and obesity among the fourth graders was 18.5% and 3.6%, respectively, and among the eighth graders 11.5% and 1.8%, respectively. A marked increase in overweight and obesity among Norwegian eighth graders from 1993 to 2000 was observed; the prevalence of overweight and obesity increased by 4 and 0.9 percentage points, respectively. Social class, time spent watching TV or in front of a computer, and breakfast frequency were associated with the odds of being overweight. An inverse relation between intake of sweets and overweight was observed. Validation studies demonstrated a high correlation between self-reported and measured height and weight in both age groups. Conclusion: The present study demonstrates a high prevalence of overweight and obesity among schoolchildren, especially among fourth graders in Norway. Moreover, the proportion of overweight and obese children has increased greatly among eighth graders during the last decade.

Changing the diet of America's children: What works and why?

Executive summary This paper examines educational efforts and programming designed to change the diet of Americas children. These programs are frequently part of school-based nutrition education; however, other outreach methods, including school-wide environmental change efforts, family-focused interventions, mass media messages, community-based interventions, and federally funded nutrition programs, also target eating behavior change in children. We identified six elements of successful nutrition education programming: (1) programs are behaviorally based and theory driven; (2) family involvement is incorporated into programs for elementary-aged children; (3) programs for middle school to senior high students include self-assessment of eating patterns; (4) behavior change programs include intervening in the school environment; (5) behavior change programs include intervening in the larger community; and (6) programs include intensive instruction time. Successful programs included most of the identified elements. Emerging trends and innovative approaches were also reviewed, though few of these have been rigorously evaluated. We found that nutrition education is increasingly included as part of multidisciplinary educational programs. For example, school-based interventions simultaneously target eating and activity behaviors. We also saw a resurgence of integrating nutrition curricular information into other core subject areas. This integration reflects the growing demands on instructional time in our schools. We also found that the mass media is becoming more powerful in influencing the diet of Americas children. This influence occurs not solely through food advertisements targeted at children, but also through industry-sponsored public service announcements and curricula teaching children about basic nutrition concepts. Interactive computer technology is one of the most exciting innovations for nutrition education. Computer-based learning allows children to move at their own pace in instructional settings that require much less teacher time. The recommendations call for five broad-reaching objectives to more effectively improve the diet of American children. Ftrst, schools, school districts, and local, state, and federal governments need to commit to comprehensive, school-based nutrition education. Effective nutrition education requires thoughtful consideration of scope and sequence so that behavioral skills can be established in early elementary grades and enriched with more abstract problem-solving skills in junior and senior high school. Teachers need to be adequately trained, and the school environment must provide healthful options for children. Second, we call for multiple instructional techniques for nutrition education. Didactic lessons are insufficient for behavior change. Experiential, hands-on learning, problem solving in group settings, and interactive computer opportunities will be most effective in promoting learning and behavior change. Third, we call for viewing diet change for children from an environmental perspective that includes family, community, the media, and the food industry. Even the best quality classroom-based education is not sufficient for teaching and modeling healthful eating behavior in children. Children learn about what to eat and why to eat, and are provided reinforcements and incentives for food-related activity from their families and larger environment. If the diet of Americas children is to change for the better, our environment must be supportive. Fourth, it is imperative that rigorous outcome evaluation be an integral part of nutrition education programs developed with the intent of national distribution. Such evaluation may be enriched by forming partnerships that draw on industrys expertise in market research. Lack of outcome evaluation and publication inhibits the acceptance and dissemination of creative and innovative approaches. Simpler evaluation is appropriate for programs disseminated locally. Fifth, it is imperative that federal and state governments develop and/or promote a system to disseminate effective nutrition education materials. Effective materials are underutilized in this country, in part due to unawareness of their existence and in part due to inaccessibility. A clearinghouse or network to collect, describe, rate, and share these programs nationally may be an important first step. Partnerships with industry, professional organizations, and private sources to reproduce and disseminate nutrition education materials may be beneficial as well; however, nutrition educators also need to be encouraged to work collectively, that is, to produce fewer, higher quality materials on the same topics. Incentives should be built into the dissemination system to encourage collective sharing of educational materials. To conclude, we can improve our interventions if the principles presented in this paper are incorporated into nutrition education programming for children. These improvements will require commitment to nutrition education at the federal, state, and local levels and the development of partnerships among government, industry, schools, families, communities, and the media. The benefits of this commitment and partnership will be realized through Americas most precious resource, the health and well-being of our children.

School-Based Approaches to Affect Adolescents’ Diets: Results From the TEENS Study:

This article reports on the outcomes of the Teens Eating for Energy and Nutrition at School (TEENS) study, a 2-year intervention study conducted in 16 middle schools with a goal of increasing students’ intakes of fruits, vegetables, and lower fat foods. Despite positive interim results for students randomized to intervention schools, the positive effects of the intervention were not seen for the primary outcomes at the end of the 2nd year. Positive effects were seen only for a food choice score (suggesting that the students usually choose lower versus higher fat foods) and not for measures of food intake. Future studies may need to take a step back toward more controlled efficacy studies in working with this age-group. In addition, future work may consider the use of peer leaders, more intensive teacher training, ongoing formative assessment, and the testing of more powerful environmental change intervention strategies.

Associations between Perceived Family Meal Environment and Parent Intake of Fruit, Vegetables, and Fat

OBJECTIVE To describe the family mealtime environment and assess associations with adult fruit, vegetable, and fat intake. DESIGN Telephone survey. PARTICIPANTS A convenience sample of 277 adults in the Minneapolis/St. Paul area were recruited through 4 schools. The sample was 85% female and 70% married. The mean number of children in the household was 2.6 (range 1 to 9). VARIABLES MEASURED Adult fruit and vegetable intake, fat intake, and perceptions of the mealtime environment. ANALYSIS Descriptive and mixed-model linear regression. RESULTS Participants reported that the television was frequently on during dinner meals and almost one third felt that their family was too busy to eat dinner together. A higher frequency of television viewing during dinner was associated with lower fruit and vegetable consumption and higher fat consumption. Planning meals in advance was associated with higher fruit and vegetable consumption; however, 46% of the adults did not plan meals in advance. Arguments concerning eating behavior during dinner were associated with higher fat consumption. CONCLUSIONS AND IMPLICATIONS The family meal environment is associated with adult eating patterns and should be considered when designing nutrition messages for families.

Understanding the perceived determinants of weight-related behaviors in late adolescence: a qualitative analysis among college youth.

OBJECTIVE Identify key factors underlying college weight gain, nutrition, and physical activity. DESIGN Six focus groups and one-on-one interviews. SETTING Large, public Midwestern university. PARTICIPANTS Fifty full-time freshman and sophomore students. MAIN OUTCOME MEASURES Factors influencing weight and weight-related behaviors among undergraduates. ANALYSIS Qualitative analysis using a specific thematic approach, identifying themes appearing consistently across transcripts from recorded sessions. RESULTS Major themes that emerged in describing important influences on weight, dietary intake, and physical activity included: unhealthful food availability on campus, snacking, late-night eating, alcohol-related eating, eating because of stress/boredom, and food in student dorm rooms. Other factors related to physical activity included: negative experiences using campus recreation facilities; poor weather; and lack of time/time management, motivation, and social support for exercise. CONCLUSIONS AND IMPLICATIONS A wide range of factors may underlie weight gain and unhealthful diet and physical activity patterns during the college years. Young adulthood is an important and overlooked area for obesity prevention efforts. Universities need to take an active role in designing and evaluating weight-related health promotion intervention strategies focusing on a variety of targets, including individual-, social-, and environmental-level influences.