INCREASING HEALTHY EATING BEHAVIORS AMONG COLLEGE STUDENTS by ANDREA MICHELLE BRACE (Under the Direction of Marsha Davis) ABSTRACT This study analyzes the impact of a stealth nutrition intervention on increasing healthy eating behaviors among college students. A stealth intervention focuses on health behavior change via process motivation to change behavior without an explicit emphasis on health-related outcomes. The intervention was delivered through a 15- week, discussion-based seminar (n=29) that used contemporary readings to explore macro-scale influences on food, nutrition, and eating behavior. Two levels of control were used; a health-based course (n=114), and a non-health based course (n=48). The intervention was a modified replication study developed at Stanford University, and used a quasi-experimental, mixed-methods, pre-post design. The goal of the intervention was to improve healthy eating behaviors, including eating more fruits and vegetables, while eating less high-fat meat, high-fat dairy, processed foods and sweets. Surveys were administered at the beginning and end of the semester to all classes (n=191), and focus groups were conducted with intervention participants (n=28) at the end of the semester. Survey data included demographics, BMI, food purchasing and eating habits, and Stages of Change and self-efficacy measures. Quantitative data were analyzed using descriptive statistics and ANOVA. Focus group data were analyzed using constant comparative analysis. Survey findings indicate that intervention participants had statistically significant increases in purchasing local and organic produce, direct from the producer, and grass-fed beef. Additionally, significant increases in the beliefs in the importance of animal rights were detected. Results from the focus groups support these findings, with participants relating these changes to the themes discussed throughout the class. The results suggest that the stealth intervention was successful at promoting healthy eating behaviors among college students. INDEX WORDS: Stealth nutrition intervention, Process motivation, College students INCREASING HEALTHY EATING BEHAVIORS AMONG COLLEGE STUDENTS by ANDREA MICHELLE BRACE B.A., University of Delaware, 2003 B.S., Mississippi State University, 2007 M.S., Mississippi State University, 2009 A Dissertation Submitted to the Graduate Faculty of The University of Georgia in Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY ATHENS, GEORGIA 2012 © 2012 Andrea M. Brace All Rights Reserved INCREASING HEALTHY EATING BEHAVIORS AMONG COLLEGE STUDENTS by ANDREA MICHELLE BRACE Major Professor: Marsha Davis Committee: Pamela Orpinas Karen Samuelsen Mark Wilson Electronic Version Approved: Maureen Grasso Dean of the Graduate School The University of Georgia December 2012 DEDICATION I would like to dedicate this dissertation to my husband. Without his support, encouragement, and sacrifice I would not have been able to complete this dissertation. Whenever I needed another point of view, motivation, suggestions, a night off from cooking, or anything else, he was there whole-heartedly and without question. iv ACKNOWLEDGEMENTS This dissertation is the epitome of the African Proverb “It takes a village…” So many people offered support and I have so much appreciation for all of the individuals who have played a part in this dissertation. I would first like to express my deepest gratitude to Dr. Marsha Davis for her guidance throughout the progression of completing the requirements of the graduate program and the dissertation process. I would also like to thank the members of my comps and dissertation committee, including Dr. Pamela Orpinas, Dr. Karen Samuelsen, Dr. Mark Wilson, and Dr. Darcey Terris for the direction and expertise they provided. I want to convey my extreme appreciation to Dr. Eric Hekler, Dr. Christopher Gardner, and Dr. Thomas Robinson for providing access to the curriculum, and especially to Eric for his continued guidance, feedback, and support during the development and implementation of this intervention. I want to thank Dr. Paulina Bounds, Everett, Nancy, and Tyra for their assistance with data collection. I want to thank Dr. Diadrey-Anne Sealey and Thomasina Adams for always being there and supporting me no matter what I needed – you both were truly instrumental in helping me, keeping me sane, and being the best friends one could ask for. Tiffany, Lourdes, Aimee, Tina, Rich, Sherrie, Apophia, Laura, and Colin – thank you for making this the best graduate experience imaginable. I would like to thank my husband Todd for his unwavering support and guidance in aiding my completion of this program of study. Finally, I would like to thank my “kids” – you were the best group of students I have had the pleasure of teaching. You all truly made this a wonderful experience and I learned so much from each of you. Without the combined support from everyone, I would not have been able to complete this project. v TABLE OF CONTENTS ACKNOWLEDGEMENTS ................................................................................................ v LIST OF TABLES ......................................................................................................... viii LIST OF FIGURES ......................................................................................................... ix CHAPTER1: INTRODUCTION ....................................................................................... 1 CHAPTER 2: REVIEW OF THE LITERATURE .............................................................. 6 2.1. Healthy Eating ....................................................................................................... 6 2.2 Overweight and Obesity ......................................................................................... 7 2.3 Influence of College on Overweight and Obesity .................................................... 8 2.4 Review of Intervention Studies ............................................................................... 9 2.5 Behavioral Constructs .......................................................................................... 22 2.6 Review of Model Research Study ........................................................................ 26 CHAPTER 3: METHODS .............................................................................................. 28 3.1 Purpose of the Study and Research Questions .................................................... 28 3.2 Study Design ........................................................................................................ 30 3.3 Description of Intervention .................................................................................... 32 3.4 Measures ............................................................................................................. 49 3.5 Data Management and Analysis ........................................................................... 59 CHAPTER 4: RESULTS ............................................................................................... 64 4.1 Description of the Sample .................................................................................... 65 4.2 Food Purchasing Behaviors ................................................................................. 68 4.3 Dietary Intake of Fruits and Vegetables ................................................................ 78 4.4 Intake of High-Fat Meat and Dairy, Processed Food, and Sweets ........................ 82 4.5 Nutritional Self-efficacy ........................................................................................ 93 vi 4.6 Readiness to Change in Healthy Eating ............................................................... 97 4.7 Beliefs in the Importance of Healthy Behaviors .................................................. 105 4.8 Process Evaluation ............................................................................................ 117 4.9 Summary ........................................................................................................... 122 CHAPTER 5: DISCUSSION, IMPLICATIONS, AND RECOMMENDATIONS ............. 123 5.1 Findings of the Study ......................................................................................... 123 5.2 Limitations .......................................................................................................... 130 5.3 Recommendations for Practice .......................................................................... 131 5.4 Further Research ............................................................................................... 132 5.5 Summary ........................................................................................................... 134 REFERENCES ............................................................................................................ 136 APPENDIX A: COURSE SYLLABUS.......................................................................... 148 APPENDIX B: CONSENT LETTER AND QUESTIONNAIRE ..................................... 159 APPENDIX C: CONSENT LETTER AND FOCUS GROUP QUESTIONS .................. 172 APPENDIX D: FOCUS GROUP NOTE TAKER FORM .............................................. 175 APPENDIX E: CLASS NOTES AND OBSERVATIONS .............................................. 181 APPENDIX F: MID-SEMESTER EVALUATIONS ....................................................... 231 vii LIST OF TABLES Table 1: Summary of Articles in Critique ....................................................................... 11 Table 2: Reported Reliability Coefficients by Study....................................................... 15 Table 3: Description of each the Stages of Change ...................................................... 23 Table 4: Transtheoretical Model Constructs ................................................................. 24 Table 5: Comparison of Model Curriculum to Current Research Study ......................... 33 Table 6: Description of each class project .................................................................... 34 Table 7: Description of discussion topics and questions ............................................... 36 Table 8: Description and frequency of op-ed articles and advocacy video topics .......... 37 Table 9: Description of each session, the learning objectives, activities, proposed outcomes, and related theoretical constructs ................................................................ 40 Table 10: Types and quantities of food questions in questionnaire ............................... 51 Table 11: Focus Group Participants, Duration, and Additional Notes ............................ 58 Table 12: Demographics .............................................................................................. 67 Table 13: Personal food purchasing behaviors ............................................................. 68 Table 14: Servings per week of fruits and vegetables ................................................... 79 Table 15: Servings per week of dietary intake variables by food group ......................... 83 Table 16: Healthful Diet Score ...................................................................................... 93 Table 17: Nutritional Self-efficacy ................................................................................. 94 Table 18: Readiness to Change variables .................................................................... 97 Table 19: Values variables ........................................................................................ 106 viii