A SCHOOL-BASED INTERVENTION INCREASED NUTRITION KNOWLEDGE IN HIGH SCHOOL STUDENTS. A Thesis. Presented in Partial Fulfillment of the Requirements for

Transcription

1 A SCHOOL-BASED INTERVENTION INCREASED NUTRITION KNOWLEDGE IN HIGH SCHOOL STUDENTS A Thesis Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University By Breanne N. Shirk, BS ***** The Ohio State University 2009 Master s Examination Committee: Dr. Christopher A. Taylor, Adviser Dr. Kay N. Wolf Dr. Jill E. Clutter Approved by Adviser Graduate Program in Allied Medical Professions

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3 ABSTRACT Being overweight or obese as a child further increases the risk for obesity later in life as well as enhances the risk for developing diseases, including metabolic syndrome. Effective education-based nutrition education programs are needed to increase nutrition knowledge to combat the rise in obesity and metabolic syndrome among adolescents. Thus, a pilot summer wellness course was offered to high school students over a 3-week period. The educational intervention focused on physical activity and nutrition education to promote lifelong healthy behavior modifications among adolescents. Three sections of 30 students completed classroom learning and application projects based on the USDA s Team Nutrition curricula. Eighty-two high school students (ages 13-18) consented to participate in the research. Changes in nutrition knowledge were assessed through an examination given before and after the 3-week pilot course. The questions were divided among five domains: nutrition guidelines, energy balance, general nutrition knowledge, lifestyle choice and health outcomes. Total nutrition knowledge significantly increased from pre-test to post-test, 63.4% to 78.8% respectively. Nutrition knowledge significantly increased in four of the five domains nutrition guidelines, energy balance, general nutrition knowledge, and health outcomes. Students overall nutritional knowledge increased significantly over the 3-week pilot course. A school-based nutrition ii

4 education program is an effective approach to develop an understanding of healthy lifestyle behaviors in adolescents. Future research should assess the changes in behaviors resulting from such education. iii

5 DEDICATION Dedicated to my loving family and supportive mentors. iv

6 VITA December 21, Born Marion, Ohio 2007 B.S. Nutrition with Science, Ohio University Major Field: Allied Medical Professions, Clinical Nutrition FIELD OF STUDY v

7 TABLE OF CONTENTS Page Abstract... ii Dedication... iii Vita... iv List of Tables... vii Chapters: 1. Introduction...1 Background...1 Consequences of Obesity...2 Significance of the Problem...4 Specific Aims of Project...5 List of Definitions...6 List of Abbreviations Review of Literature...9 Defining Childhood Obesity...9 Background of Childhood Obesity...10 Background of Metabolic Syndrome...10 Prevalence of Metabolic Syndrome in Children and Adolescents...11 Potential Solutions for Childhood Obesity and Metabolic Syndrome...12 Barriers to Healthy Eating...13 Adolescents Nutrition Knowledge...15 Education-Based Obesity Prevention Programs Materials and Methods...22 Overview of the Project...22 Purpose and Objectives of the Study...22 Course Development and Planning...23 Implementation...26 Data Collection...28 Data Analysis...28 vi

8 Page 4. A School-Based Intervention Increased Nutrition Knowledge in High School Students...30 Abstract...30 Introduction...32 Methods...34 Results...36 Discussion...37 Limitations...40 Conclusions and Implications Conclusion and Implications...43 Conclusions...43 Limitations...45 Recommendations...46 Future Research...46 References Cited...48 Appendix A: Questionnaire...55 vii

9 LIST OF TABLES Table Page 3.1 Domains Used to Develop Course Content Correct Responses of Pre-Test and Post-Tests for Adolescents Completing the Education Program Mean Total Scores and Subscale Scores for Pre-Test and Post-Tests of Adolescents Completing the Education Program...42 viii

10 CHAPTER 1 INTRODUCTION Overweight and obesity have become a significant health concern affecting all ages of the American population. More specifically, the prevalence of childhood obesity has increased during the past three decades and currently shows no signs of declining in the near future (1). Obesity is defined as having a body mass index (BMI)-for-age at or above the 95 th percentile by gender on the 2000 Centers for Disease Control and Prevention growth charts (2;3). Nationally-representative data indicated that the prevalence of childhood obesity has increased in all age groups: ages 2-5 years (5% to 13.9%); 6-11 years (4% to 18.8%); and years (6.1% to 17.4%) from and , respectively (2;3); furthermore, nearly one-fifth of non-hispanic white adolescent females and males are overweight (16% and 19.1%, respectively) (3). For the majority of adolescents, obesity is significantly related to excessive energy intake and inadequate physical activity both of which are deemed modifiable risk factors (4). In addition to matching energy intake to energy expenditure, the 2005 Dietary Guidelines for Americans recommend consuming a diet with a variety of nutrient-dense foods and beverages while limiting the intake of saturated and trans fats, cholesterol, added sugars, and salt (5). The 2008 Physical Activity Guidelines for 1

11 Americans (6) states that children and adolescents should engage in 60 minutes or more of physical activity daily, including aerobic, bone-strengthening, and musclestrengthening activities. One goal of the Healthy People 2010 initiative is to reduce the prevalence of obesity among children and adolescents to less than 5%. More specific nutrition goals have been established, which include consuming a minimum of two fruit servings per day, a minimum of three vegetable servings per day (with one-third being dark green or orange), and at least six grain servings per day (half of which are whole grains). Targeted fitness objectives to be achieved by 2010 include: increase the amounts of moderate and vigorous physical activity in adolescents grades 9-12 to 35% and 85%, respectively (7). Data from the 2007 Youth Risk Behavior Surveillance revealed that 34.7% of American students met the recommended levels of physical activity, which included doing any type of physical activity that increased their heart rate and made them breathe hard for a total of at least 60 minutes per day on 5 or more days per week (8). On the other hand, nearly one-quarter (24.9%) of students did not participate in 60 minutes or more of physical activity on any day during the week. Consequences of Obesity Children who are overweight are more likely to become obese as adults (9;10). Whitaker et al. (10) found that 80% of overweight children ages will become obese adults by the age of 25. Being overweight also places a child or adolescent at higher risk for developing diseases that were once primarily found in adults. As well, short-term health problems linked to childhood obesity include adverse blood lipid profile, altered glucose metabolism, and obstructive sleep apnea (10). Furthermore, childhood obesity 2

12 increases the risk for chronic diseases, such as hypertension, type 2 diabetes, cardiovascular disease, gallbladder disease, osteoarthritis, and certain cancers (10). Being overweight or obese can also affect one psychologically through decreased selfesteem, increased body dissatisfaction, and depression (11). Another concern for overweight and obese adolescents is the risk for metabolic syndrome, a cluster of metabolic risk factors linked to type 2 diabetes and cardiovascular disease. Metabolic syndrome is characterized by abdominal obesity and the presence of two or more of the following: elevated triglycerides, low HDL (high-density lipoproteins), high blood pressure, and increased plasma glucose (12). Metabolic syndrome is currently estimated to affect 10-31% of adolescents (13), and up to 49% of morbidly obese youth (14). Sixty percent of overweight children from the Bogalusa Heart Study had at least one biochemical or clinical cardiovascular risk factor and 25% have more than two by the age of 10 years (15). Pan et al. (14) found that metabolic syndrome is more common in overweight adolescents, those with a poor overall diet quality and those with low physical activity levels. To promote health and decrease for metabolic syndrome, weight control via regular physical activity and healthy dietary practices should be the primary intervention (14). Research in adults has found that diets high in fruits and vegetables are generally associated with a lower prevalence of metabolic syndrome (16-18). Overall, early detection and lifestyle modification is essential in preventing the onset of metabolic syndrome among overweight and obese adolescents as well as reducing further complications during adulthood (13). Previous research has indicated that adolescents possess a variable amount of nutrition-related knowledge; however, barriers such as time, limited availability of 3

13 healthy foods in school, and lack of concern about following healthy recommendations most likely interfere with healthy food choices (19;20;20;21). Other influences affecting healthy eating habits include hunger and food craving, food appeal, amount of time to eat, convenience, parental influences, media and cost (19). Helping students overcome barriers and engage in a healthy lifestyle composed of a balanced diet and regular physical activity has been indicated as a concern in reducing childhood obesity and metabolic syndrome. Schools have been identified as the ideal environment to promote lifelong healthy lifestyles in youth (22;23). The environment is consistent on a day-today basis and it allows educators the opportunity to reach out to a large population simultaneously. In fact, schools reach more than 95% of youth ages 5-17 (22). Significance of the Problem Diet and physical activity are key components to maintaining health and adolescents, in particular, are encouraged to lead a healthy lifestyle to prevent complications throughout life. The poor overall diet quality and low levels of physical activity in adolescents suggest a path towards poor health and becoming at risk for obesity, if they are not already (24). Thus, it is important to intervene at this stage and provide nutrition education. The dietary patterns adolescents follow during these changing years can become the foundation for eating patterns later in life (25). Early interventions in changing adolescents lifestyle behaviors can progress into the future and promote positive changes. Delivering and reinforcing nutrition information as well as the skills needed to make healthy choices can prevent current dietary practices from 4

14 becoming the standard for the future. Therefore, the purpose of this project was to develop a school-based wellness course to promote healthy lifestyle behaviors that can be sustained for a lifetime. Specific Aims of Project This school-based pilot educational intervention aimed to promote lifelong physical activity and healthy eating habits among adolescents. More specifically, this study assessed changes in students nutritional knowledge through the utilization of a preand post-test. The project goals and objectives included: 1. Develop a wellness course for a summer physical education program 2. Determine the impact of a student-centered proactive approach on nutrition knowledge by comparing the pre- and post-intervention examinations. 5

15 List of Definitions Body Mass Index (BMI) BMI-for-age percentile Used to estimate risk of overweight in adults. Body mass index adjusted for age and growth of children and adolescents age 2-19 years old. Dietary Guidelines for Americans Federal guidelines that established the definition of a healthy diet to decrease the risk of dietary related diseases. Fitness Gram Growth Charts An assessment tool to determine students fitness levels. Age and gender specific charts used by pediatricians and other health care providers to follow a child s growth over time. They have been constructed by observing the growth of large numbers of normal children over time. Healthy People 2010 A set of health objectives for Americans to achieve over the first decade of the new century. MyPyramid Created by the American Dietetic Association to provided recommendations to Americans on food groups, portion sizes, variety of nutrients, and physical activity for a healthy lifestyle. NHANES National Health and Nutrition Examination Survey; a large US nationally representative cross-sectional survey. Obesity BMI > 30 in adults and >95 th BMI-for-age percentile in children and adolescents. 6

16 Overweight BMI-for-age between 85 th and 95 th percentile on 2000 CDC Growth Charts. Physical Activity Guidelines for Americans A comprehensive set of physical activity recommendations for people of all ages and physical conditions. Team Nutrition An initiative of the USDA Food and Nutrition Service to support the Child Nutrition Programs through training and technical assistance for foodservice, nutrition education for children and their caregivers, and school and community support for healthy eating and physical activity. Youth Risk Behavior Survey A survey created by the CDC to monitor health risk behaviors that contribute markedly to the leading causes of death, disability and social problems among youth and adults in the United States. 7

17 List of Abbreviations BMI CDC HDL IDF IRB NHANES NIH USDA WHO Body Mass Index Center for Disease Control and Prevention High-density Lipoprotein International Diabetes Federation Institutional Review Board National Health and Nutrition Examination Survey National Institutes of Health United States Department of Agriculture World Health Organization 8

18 CHAPTER 2 REVIEW OF LITERATURE Defining Childhood Obesity The criteria for describing and defining health risk regarding weight status is different in adults than that for children and adolescents. Body mass index (BMI), a measure of weight-for-height, is used in adults to classify weight status. The weight categories based on BMI (kg/m²) are underweight (<18.5 kg/m²), normal ( ), overweight ( ), and obese ( 30) (26). Children and adolescents, however, are continuously growing during these years, making BMI an inaccurate representation of weight status. Furthermore, the BMI does not measure adiposity, and body fat changes with age. The 2000 Centers for Disease Control and Prevention (CDC) BMI-for-age growth charts were developed to assess the weight status for children and adolescents ages 2-20 years. These growth charts compare measurements using a nationally representative reference based on children of all ages and racial or ethnic groups for normal growth patterns specific to age, sex, height, and weight (27). Overweight corresponds to a BMI-for-age between the 85 th and 95 th percentile while obesity is defined as having a BMI greater than the 95 th percentile. Overall, the growth charts are 9

19 used as a comparative mechanism to assess a child or adolescent s risk for obesity and other associated conditions. Background of Childhood Obesity Being overweight places a child or adolescent at higher risk for developing diseases that were once primarily found in adults (9;10). Whitaker et al. (10) found that 80% of overweight children ages years will become obese adults by the age of 25. Furthermore, short-term health problems linked to childhood obesity include adverse alterations in blood lipid and glucose profile, and obstructive sleep apnea, while also increasing the risk for chronic disease such as hypertension, type 2 diabetes, cardiovascular disease, gallbladder disease, osteoarthritis, certain cancers and metabolic syndrome. Being overweight or obese can also affect one psychologically through decreased self-esteem, increased body dissatisfaction and depression (11). Background of Metabolic Syndrome Metabolic syndrome is a cluster of risk factors linked to an increased risk for cardiovascular disease and diabetes two of the leading health problems in the US. Until recently, there was no formal definition of metabolic syndrome in youth. In children and adolescents, metabolic syndrome is diagnosed by abdominal obesity (>90 th percentile) and the presence of two or more of the following clinical outcomes: elevated triglycerides, low high-density lipoprotein (HDL)-cholesterol, high blood pressure, and increased plasma glucose (12). The International Diabetes Federation (IDF) recommends diagnosing metabolic syndrome after age 10 primarily stressing weight reduction for overweight children under age 10 (13). For adolescents ages 16 years and older, the adult criteria can be used (28). 10

20 The pathogenesis of metabolic syndrome can be linked to obesity, insulin resistance, sedentary lifestyle and genetic predispositions (13). Other prenatal and perinatal risk factors, such as maternal gestational diabetes (29), low birth weight (30), infant feeding practices (31), early adiposity rebound (32), may contribute to obesity and dysglycemia (13). Furthermore, being raised in an obesogenic environment (33) may also be linked to obesity and metabolic syndrome. Those with metabolic syndrome are two-fold more likely to experience a stroke or heart attack and five times more likely to develop diabetes than those who do not have metabolic syndrome (28). Many of the conditions associated with metabolic syndrome typically co-exist, further increasing the risk for cardiovascular disease (13). Prevalence of Metabolic Syndrome in Children and Adolescents A study of US adolescents was conducted to assess the association between metabolic syndrome and lifestyle behaviors related to diet and physical activity. Data from the National Health and Nutrition Examination Survey (NHANES), estimated the prevalence of metabolic syndrome in adolescents to be 3.5%.(14); however, this indicates that 30% of overweight adolescents met the criteria for metabolic syndrome (34). This equates to roughly 1 million US adolescents currently affected with metabolic syndrome. The prevalence of metabolic syndrome was higher in males (5.1%) compared to females (1.7%) and was greater in whites (3.8%) than African Americans (2.0%) or Mexican Americans (3.3%). Furthermore, metabolic syndrome was more prevalent in older adolescents years old (3.8%) compared to those years old (3.0%). Adolescents with low activity levels were more likely to have metabolic syndrome (4.3%) than those with moderate (3.1%) or high (2.6%) activity levels. As the prevalence 11

21 of metabolic syndrome increases, the obese population and individuals with type 2 diabetes also increases (13). In 2006, it was estimated that 50-80% of 250 million adults with type 2 diabetes are at risk of death from cardiovascular disease (35). Potential Solutions for Childhood Obesity and Metabolic Syndrome Previous studies have extensively examined the relationship between metabolic syndrome and diet and physical activity in adults. For example, diets high in fruits and vegetables are linked to lower prevalence of metabolic syndrome (16-18). The relationship between metabolic syndrome and diet and physical activity remains poorly understood in adolescents (14). A lower prevalence of metabolic syndrome has been reported in adolescents with regular physical activity patterns, defined as the daily average of minutes spent engaging in moderate-to-vigorous physical activity over the past 30 days, and in those with a higher overall diet quality, which is consistent with previous findings in adults. Current treatment options for combating childhood obesity include school-based programs that address healthy eating and physical activity, pharmacotherapy and bariatric surgery. Considering that the adolescent population is highly susceptible to noncompliance, the long-term use of pharmacologic agents may need to be ruled out (28), and little data exists regarding bariatric surgery in this population (36). Common aspects of healthy lifestyles encouraged in schools include increasing fruit and vegetable intake, encouraging physical activity, controlling portion sizes, limiting soft drink consumption, and limiting screen time. (37). Pan et al. (14) recommends lifestyle changes in diet and physical activity as the first-line intervention in decreasing metabolic syndrome in adolescents. Additional 12

22 recommendations suggested that moderately increasing physical activity, eating a diet lower in saturated fat and a moderate decrease in caloric intake is associated with lowering the risk of developing metabolic syndrome (38). Furthermore, high school students who adopt a healthy diet and physical activity regimen for life may be successful in decreasing the syndrome (14). Barriers to Healthy Eating For most adolescents, obesity results from excessive energy consumption and/or decreased physical activity levels (39). Urbanization, sedentary lifestyles and unhealthy diets all lead to the increasing obesity epidemic (28). As adolescents become more independent, they spend more time away from home either in school or around the community with their friends. Thus, eating behaviors are altered based on the surroundings. Adolescents indicated their food choices are influenced by hunger and food cravings, food appeal, convenience, food availability, parental influences, media, cost, and lack of concern about eating healthy (19-21;40;41). The most significant barrier to eating healthy foods, particularly at school, is time. This explains the frequent use of vending machines and quick-service restaurants (42). A study by Dwyer et al. (21) reported that as the number of meals or snacks outside regular planned meals increased, intakes of energy from sugars, total carbohydrates and sodium also increased. More than 80% of adolescents reported eating high-fat processed or junk foods between meals. The risk for overweight and associated conditions also increased with the increased intake of junk foods and decreased physical activity levels. 13

23 Adolescents are also a target for food advertising. Adolescents spend more than $5.4 billion on fast food restaurants and $9.6 billion on food and snacks each year (42). Family influences also play a significant role on adolescents eating habits (43). A systematic review of adolescent eating patterns and nutritional intake found that adolescents who participated in family meals showed lower consumption of fat and higher intakes of fruits, vegetables and dairy when compared with those who rarely ate meals with family members. Additionally, adolescents whose parents practice or portray healthy eating patterns tend to have better eating patterns as well (43). These lifestyle behaviors are leading to few adolescents meeting dietary and physical activity recommendations. The current eating patterns of adolescents consist of high-fat, high-sugar, high-salt foods typically consumed outside of the home (43). The easily accessible sources fast-food restaurants, vending machines, convenience stores are primarily sought out by adolescents, further contributing to unhealthy eating behaviors (43). The relationship between adolescent diet and obesity and metabolic syndrome stems from the idea that eating behaviors learned in childhood continue into adulthood (44). In a cross-sectional study of 878 adolescents (11-15 years), as many as 55% of adolescents did not meet physical activity guidelines at least 60 minutes per day as measured by accelerometers worn by participants (24). Only 2% of the 878 adolescents met all four guidelines: at least 60 minutes physical activity per day, less than 2 hours of television-watching per day, less than 30% total fat intake, and 5 or more daily servings of fruits and vegetables. (Dietary intake was based on three 24-hour food recall 14

24 interviews). Furthermore, adolescents were least likely to consume five fruits and vegetables per day with only 12% meeting the guideline. The overall findings from this study correlate with other findings of the poor diet and exercise habits of adolescents. Adolescents Nutrition Knowledge Currently, there is conflicting research about how well nutrition knowledge precipitates change in healthy lifestyle behaviors. School-based programs have been shown to have a significant impact on the nutrition knowledge of adolescents. Abood et al (45) conducted an obesity prevention study on 551 teens in 14 schools and found that nutrition knowledge increased from 64.1% to 71.8% in the experimental group, as measured by a 22-item multiple choice pre- and post-test. This program also positively changed adolescents behavioral intentions, including maintaining a healthy body weight, eating fewer fried foods and sweets, reading food labels and limiting television watching. This minimal intervention program consisted of two 30-minute education sessions. A minimal intervention program is characterized as a brief, population-based approach that is low in complexity and program cost and is not designed to be intensive or demanding of clients or the staff who implement it (45). Minimal intervention programs have been used in numerous adult studies and possess the potential to make changes in large numbers of people (46). Reinhardt and Brevard (47) developed a curriculum that integrated the Food Guide Pyramid and the Physical Activity Pyramid in order to promote healthy dietary and physical activity habits among adolescents. During this 5-week course, 192 students participated in 18 lessons given during health and physical education classes. Nutrition 15

25 knowledge was measured in a 34-question survey and physical activity knowledge was assessed in a 30-question survey. The study revealed that nutrition knowledge increased 17% from pre- to post-assessment while physical activity knowledge increased 19%. Fahlman et al (48) conducted a pilot study to examine the effects of a nutrition intervention on nutrition knowledge, behaviors, and efficacy expectations in 783 middle school students. This quasi-experimental study was conducted in classrooms and consisted of 8 lesson plans related to nutrition knowledge, including the food groups, food pyramid, food labels, advertising, and body image. The course also contained components sought to target healthy eating patterns, including increasing consumption of fruits, vegetables, and dairy products. A pre/post-assessment was comprised of 33 questions relating to a 24-hour food recall, 20 questions determining nutrition knowledge and 8 questions assessing healthy eating efficacy expectations. Students in the experimental group demonstrated a significant improvement pre to post-test and also scored significantly higher on the post-test compared to students in the control group. Not only did nutrition knowledge increase, students were also more likely to report making positive changes to their diet, such as increasing their consumption of fruits, vegetables, and dairy products. Worsley (49) suggests that nutrition knowledge is necessary, but not a significant factor for changes in dietary behavior. Little information is available regarding nutrition knowledge and behavior for children and adolescents; however, some studies of other populations found that nutrition knowledge is unlikely to affect eating habits (50;51). Wardle et al. (52) examined individuals years old in England, and found that 16

26 nutrition knowledge was linked to healthy eating, with the more knowledgeable individuals being 25 times more likely to eat the daily recommended amounts of fruits and vegetables. Nutrition knowledge significantly increased in a group of low-income fourth and fifth graders who participated in a 12-week school wellness program compared to the control group (53). The theory-based multi-component program aimed to increase the knowledge of healthy nutrition practices, encourage fruit and vegetable consumption and assess the psychosocial variables associated with fruit and vegetable consumption. The program consisted of an interactive wellness assembly followed by a classroom curriculum that emphasized consumption of fruits and vegetables. Fifth graders scored higher than fourth graders on the pre/post test, and there was no difference in scores between boys and girls. Furthermore, children who participated in the program also expressed more confidence that they could eat a fruit instead of a favorite dessert, drink fruit juice and consume the recommended number of fruit and vegetable servings each day. Overall, the students who participated in this school-based program demonstrated improved nutrition knowledge and psychosocial variables associated with consuming fruits and vegetables. In an Australian national study of 4,441 students ages 6-18 years, O Dea et al. (1) found that there is no relationship between the degree of overweight and nutritional knowledge in children and adolescents, which is consistent with previous studies (54;55). Conclusions from this study support the findings of Reinehr et al. (54) suggesting that childhood overweight is not caused by a lack of nutrition knowledge. 17

27 Nutrition knowledge scores were significantly lower in low-income boys and girls compared to higher-income peers. On an eight-item multiple choice test, students were asked to identify foods that were high in fat, carbohydrate, dietary fiber and iron as well as choose snacks, fast-food and home-cooked meal choices with the lowest fat content. Aside from the nutrition knowledge scores, low-income boys and girls had a significantly higher BMI than middle-high income boys and girls, respectively. A study by Beech et al (25) assessed 2,213 high school students nutrition-related knowledge using questions about fruits and vegetables on a 22-item nutrition questionnaire. The average score on the questionnaire was 39% correct, suggesting low nutrition knowledge among high school students, which is consistent with earlier studies (56;57). Additionally, White adolescents scored higher than non-white adolescents (39.4% and 34.7%, respectively), and females scored higher on knowledge items than males (40.7% and 36.6%, respectively) (25). Kolodinsky et al. (58) found that higher nutrition knowledge translated into better eating behaviors in college students. For each food group, the more knowledgeable individuals made more healthful food choices. When asked about individual food choices, participants based the decision to choose healthy foods on their nutrition knowledge. Nelson et al (59) assessed adolescent and parental knowledge related to energy intake and expenditure using a 15-item questionnaire. From the 349 adolescent-caregiver pairs, the mean score on the 15-item questionnaire was 7.5 (±2.6) for adolescents and 10.7 (±2.5) for caregivers. These results demonstrate poor nutrition and physical activity knowledge related to energy intake and expenditure among adolescents. Although the 18

28 adults possessed higher levels of knowledge, there is still much room for improvement. Furthermore, there was a positive association of adolescent knowledge with grade level and socioeconomic status and a positive association among parental knowledge and socioeconomic status. The study also revealed that parental knowledge was a significant predictor of adolescent knowledge. As more and more adolescents are becoming obese, they are experiencing diseases, such as metabolic syndrome, once only seen in adults. Previous research has identified a need for effective educational programs to help combat this disease. Therefore, this project aims to teach students the skills needed to lead a healthy lifestyle, with specific objectives to enhance nutrition knowledge. Education-Based Obesity Prevention Programs The CDC developed guidelines including multiple intervention components for developing school and community-based programs to promote healthy living beginning at a young age. These components include: school nutrition policies curriculum for nutrition education; integration of food service and nutrition education; healthy environment; counseling and psychology programs; physical education classes; health promotion and training for faculty and staff; family and community involvement; and program evaluation(23). 19

29 School-based nutrition education is particularly important considering schools have the ability to reach out to nearly all children and adolescents while also providing the opportunity to practice healthy eating in a social setting without guided parental supervision and influence. Classroom lessons alone may not provide enough support to change dietary behaviors, but focusing on the connection between the classroom and the lunchroom may encourage students to make changes by having the continuous support available. The National Center for Education Statistics guidelines recommends providing 50 hours of food and nutrition education per student per school year (60). The School Health Education Evaluation Study (61) reported that program-specific effects generally occur after 10 hours of classroom instruction; however, an average of 50 hours of instruction is required in order to result in behavior change. The average amount of time devoted to nutrition education in the classroom is 3.4 hours for elementary schools and 5 hours per year for middle and high schools (62). A successful obesity prevention program should utilize a combination of approaches, such as diet and physical activity, rather than focus solely on an individual component like physical activity. Little data exists to support any single variable as more significant than another in an effective weight-loss program (4;63-66). Effective programs should consist of a combination of variables including: diet (67); physical activity (68;69); behavioral change (67); and parental involvement (70-73). Additionally, many school-based interventions have provided positive short-term results regarding nutrition and physical activity knowledge; however, long-term results regarding behavior 20

30 modification are lacking (74). Hill and Peters (75) reported that longer intervention programs produced better weight-loss outcomes in adult populations but the long-term data on weight maintenance is limited for children and adolescents. Furthermore, concerns about the development of programs that single out obese children have surfaced (76). Overweight and obese children may be at higher risk for decreased self-esteem, discrimination and peer rejection, which can affect one s ability to meet weight loss goals (74). Therefore, all children and adolescents should strive for daily physical activity and optimal nutrition, regardless of body weight. School-based programs have had an impact on child health. Because lifestyle behaviors develop early in life, it is important to reach out to children and adolescents early on. As behavior change occurs slowly over time, students should be taught, motivated, and positively reinforced throughout their entire academic career. Thus, the purpose of this program was to develop a wellness course to promote lifelong physical activity and healthy eating habits among adolescents. 21

31 CHAPTER 3 MATERIALS AND METHODS Overview of the Project With childhood obesity and metabolic syndrome on the rise, interventions to provide adolescents with the necessary tools to adapt a healthy lifestyle are crucial. Fit to Be a Buckeye was a school-based pilot educational intervention that sought to promote lifelong physical activity and healthy eating habits among adolescents. More specifically, this study measured changes in nutrition-related knowledge pre- and postintervention targeting lifestyle behaviors using a multiple choice test. The project was divided into three phases. The first phase involved course content planning and the development of the nutrition education curriculum. The second phase was program implementation, and the pilot of the course was offered in the summer of The third phase was the evaluation of the program, which examined knowledge, self-efficacy and parental influences in relation to adolescent s perceptions of a healthy lifestyle. Purpose and Objectives of the Study The primary goal for the pilot wellness course was to emphasize healthy eating, physical activity and emotional well-being. The course lessons were based on the USDA 22

32 Team Nutrition curriculum, a standard for a wellness component. The wellness-focused curriculum can serve as a model program to address the lack of school health education, especially considering the pervasiveness of the obesity epidemic in the US and central Ohio. The purpose of this study was to assess the changes in nutritional knowledge between pre- and post-participation in the pilot course. The goals of the project are twofold: 1. Develop a wellness course for a summer physical education program 2. Determine the impact of a student-centered proactive approach by comparing the pre- and post-intervention health outcomes for students. Course Development and Planning The project first began through a community partnership with a suburban, Midwestern school district. The university faculty joined with the district s School Health and Wellness Initiative Subcommittee to develop a pilot physical education course to promote a healthy lifestyle. An established goal of this committee was to develop a new course to promote wellness and healthy lifestyle behaviors among the students. University faculty and students collaborated with the Wellness subcommittee to generate the key topics to be included in the pilot offering of the course. The general course outline was developed in March and submitted to the school district s administration for program approval. A course syllabus was then submitted to the curriculum committee for physical education course approval. During this same time frame, the protocol was approved by the Institutional Review Board of The Ohio State University. 23

33 From April to June, three graduate students developed the nutrition-related course lessons plans. These students attended meetings with school district to discuss primary goals and outcomes of the course. In addition, these students met weekly to identify the main topics for each day as well as map out the entire course for consistency and thoroughness. Concepts from Team Nutrition, My Pyramid and Fitness Gram were used to develop course content and lesson plans. The questionnaire utilized five modified subcategories, or domains, taken from the Team Nutrition curricula, which included nutrition guidelines, energy balance, general nutritional knowledge, lifestyle choices and health outcomes. The questions for the pre/post-test were then created to fit within one of these five domains. Each class was divided into time slots, with two-thirds focusing on physical activity, and one-third on nutrition and healthy eating. Creative, interactive lesson plans, including presentations, activities, and interactive websites were developed to highlight health facts, food and exercise tips and encourage students to adhere to their personalized plan. Logs were developed for students to track their own progress in terms of nutrition and physical activities. The course allowed students to individualize the information learned and apply it to their personal lives. Furthermore, measurements of self-efficacy, knowledge, and the parental perceptions surrounding a healthy lifestyle were developed by the team. These measurements were pilot tested for reliability and reviewed by expert panels for validity. 24

34 Domain Nutrition Guidelines Energy Balance General Knowledge Lifestyle Choices Health Outcomes Question Content Recognize healthy BMI Portion size recognition Understand Dietary Guidelines Reading a food label Identify nutrients for healthy bones Understand a food label Understand energy balance BMR definition Link between weight loss and energy balance Link between diet and weight gain Calorie definition Recommendation for whole grains Physical activity recommendations Understand role of dietary fiber Identify cholesterol sources Identify reasons for overweight Incorporate physical activity into weight loss Identify risks of being overweight Link nutrients to disease Understand nutrients and disease Table 3.1 Domains Used to Develop Course Content During this time, community partnerships were also identified to locate wellness activities during class. For example, a chef was arranged to allow students to taste healthy foods as well as learn ways to prepare healthy snacks using a microwave. A local grocery store was also secured to allow students to engage in a scavenger hunt for specific foods. 25

35 Implementation Subjects Ninety-three participants were enrolled in the summer physical education course at the local high school. Students were permitted to enroll in the program if they lived within the local community and were entering ninth, tenth, eleventh or twelfth grade. Of the 93 participants, 82 returned parental permission forms and were included in the study. In accordance with IRB protocol, parental permissions forms were sent home with each student for enrollment in the program. Setting The study was conducted at within a local high school, one of three high schools in the school district. Approximately 600 students participate in the summer physical education program, an option to fulfill one of the two required physical education credits outside of the regular academic year. Course offering The initial course was offered as a summer physical education course five days per week for three weeks in June four hours each day. Each day was comprised of three to four components physical activity components included fitness, strength and conditioning, aerobics, and stretching; the nutrition program included education and activities such as a cooking demonstration, taste-test, and a grocery store scavenger hunt. An individual planning session allowed each student to make a Fit to be a Buckeye plan signifying a personal commitment to a healthy lifestyle. During the three week course, students received nutrition education for approximately 60 minutes each day, except on Fridays, in which the lessons were solely 26

36 based around physical activity. On the first day of the course, students received a pre-test to measure nutrition-related knowledge. The first week primarily consisted of the foundational nutrition-related knowledge needed for the following weeks. Topics included MyPyramid, energy balance, portion sizes and reading food labels. The final two weeks of the course featured nutrition components including nutrients, disease states, healthy tips for dining out, fad diets, a grocery store scavenger hunt, a cooking demonstration and taste tests. During the grocery store scavenger hunt, students were placed in groups and given a worksheet to guide the activity. Some objectives required the comparison of specific items whereas some sought to identify information by reading the food label. The objective was for students to become familiar with the grocery store and to be able to apply the concepts learned in the classroom to a real-life situation. As the course progressed, the topics focused more on applying the information learned during the previous two weeks. For example, students completed a 24-hour food recall at the beginning of the course. Students were then encouraged to modify the meal to make it healthier, using personal choices that would be realistic and obtainable for the individual. This was the time students were also encouraged to create a personal contract for the future, utilizing both nutrition and physical activity components. The final day consisted of round table discussions. Students were placed in groups of 5-10, and discussions were led by physical education teachers and SAMP graduate and undergraduate students. Questions used in the discussion featured a variety of topics, including, but not limited to, food choices and habits in the school setting and at home, perceptions of body image and overweight, the role of the media in marketing 27

37 specifically to teenagers, and the overall perception of the pilot course. The answers were not recorded, but provided the facilitators greater insight regarding the teenage perception of a healthy lifestyle and the associated barriers. Data Collection The purpose of this study was to assess the impact of a targeted nutrition education curriculum on knowledge in high school students. To assess changes in nutrition knowledge, students were given a pre-test at the beginning of the course and an identical post-test at the end all of which sought to measure nutritional knowledge. The questionnaire utilized modified subcategories taken from the Team Nutrition Manual, which serves as a standard for a wellness component. Using the five domains used to structure the curriculum, questions were developed to assess retention and understanding of the course material. The five domains to be assessed included: nutrition guidelines; energy balance; general nutritional knowledge; lifestyle choices; and health outcomes. The test consisted of 20 multiple choice and true/false questions, each with a response indicating I don t know. Data Analysis Responses from the pre-tests and post-tests were entered into Microsoft Excel and imported into the Statistical Package for the Social Sciences (SPSS Corporation, version 16.0, Chicago, IL) for analysis. Individual test items were recoded to correct (1) and 28

38 incorrect (0) values for the calculation of test scores. Summative scores were generated for the total test as well as for the 5 subscales. Data were analyzed using SPSS version Frequency analyses and paired-samples t-tests were used to determine the percent correct on pre- and post-tests, change scores, and percent correct for each domain. 29

39 CHAPTER 4 A SCHOOL-BASED INTERVENTION INCREASED NUTRITION KNOWLEDGE IN HIGH SCHOOL STUDENTS Abstract Learning Outcome & Conclusion: To determine the effectiveness of a school-based nutrition education program in increasing students nutrition knowledge. Background: Being overweight or obese as a child further increases the risk for obesity later in life as well as enhances the risk for developing diseases, including metabolic syndrome. Effective education-based nutrition education programs are needed to increase nutrition knowledge to combat the rise in obesity and metabolic syndrome among adolescents. Methods: A pilot summer wellness course was offered to high school students over a 3- week period. The educational intervention focused on physical activity and nutrition education to promote lifelong healthy behavior modifications among adolescents. Three sections of 30 students completed classroom learning and application projects based on the Team Nutrition curricula. Eighty-two high school students (ages 13-18) consented to participate in the research. Changes in nutrition knowledge were assessed through an examination given before and after the 3-week pilot course. 30

40 Results: Total nutrition knowledge significantly increased from pre-test to post-test, 63.4% to 78.8% respectively. Nutrition knowledge significantly increased in four of the five domains nutrition guidelines, energy balance, general nutrition knowledge, and health outcomes. Students overall nutritional knowledge increased significantly over the 3-week pilot course. Conclusions: A school-based nutrition education program is an effective approach to develop an understanding of healthy lifestyle behaviors in adolescents. Future research should assess the changes in behaviors resulting from such education. 31

41 Introduction The prevalence of childhood overweight and obesity has increased during the past three decades and currently shows no signs of declining in the near future (2;3). NHANES surveys from and estimate the prevalence of childhood overweight has increased in all age groups: ages 2-5 increased from 5% to 13.9%; ages 6-11, 4% to 18.8%; and ages 12-19, 6.1% to 17.4%. Furthermore, nearly one-fifth of non- Hispanic white adolescent females and males are overweight (16% and 19.1% respectively) (3). Children who are overweight are more likely to become obese as adults (9;10). Whitaker et al (10) reported that 80% of children who were overweight between the ages will become obese adults by the age of 25. Being overweight places a child or adolescent at higher risk for developing chronic diseases that were once primarily found in adults hypertension, type 2 diabetes, cardiovascular disease, gallbladder disease, osteoarthritis, certain cancers (10), and metabolic syndrome a cluster of risk factors linked to type 2 diabetes and cardiovascular disease (12). Diet and exercise are key components to maintaining health, and adolescents, in particular, are encouraged to lead a healthy lifestyle to prevent complications throughout life. For the majority of adolescents, obesity is linked to excessive energy intake and/or inadequate physical activity both of which are deemed modifiable (4). The 2005 Dietary Guidelines for Americans (5) recommend consuming a diet with a variety of nutrient-dense foods and beverages while limiting the intake of saturated and trans fats, 32

42 cholesterol, added sugars and salt. The 2008 Physical Activity Guidelines for Americans (6) recommend that children and adolescents engage in 60 minutes or more of physical activity daily, including aerobic, bone-strengthening, and muscle-strengthening activities. The current poor diet quality and low levels of physical activity in adolescents predispose them to poor health and increased risk for overweight and obesity, if they are not already (24). Beside knowledge, other influences impact healthy eating habits, including hunger and food cravings, food appeal, amount of time to eat, convenience, parental influences, media and cost (19). Thus, it is important to intervene at this early stage, helping students overcome barriers and engage in a healthy lifestyle composed of a balanced diet and regular physical activity. Schools have been identified as the ideal environment to promote lifelong healthy lifestyles in youth (22;23). The environment is consistent on a day-to-day basis and it allows educators the opportunity to reach out to a large population simultaneously. Adolescents have exhibited some nutrition-related knowledge; however, barriers such as time, limited availability of healthy foods in school, and lack of concern about following healthy recommendations most likely interfere with healthy food choices (19;21;40;41). The dietary patterns of adolescents established during these maturing years can become the foundation for eating patterns later in life (25). Early interventions in changing adolescents lifestyle behaviors should promote healthy lifestyle practices while also addressing barriers to lifestyle behavior changes. Thus, the purpose of this study was to assess changes in nutrition knowledge from a lifelong lifestyle behavior-based educational program in a school-based setting while also providing skill-building activities that will help adolescents overcome obstacles. 33

43 Methods Background Information A lifestyle behavior modification program was conducted at a suburban mid- Western high school participating in a summer physical education program. A curriculum was developed focusing on physical activity and nutrition education to promote lifelong healthy behavior modifications among adolescents. Changes in nutrition knowledge were assessed through as examination administered at baseline and after a pilot 3-week school-based educational intervention. Subjects Ninety-three participants were enrolled in the summer physical education program for high school students. Students were permitted to enroll in the program if they lived within the community and were entering ninth, tenth, eleventh or twelfth grade. In accordance with the approved IRB protocol, parental permission forms were sent home with each student prior to participation in the research portion of the course. Of the 93 students enrolled in the course, 82 (88%) returned parental permissions forms; student assent was also obtained prior to administration of the assessments. Course Development The wellness program was a collaboration between the district s health and wellness initiative and a large mid-western university. The development process of the course was divided into three phases: planning; implementation; and evaluation. The initial phase consisted of course content planning and development of the nutrition education curriculum. The US Department of Agriculture s Team Nutrition curriculum 34

44 served as the basis for the curriculum. Content of the curriculum was divided into five domains including nutrition guidelines, energy balance, general nutritional knowledge, lifestyle choices and health outcomes (Table 1). Key concepts of the curriculum included energy balance, nutrition label reading, portion control, meal planning, the role of nutrition in disease states and fad diets. The lessons were created to include didactic information as well as active participation. Community resources were also utilized and played a role in the activities and implementation of concepts. Activities included meal planning, diet modification, taste tests, a cooking demonstration and a scavenger hunt hosted by a local grocery store. Questionnaire Development The pre- and post-test questionnaire was developed to assess knowledge of key concepts provided during the course. Examination items were drafted to measure comprehension of content taken from the Team Nutrition curricula. Using five domains, questions were then developed according to the learning curriculum. The five domains included: nutrition guidelines, energy balance, general nutritional knowledge, lifestyle choices, and health outcomes. The test consisted of 20 multiple choice and true/false questions, each with a response indicating I don t know. The questions did not equally represent each domain; and questions were randomly disbursed throughout the questionnaire. Finally, the questionnaire was pilot tested for reliability and reviewed by an expert panel for validity. 35

45 Data Collection Students completed a pre-test at the beginning of the course and again at the end both measuring nutritional knowledge. The test consisted of 20 multiple choice and true/false questions, each with a response indicating I don t know. Data Analysis The pre- and post-tests were matched and coded for each individual to assess changes in scores before and after course implementation. Responses from the pre-tests and post-tests were entered into Microsoft Excel and imported into the Statistical Package for the Social Sciences (SPSS Corporation, version 16.0, Chicago, IL) for analysis. Individual test items were recoded to correct (1) and incorrect (0) values for the calculation of test scores. Summative scores were generated for the total test as well as for the 5 subscales. Data were analyzed using SPSS version Frequency analyses and paired-samples t-tests were used to determine the percent correct on pre- and posttests, change scores, and percent correct for each domain. Results Overall, the mean percent of correct responses of nutrition knowledge significantly (P<0.001) improved from pre-test to post-test, 63.4% to 78.8%, respectively after completion of the 3-week pilot wellness course. More specifically, the mean score also improved in 4 of the 5 domains nutrition guidelines, energy balance, nutrition knowledge, and health outcomes. The domain featuring questions regarding health outcomes showed the highest increase in the mean score, over 20% from pre-test to post- 36

46 test. Furthermore, the lifestyle choices domain was the only category that did not show significant improvement; however, scores in this domain were highest of all subscales at baseline. The general nutrition knowledge domain featured the lowest score at baseline with 40.7% correct responses. The concepts included within this domain are calorie definition, recommendations for whole grain consumption, recommendations for physical activity, the role of dietary fiber, and dietary sources of cholesterol. In the question regarding the recommendations for whole grains, students were asked what percentage of grain consumption should be whole grains with answer choices including 25%, 50%, 75% and 100%. There was no change in scores between the pre- and post-test. However, 70% of the students answered 100%, 12% answered 75%, and only one person answered less than 50%. Thus, the students understand the importance of consuming whole grains although the lack of change in the low test-scores shows otherwise. Discussion An educational, school-based intervention significantly improved the nutrition knowledge of high school students. The program successfully reached out to a large population while also providing nutrition education during a short period of time. The information provided can be reproduced by other educators, allowing congruency in implementation. Thus, the results from this study support previous findings of the benefit of an educational-based school intervention (45;47;48;53). School-based programs have been shown to have a significant impact of the nutrition knowledge of adolescents. Abood et al (45) increased nutrition knowledge by nearly 8% (64.1% and 71.8%) in 551 teens from 14 schools, as measured by a 22-item 37

47 multiple choice pre- and post-test. This program also positively changed adolescents behavioral intentions, including maintaining a healthy body weight, eating fewer fried foods and sweets, reading food labels and limiting television watching. Reinhardt and Brevard (47) developed a curriculum that integrated the Food Guide Pyramid and the Physical Activity Pyramid to promote healthy habits among adolescents. During this 5-week course, 192 students participated in 18 lessons given during health and physical education classes. Nutrition knowledge was measured using a 34-question survey and physical activity knowledge was assessed in a 30-question survey. Nutrition knowledge increased 17% from pre- to post-assessment while physical activity knowledge increased 19%. Data from the present study showed smaller gains in physical activity knowledge, although baseline knowledge was the highest in this domain. Fahlman et al (48) conducted a pilot study to examine the effects of a nutrition intervention on nutrition knowledge, behavior modification, and self-efficacy expectations in 783 middle school students. This quasi-experimental study was conducted in classrooms and consisted of 8 lesson plans related to nutrition knowledge and healthy eating patterns. A pre/post-assessment was comprised of 33 questions relating to a 24-hour food recall, 20 questions determining nutrition knowledge and 8 questions assessing healthy eating efficacy expectations. Students in the experimental group demonstrated a significant improvement in nutrition knowledge pre to post-test and also scored significantly higher on the post-test compared to students in the control 38

48 group. Not only did nutrition knowledge increase, students were also more likely to report making positive changes to their diet, such as increasing consumption of fruits, vegetables, and dairy products. Nutrition knowledge was also shown to increase in fourth and fifth graders in a school wellness program that included an interactive wellness component as well as a 12- week classroom curriculum that emphasized consumption of fruits and vegetables (53). In addition to the increase in nutrition knowledge, the students expressed more confidence that they could make healthier food choices, such as eating a fruit instead of a favorite dessert. Similarly, Nelson et al (59) found that adolescent knowledge was significantly associated with more moderate physical activity and less television watching, but not weight status and/or body fat using 349 adolescent-caregiver pairs. The results from the present study suggest that, although adolescents possess some nutrition-related knowledge, there is still a plethora of information to be learned. As students become more educated, they may be more likely to adopt healthy lifestyle behaviors. Improvements in nutrition knowledge after an education-based course require further efforts as making a lifestyle change is a matter of both knowing and doing. Knowledge does not directly relate to behavior change; however, it is the first step in creating a healthy lifestyle (49). Behavior change occurs slowly over time and requires positive reinforcement (49). Educators can impact what students learn, but they cannot control students behavior adaptation: they can only encourage students and provide the benefits and risks with and without a healthy lifestyle. 39

49 Limitations As the students improved their knowledge through nutrition education, the learning could have occurred from the instrument rather than the course itself. Students may have identified the specific topics covered in the pre-test and specifically tuned in to the education regarding information already seen. But, with the improvement of nutrition knowledge overall as well as in four of the five domains, it is reasonable to say the learning occurred from the course, not the instrument. The short time frame of this summer course (3 weeks) limited the amount of information presented to students. If the program was administered for an entire semester, students could receive more information and the changes in nutrition knowledge could be continuously monitored. Furthermore, long-term data measurements were not collected, leaving no information regarding the long-term impact of the course on knowledge retention and lifestyle behavior change. Conclusions and Implications Future research is needed to identify successful lifestyle intervention programs for adolescents. Previous research has identified the need for the incorporation of multiple elements for a successful obesity intervention program, including dietary habits, physical activity, behavioral change and parental involvement. Long-term studies are needed to further determine the success and impact of such interventions. 40

50 PRE POST Domain Question Content N (%) N (%) Nutrition Recognize healthy BMI 73 (89) 79 (96.3) Guidelines Portion size recognition 40 (48.8) 63 (76.8) Understand Dietary Guidelines 62 (75.6) 74 (90.2) Reading a food label 45 (54.9) 66 (80.5) Identify nutrients for healthy bones 37 (45.1) 35 (42.7) Energy Balance General Knowledge Lifestyle Choices Health Outcomes Understand a food label 68 (82.9) 77 (93.9) Understand energy balance 69 (84.1) 78 (95.1) BMR definition 52 (63.4) 71 (86.6) Link between weight loss and energy balance 65 (79.3) 72 (87.8) Link between diet and weight gain 36 (43.9) 49 (59.8) Calorie definition 35 (42.7) 45 (54.9) Recommendation for whole grains 9 (11) 9 (11) Physical activity recommendations 25 (30.5) 68 (82.9) Understand role of dietary fiber 30 (36.6) 50 (61) Identify cholesterol sources 68 (82.9) 74 (90.2) Identify reasons for overweight 73 (89) 78 (95.1) Incorporate physical activity into weight loss 79 (96.3) 80 (97.6) Identify risks of being overweight 61 (74.4) 77 (93.9) Link nutrients to disease 54 (65.9) 78 (95.1) Understand nutrients and disease 59 (72) 69 (84.1) Table 4.1 Correct Responses of Pre-Test and Post-Tests for Adolescents Completing the Education Program 41

51 pretest posttest Domains Mean SD Mean SD P Number Correct Nutrition Guidance <0.001 Energy Balance <0.001 Nutrition Knowledge <0.001 Lifestyle Choices Health Outcomes <0.001 Total Score <0.001 Percent Correct Nutrition Guidance <0.001 Energy Balance <0.001 Nutrition Knowledge <0.001 Lifestyle Choices Health Outcomes <0.001 Total <0.001 Table 4.2 Mean Total Scores and Subscale Scores for Pre-Test and Post-Tests of Adolescents Completing the Education Program 42

52 CHAPTER 5 CONCLUSIONS AND IMPLICATIONS Conclusions Results from this study suggest that a school-based educational intervention can significantly improve the knowledge of high school students regarding healthy lifestyle behaviors. Although high school students possess some nutrition-related knowledge, there is still a plethora of information to be learned. As students become more educated, they may be more likely to adopt healthy lifestyle behaviors. Knowledge does not directly relate to behavior change; however, it is the first step in creating a healthy lifestyle (49). Behavior change occurs slowly over time and requires positive reinforcement (49). Educators can impact what students learn, but they cannot control students behavior adaptation: they can only encourage students and provide the benefits and risks with and without a healthy lifestyle. The concepts used in this course were adapted from the USDA Team Nutrition curricula and consisted of topics such as nutrition guidelines, energy balance, general nutrition knowledge, lifestyle choices and health outcomes. A course curriculum should include these topics, but could go beyond and assess other components affecting adolescents. For example, adolescents indicated their food choices are influenced by 43

53 hunger and food cravings, food appeal, convenience, food availability, parental influences, media, cost, and lack of concern about eating healthy (19;21;40;41) while the most significant barrier to eating healthy foods, particularly at school, is time (42). A future course could address these barriers and work with adolescents to develop ideas and plans that will help them make healthy decisions when faced with such circumstances. Additionally, incorporating additional real-life scenarios, such as making food selections during lunch, in vending machines and at restaurants, may be beneficial in helping adolescents apply their knowledge into potential situations. The present course followed a format consisting of creative, interactive lesson plans that included presentations, activities, and interactive websites. The students appeared to be more interested in the interactive lessons and activities than the typical lecture format. Thus, a nutrition education course should incorporate unique interactive approaches that will both teach the student and maintain interest. Another challenge was providing information in such a way that the student can relate it to his or her life. One possible mechanism to address this concern is to provide the calorie content of common foods and relate that to the amount of physical activity required to burn off those calories. Ideally, a successful intervention would target adolescents as well as their families. Schools should provide a supportive environment to encourage healthy nutrition practices and regular physical activity. Educators can provide students with the knowledge and skills, but it is important to look beyond school hours. Thus, parents become an integral factor and should serve as role models by reinforcing the importance of healthy lifestyle practices. Aside from schools, easily-accessible community programs should be created to involve both the adolescent as well as the rest of the family. 44

54 Limitations The short time frame of this summer course (3 weeks) limited the amount of information presented to students. If the program was administered over an entire semester, students could receive more information and the changes in nutrition knowledge could be continuously monitored. A three week program is not enough time to increase students knowledge and observe transition into a behavior change, yet alone observe the optimal goal of transitioning into healthy lifestyle habits. Since this course was offered over the summer, the students were self-enrolled in the course, thereby affecting the sample size. If the program were implemented during the regular school session, it would have the capacity to reach a greater number of students. Additionally, long-term data measurements were not collected, leaving no information regarding the long-term impact of the course. This program evaluated students nutrition knowledge, but not the utilization of the knowledge outside the classroom. Had more time been available, it would have been ideal to conduct a followup study at three, six, nine and twelve months following the course in order to see the relationship between knowledge and lifestyle choices. As the students improved their knowledge through nutrition education, the learning could have occurred from the instrument rather than the course itself. Students may have identified the specific topics covered in the pre-test and specifically tuned in to the education regarding information already seen. But, with the improvement of nutrition knowledge overall as well as in four of the five domains, it is reasonable to say the learning occurred from the course, not the instrument. 45

55 Recommendations Students spend the majority of their time in school; thus, schools have been identified as the ideal environment to promote lifelong healthy lifestyles in youth (22;23). As part of their wellness policies, school districts should incorporate nutrition education into their curriculum and encourage physical activity outside of the physical education classes. This can be done through extracurricular activities or clubs offered before or after school. Some school districts, however, may face the financial challenges of implementing such programs. Another challenge is educating teachers and developing a nutrition education curriculum that will be consistent or partnering with local nutrition professions. Additionally, students consume between 19 to 50 percent of their total daily calories at school (77), signifying the impact the school environment can have on the diets of children and adolescents. Educators within the schools should serve as role models by promoting healthy eating habits and reinforcing the benefits of a healthy lifestyle. Schools may also consider evaluating the foods that are offered, including breakfast and lunch items that are sold outside of the formal meal programs as well as items in vending machines. Future Research Future research is needed to identify successful lifestyle intervention programs for adolescents. Previous research has identified the need for the incorporation of multiple elements for a successful obesity intervention program, including dietary habits, physical activity, behavioral change, social support and parental involvement. Future research 46

56 should also focus on the barriers to healthy eating time, limited healthy food availability, convenience, parental influence, media and cost as indicated by adolescents and how these can be overcome. Long-term studies are needed to further determine the success and impact of education-based interventions. Nutrition knowledge may improve after an educationbased course, but making a lifestyle change requires more than knowledge. Thus, future studies should assess nutrition knowledge as well as evaluate its relationship with behavior change in both short-term and long-term settings. Another way to evaluate the effectiveness of an obesity prevention program is to measure physical outcomes, such as changes in weight, waist circumference, blood pressure and cholesterol and triglyceride levels. 47

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64 Appendix A Questionnaire 55

65 Last 4 digits of home phone # Fit to be a Buckeye: Wellness the XXX Way Directions: Circle the correct response for each question 1. When the amount of food energy taken in equals the amount of energy you use, the result is a. weight loss b. weight gain c. energy balance d. obesity e. I don't know 2. Being overweight can lead to a. type 2 diabetes b. metabolic syndrome c. certain forms of cancer d. all the above e. I don't know 3. The rate at which your body uses energy when at rest is a. basal metabolic rate (BMR) b. body mass index (BMI) 4. e. weight management a. body composition b. I don't know 5. In terms of energy balance, which of the following situations will result in weight loss? a. the amount of energy used is equal to the amount of food energy taken in b. the amount of food energy taken in is more than the amount of energy used c. the amount of energy used is half as much as the amount of food energy taken in d. the amount of food energy taken in is less than the amount of energy used e. I don't know 6. The reason for the development of excess body fat is a. eating too much fat in the diet b. drinking too much water in the diet 7. e. eating too much fat, protein, and carbohydrate in the diet a. eating too many carbohydrate in the diet b. I don't know 56

66 8. According to the healthy BMI range for her age, Mia's body mass index (BMI) should be between 17.3 and Mia's calculations show her BMI to be 23. According to this index, Mia is a. at a healthy body weight b. overweight c. obese d. between being overweight and obese e. 1don't know 9. All the following are reasons why more Americans are becoming overweight except a. less physical activity b. eating more foods high in fat c. easier access to food d. eating more fiber e. I don't know 10. Taylor is creating a healthful weight-loss plan for herself. Which of the following can Taylor add to her plan to increase her activity level in a healthy way? a. stay up later at night b. eat meals on the way to school c. add a I5-minute walk to her routine each evening d. eat six instead of three meals per day e. I don't know 11. Serving sizes on the food labels are the same as portion sizes on MyPyramid. a. True b. False c. 1 don't know 12. What is a calorie? a. a unit of fat b. a type of diet that involves major changes in eating habits and promises quick results c. a way to measure the energy used by the body, and the energy that food supplies the body d. an index of weight in relation to height that is used to assess healthy body weight e. 1 don't know 57

67 13. What percentage of the grains that you eat should be whole grains? a. 25% b. 50% c. 75% d. 100<10 e. I don't know 14. The intake of milk products is especially important to prevent a. cardiovascular disease b. diabetes c. cancer d. osteoporosis e. I don't know 15. Which of the following statements isfalse? a. research shows some fruits and vegetables are known causes of certain cancers b. eating a diet low in saturated and trans fats as part of an overall healthy diet may reduce the risk of coronary heart disease c. eating a diet rich in fruits and vegetables as part of an overall healthy diet may reduce risk for type 2 diabetes d. diets rich in foods containing fiber may reduce the risk of coronary heart disease e. I don't know 16. Adolescents should achieve a minimum of how many minutes of moderate to vigorous physical activity on most days? a. 30 b. 60 c. 90 d. 120 e. I don't know 17. As part of an overall healthy diet, dietary fiber a. helps reduce blood cholesterol levels b. keeps eyes and skin healthy c. helps heal cuts and wounds d. helps protect against infections e. I don't know 18. Fruits and vegetables are high in cholesterol. a. True b. False c. I don't know 58

68 19. A healthy diet as defined by the Dietary Guidelines a. emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products. b. includes lean meats, poultry, fish, beans, eggs, and nuts. c. is low in saturated fats, trans fats, cholesterol, salt, and added sugars. d. all the above e. I don't know 20. When reading a food label, what component should you look at first? a. serving size b. servings per container c. calories per serving d. % daily value e. I don't know 21. Which nutrient is important in building healthy bones? a. calcium b. vitamin D c. vitamin E d. both a and b e. I don't know 22. The following label is taken from a box of macaroni and cheese. How many total calories would you consume if you ate the entire box? a. 110 b. 250 c. 500 d. 750 e. I don't know 59