Multilevel Structural Equation Modeling of Students' Dietary Intentions/Behaviors, BMI, and the Healthfulness of Convenience Stores.

BACKGROUND: When dietary behaviors are habitual, intentions are low, and environmental cues, such as the consumer food environment, might guide behavior. How might intentions to eat healthily and ultimately actual dietary behaviors, be influenced by the consumer food environment (including the availability and affordability of healthy foods) in convenience stores? This study will determine pathways between the healthfulness of convenience stores and college students' dietary intentions/behaviors, and body mass index (BMI). METHODS: Through multilevel structural equation modeling, a comparison was made of students' healthful meal intentions (HMI); intake (fruits/vegetables, %kcal/fat, sugar-sweetened beverages (SSBs) and whole-grains); and measured BMI; as well as the healthfulness of convenience stores (fruits/vegetables availability/quality, healthy food availability/affordability). Data was collected on 1401 students and 41 convenience stores across 13 US college campuses. RESULTS: Controlling for gender, HMI was negatively associated with SSBs (ß = -0.859) and %kcal/fat (ß = -1.057) and positively with whole-grains (ß = 0.186) and fruits/vegetables intake (ß = 0.267); %Kcal/fat was positively (ß = 0.098) and fruits/vegetables intake (ß = -0.055) negatively associated with BMI. Campus level, fruits/vegetables availability were positively associated to HMI (ß = 0.214, ß = 0.129) and directly/negatively to BMI (ß = -2.657, ß = -1.124). CONCLUSIONS: HMI modifies dietary behaviors, with energy from fat and fruit/vegetable intake the most predictive of weight. Availability of fruit/vegetables in convenience stores make it easier for young adults to eat well.

Concordance of self-report and measured height and weight of college students.

OBJECTIVE: This study examined associations between college students' self-report and measured height and weight. METHODS: Participants (N = 1,686) were 77% white, 62% female, aged 18-24 years (mean ± SD, 19.1 ± 1.1 years), and enrolled at 8 US universities. Body mass index (BMI) was calculated for self-report (via online survey); trained researchers measured height and weight and categorized them as normal (18.5 to < 25), overweight (25 to < 30), obese (30 to < 35), and morbidly obese (≥ 35). RESULTS: Concordance of self-report vs objectively measured BMI groups using chi-square revealed that 93% were accurate, 4% were underestimated, and 2.7% were overestimated. Pearson correlations and adjusted linear regression revealed significant associations between self-report and measured BMI (r = .97; P < .001) and BMI adjusted for age, gender, and race/ethnicity (R² = .94). Concordance was also high between BMI categories (kappa = 0.77; P < .001). CONCLUSIONS AND IMPLICATIONS: Findings provide support for the utility of self-report height and weight for survey research in college students.

The effects of Young Adults Eating and Active for Health (YEAH): a theory-based Web-delivered intervention.

OBJECTIVE: To assess the effectiveness of a tailored theory-based, Web-delivered intervention (Young Adults Eating and Active for Health) developed using community-based participatory research process. DESIGN: A 15-month (10-week intensive intervention with a 12-month follow-up) randomized, controlled trial delivered via Internet and e-mail. SETTING: Thirteen college campuses. PARTICIPANTS: A total of 1,639 college students. INTERVENTION: Twenty-one mini-educational lessons and e-mail messages (called nudges) developed with the non-diet approach and focusing on eating behavior, physical activity, stress management, and healthy weight management. Nudges were short, frequent, entertaining, and stage-tailored to each behavior, and reinforced lesson content. MAIN OUTCOME MEASURE: All participants were assessed at baseline, postintervention (3 months from baseline), and follow-up (15 months from baseline) for primary outcomes of weight, body mass index (BMI), fruit and vegetable intake (FVI), physical activity (PA), and perceived stress; and secondary outcomes of waist circumference, percent dietary fat, energy from sugar-sweetened beverages, servings of whole grains, self-instruction and regulation for mealtime behavior, hours of sleep, and stage of readiness for change for consuming 5 cups of FVI, completing 150 minutes of PA/wk, and managing stress on most days of the week. Demographics were collected at baseline. ANALYSIS: Chi-square analysis and mixed-models repeated measures analysis were performed to determine differences between experimental and control outcomes. RESULTS: There were no differences between experimental and control participants in BMI, weight, and waist circumference. There were small improvements in FVI (P = .001), vigorous PA in females (P = .05), fat intake (P = .002), self-instruction (P = .001), and regulation (P = .004) for mealtime behavior, and hours of sleep (P = .05) at postintervention, but improvements were not maintained at follow-up. At postintervention, a greater proportion of experimental participants were in the action/maintenance stages for FVI (P = .019) and PA (P = .002) than control. CONCLUSIONS AND IMPLICATIONS: Young Adults Eating and Active for Health is one of the first studies to use the community-based participatory research process of PRECEDE-PROCEED to develop a non-diet approach intervention. Although there were no differences between experimental and control participants in weight change or BMI, the intervention supported positive change in behaviors that may mediate excessive weight gain, such as increasing FVI and more healthful self-regulation mealtime behaviors immediately postintervention. Additional strategies to maintain the behavior changes need to be explored.

Development of Young Adults Eating and Active for Health (YEAH) internet-based intervention via a community-based participatory research model.

OBJECTIVE: To develop a tailored, theory-based, Web-delivered intervention to prevent excessive weight gain in young adults using a Community-Based Participatory Research model. DESIGN: Investigators from 14 universities developed the intervention and supporting administrative portal using the 4 phases of the PRECEDE model. Steering committees were composed of the target audience (aged 19-24 years) and key health/wellness personnel were formed at each institution and provided information during each phase that was used to guide development of the intervention, Project YEAH (Young Adults Eating and Active for Health). Piloting results were used to refine the curriculum and identify and avoid barriers to delivery. RESULTS: Qualitative and quantitative data collected at each phase informed Project YEAH development. In Phase 1, factors of highest priority to young adults were identified. In Phase 2, environmental supports for healthful lifestyles were elucidated. In Phase 3, behavior and environmental changes considered important and changeable were identified. In Phase 4, the 10-week, theory-based, stage-tailored, interactive-learning intervention with a 10-month reinforcement period was developed. CONCLUSIONS AND IMPLICATIONS: Applying the PRECEDE model with fidelity during development of Project YEAH resulted in an intervention that pilot participants found relevant and useful, gained attention, instilled confidence in the ability to apply the information, and provided a sense of satisfaction.

Evaluation of the food store environment on and near the campus of 15 postsecondary institutions.

PURPOSE: This study evaluated the food stores on and near postsecondary campuses varying in institutional size. DESIGN: The design of the study is an environmental audit survey. SETTING: Fifteen U.S. postsecondary education institutions participated in this study between 2009-2011. SUBJECTS: Eighty-one stores (44% grocery, 17% campus, and 39% convenience/drug) were evaluated. MEASURES: The Nutrition Environment Measures Survey for Stores was modified to evaluate food stores. Analysis. Analysis of variance with post hoc Tukey B and t-tests assessed differences between store types and by institutional size. RESULTS: Grocery stores had significantly higher scores than campus/convenience stores for healthy foods (19.5 ± 3.8 vs. 2.4 ± 1.7), and for the availability (19.5 ± 3.8 vs. 2.4 ± 1.7) and quality (5.9 ± 0.5 vs. 1.8 ± 2.2) of fruits/vegetables (p < .001). Healthy foods and beverages were significantly more expensive (-0.6 ± 3.4 vs. 0.9 ± 2.0; p < .031) than their less healthful alternatives in grocery stores, but not in convenience stores. There were no differences by institutional size for grocery stores; however, smaller institutions' convenience stores had significantly lower availability and quality of fruits/vegetables and total food store environment scores. CONCLUSION: A college campus provides a food environment with an array of shopping venues, most of which are not consistent with dietary recommendations for obesity prevention. The limited quality of healthy food in on-campus and convenience stores and the exacerbated deficiencies for small postsecondary institutions provide evidence to support environmental and policy initiatives to improve the quality of campus food store environments.

Process evaluation of Project WebHealth: a nondieting Web-based intervention for obesity prevention in college students.

OBJECTIVE: To evaluate the motivational effect of the Project WebHealth study procedures and intervention components on weight-related health behavior changes in male and female college students. DESIGN: Process evaluation. SETTING: Eight universities in the United States. PARTICIPANTS: Project WebHealth participants (n = 653; 29% men). MAIN OUTCOME MEASURES: Participants rated motivational effects of study procedures and intervention components. Participants were grouped into outcome-based health behavior categories based on achievement of desired targets for fruit and vegetable intake, physical activity, and/or body weight. ANALYSIS: Differences in motivation from each procedure and component were analyzed by gender- and outcome-based health behavior category. RESULTS: Women were generally more motivated than men. Compared to those who did not meet any target health behaviors, men with improved health outcomes (68%) were significantly more motivated by the skills to fuel the body lesson, goal setting, and research snippets. Their female counterparts (63%) were significantly more motivated by the lessons on body size and eating enjoyment, and by the suggested weekly activities. CONCLUSIONS AND IMPLICATIONS: Specific study procedures and components of Project WebHealth motivated study participants to improve their weight-related health behaviors, and they differed by gender. Findings support the need for gender-tailored interventions in this population.

The development and preliminary validation of the behavior, environment, and changeability survey (BECS).

OBJECTIVE: To develop and test the validity of the Behavior, Environment, and Changeability Survey (BECS) for identifying the importance and changeability of nutrition, exercise, and stress management behavior and related aspects of the environment. DESIGN: A cross-sectional, online survey of the BECS and selected validated instruments. SETTING: Ten state universities. PARTICIPANTS: A convenience sample of college students (n = 1,283), ages 18-24 years. ANALYSIS: Principal component analysis was used to confirm a 6-component structure of the BECS in 2 independent samples for the purpose of cross-validation. Internal consistency was measured and construct and criterion-related analyses were conducted to test the reliability and validity of the BECS subscales. RESULTS: Six components representing 34 BECS items were revealed from the original 69 items and explained 64% of the total variance. Six scales were retained, and internal consistency of each ranged from α = .82 to .93. BECS Nutrition Behavior and Nutrition Changeability scale scores were highest for participants in action/maintenance Stages of Change for fruit and vegetable intake. CONCLUSIONS AND IMPLICATIONS: There is strong support for the use of the BECS when planning health programs to gain insight into behavior that young adults are willing to improve, specifically related to nutrition, exercise, and sleep.

Impact of an online healthful eating and physical activity program for college students.

PURPOSE: To identify impact of an online nutrition and physical activity program for college students. DESIGN: Randomized, controlled trial using online questionnaires and on-site physical and fitness assessments with measurement intervals of 0 (baseline), 3 (postintervention), and 15 months (follow-up). SETTING: Online intervention delivered to college students; a centralized Web site was used for recruitment, data collection, data management, and intervention delivery. SUBJECTS: College students (18-24 years old, n = 1689), from eight universities (Michigan State University, South Dakota State University, Syracuse University, The Pennsylvania State University, Tuskegee University, University of Rhode Island, University of Maine, and University of Wisconsin). INTERVENTION: A 10-lesson curriculum focusing on healthful eating and physical activity, stressing nondieting principles such as size acceptance and eating competence (software developer: Rainstorm, Inc, Orono, Maine). MEASURES: Measurements included anthropometrics, cardiorespiratory fitness, fruit/vegetable (FV) intake, eating competence, physical activity, and psychosocial stress. ANALYSIS: Repeated measures analysis of variance for outcome variables. RESULTS: Most subjects were white, undergraduate females (63%), with 25% either overweight or obese. Treatment group completion rate for the curriculum was 84%. Over 15 months, the treatment group had significantly higher FV intake (+.5 cups/d) and physical activity participation (+270 metabolic equivalent minutes per week) than controls. For both groups, anthropometric values and stress increased, and fitness levels decreased. Gender differences were present for most variables. First-year males and females gained more weight than participants in other school years. CONCLUSION: A 10-week online nutrition and physical activity intervention to encourage competence in making healthful food and eating decisions had a positive, lasting effect on FV intake and maintained baseline levels of physical activity in a population that otherwise experiences significant declines in these healthful behaviors.

Sweet and salty. An assessment of the snacks and beverages sold in vending machines on US post-secondary institution campuses.

This study assessed the nutritional quality of snacks and beverages sold in vending machines. The contents of snack and beverage vending machines in 78 buildings on 11 US post-secondary education campuses were surveyed. Of the 2607 snack machine slots surveyed, the most common snacks vended were salty snacks (e.g., chips, pretzels) and sweets (i.e., candy and candy bars). The 1650 beverage machine slots assessed contained twice as many sugar-sweetened beverages as non-calorie-containing beverages. Only two institutions sold both milk and 100% juice in vending machines. The portion of snacks and beverages sold averaged more than 200 cal. Neither snacks nor beverages were nutrient dense. The majority of snacks were low in fiber and high in calories and fat and almost half were high in sugar. Most beverages were high in calories and sugar. This study's findings suggest that vending machines provide limited healthful choices. Findings from benchmark assessments of components of the food environment, like the vending options reported here, can provide valuable input to campus administrators, health services, food service, and students who want to establish campus policies to promote healthful eating.

Sneakers and spokes: an assessment of the walkability and bikeability of U.S. postsecondary institutions.

The purpose of the study described in this article was to assess the walkability and bikeability of 15 U.S. postsecondary education campuses. The Centers for Disease Control and Prevention's evidence-based Healthier Worksite Initiative Walkability Audit was modified to rate campus walking and biking path segments for path safety, quality, and comfort. Universities (n = 13) assessed an average of 44 path segments, which earned a mean score of 72.71 +/- 10.77 SD (possible range 0 to 100). Postsecondary technical schools (n = 2) assessed 20 path segments, which received an average score of 76.56 +/- 13.15. About 70% of path segments received a grade A or B, but almost 1 in 10 received a failing or poor support score for walking and biking. Nearly half or more campus environments scored significantly below an acceptable score on many path safety and quality criteria. Postsecondary education campuses that are supportive of walking and biking offer numerous benefits to the environment and people. Findings from environmental assessments like the data reported here can provide valuable input to campus planners.

Maternal parenting behaviors during childhood relate to weight status and fruit and vegetable intake of college students.

OBJECTIVE: Examine how maternal parenting behaviors in childhood, both general and feeding specific, relate to weight status and fruit and vegetable consumption in college students. DESIGN: Retrospective surveys on maternal behaviors and assessments on the college-aged child's current anthropometric measures and dietary intakes. PARTICIPANTS: College students (n = 424; 66% women). MAIN OUTCOME MEASURES: Students' weight, height, waist circumference, fruit and vegetable intakes, students' reports on mothers' general and feeding-specific parenting behaviors during childhood. ANALYSIS: Correlation and regression analyses tested how maternal behaviors in childhood related to students' body mass index, waist circumference, and fruit and vegetable intake. RESULTS: Mothers' psychological control during childhood was associated with higher body mass index and waist circumference in students, and behavioral control was associated with lower waist circumference. Parent-centered feeding behaviors related to lower fruit and vegetable intakes of students, whereas child-centered feeding behaviors related to higher fruit and vegetable intakes. CONCLUSIONS AND IMPLICATIONS: Findings suggest that parental use of behavioral control and child-centered feeding practices and minimal use of psychological control and parent-centered feeding practices during childhood may promote a child's healthful weight status and fruit and vegetable consumption in young adulthood, specifically during college.

Identifying clusters of college students at elevated health risk based on eating and exercise behaviors and psychosocial determinants of body weight.

Weight gain and an increase in overweight and obesity in college students raise serious health concerns. Weight management interventions for college-age men and women might be more effective if they were tailored to subgroups of students with similar behavioral and psychosocial characteristics associated with body weight status. The purpose of this study was to use cluster analysis to identify homogenous subgroups of college-aged men and women enrolled in a weight gain prevention study (Project WebHealth) using baseline data collected in 2008. Project WebHealth was a 15-month nutrition and physical activity intervention designed to decrease the rate of unwanted weight gain in 1,689 college students at eight geographically diverse universities in the United States. Outcome measures included anthropometrics, fruit and vegetable intake, physical activity, cardiorespiratory fitness, and psychosocial variables associated with weight status in college students. Cluster analysis was performed separately by sex using a two-step clustering procedure using weight-related eating and exercise behaviors and psychosocial variables. Cluster groupings were validated against students' measured weight status and waist circumference as indicators of health risk. The study design was cross-sectional. Results showed that three similar clusters were identified for each sex. Validity of the cluster solution was supported by significant group differences in body mass index and waist circumference with the High Risk cluster at elevated health risk compared to the others. For men, variability in eating competence and cognitive restraint scores contributed most to the difference between clusters, whereas for women, emotional eating and uncontrolled eating scores did. These findings could be used to improve effectiveness of messages and interventions by tailoring them to subgroups of college students with similar behavioral and psychosocial characteristics associated with elevated health risk.

Use of the Nominal Group Technique (NGT) to understand the perceptions of the healthiness of foods associated with African Americans.

PURPOSE: To determine the degree of overlap between foods considered part of African American (AA) culture and those considered to be healthy. METHODS: A total of 44 AA men and women were recruited from the Birmingham, AL area, 25 years of age and older to participate in four Nominal Group Technique (NGT) meetings. Participants from the first two groups generated 90 unique food items in response to the question "What are the foods you associate with being African American?" Participants individually ranked their top three most unhealthy foods. The next two groups generated 116 unique food items in response to the question "What foods do you consider to be healthy?" Participants individually ranked their top three foods that were considered most associated with AA. RESULTS: The top five foods associated with AA were chitterlings, fried chicken, pig parts, greens prepared with ham hock, and pork ribs. Of the foods associated with AA, chitterlings, pig parts, fatback, fried chicken, and greens prepared with ham hocks were ranked as the unhealthiest. The top five healthy foods were broccoli, boiled greens, baked fish, grapefruit, and broiled fish. From these top five healthy foods, only boiled greens were considered to be associated with AA. CONCLUSIONS: Many of the foods AA consider as traditional foods are also perceived as unhealthy. On the contrary, foods perceived to have the most health value may not be a routine part of AA food patterns. Understanding AA perceptions of the healthfulness of foods can be informative for culturally appropriate nutrition intervention development.

Low-income young adults report increased variety in fruit and vegetable intake after a stage-tailored intervention.

The objective of this study was to determine if a fruit and vegetable (FV) intervention, previously demonstrated to increase amount of FV per day, also increased the variety consumed. Variety in FV intake was assessed using a 26-item FV (12 fruit and 14 vegetable) food frequency questionnaire on 1255 low-income adults, with ages from 18 to 24 years (control = 684 vs experimental = 571), after completion of a stage-tailored intervention to increase FV intakes. The food frequency questionnaire was administered at 12 months to assess how often and how much participants ate of each item over the previous year. Variety was defined as the number of different types of fruits and vegetables consumed. At completion, the experimental group vs the control group had significantly greater variety in number of fruit items (9.5 +/- 0.1 vs 9.1 +/- 0.1, P < or = .001) and vegetable items (11.5 +/- 0.1 vs 11.2 +/- 0.1, P < .01) as well as greater total intake of fruits (2.73 +/- 0.09 vs 2.33 +/- 0.11 cups, P < .01) and vegetables (1.87 +/- 0.10 vs 1.62 +/- 0.01 cups, P < or = .001) and a greater consumption of the categories of seasonal fruits (P < .05), juices (P < .01), and high-beta-carotene vegetables (P < or = .001). This is one of the first studies to document an increase in FV variety as a result of an educational intervention for low-income young adults.