Nutrition Knowledge and Perception of Vegetarian Diets in Vegetarian and Non-Vegetarian, Male and Female College Students

NUTRITION KNOWLEDGE AND PERCEPTION OF VEGETARIAN DIETS IN VEGETARIAN AND NON-VEGETARIAN, MALE AND FEMALE COLLEGE STUDENTS

A thesis submitted to the Kent State University College of Education, Health and Human Service in partial fulfillment of the requirements for the degree Master of Science in Nutrition and Dietetics

Brielle Stark Gay

December 2018

A thesis written by

Brielle Stark Gay

B.S., Kent State University, 2017

M.S., Kent State University, 2018

Approved by

______, Director, Master’s Thesis Committee

Natalie Caine-Bish

______, Member, Master’s Thesis Committee

Amy Miracle

______, Member, Master’s Thesis Committee

Karen Lowry Gordon

Accepted by

______, Interim Director, School of Health Sciences

Ellen Glickman

______, Dean, College of Education, Health, and Human Services

James C. Hannon

iii GAY, BRIELLE STARK, M.S., December 2018 Nutrition and Dietetics

NUTRITION KNOWLEDGE AND PERCEPTION OF VEGETARIAN DIETS IN VEGETARIAN AND NON-VEGETARIAN, MALE AND FEMALE COLLEGE STUDENTS (142 pp.)

Director of Thesis: Natalie Caine-Bish, Ph.D, R.D., L.D.

Vegetarianism is becoming a more popular diet option for health, ethical and environmental reasons as well as for religious beliefs. However, most college students are not presently considering the vegetarian diet as a healthy alternative to their current lifestyle. The purpose of this study was to understand the nutrition knowledge and perception of vegetarian diets in male and female vegetarian and non-vegetarian college students. Participants were limited to male and female undergraduate students over the age of 18 years, who completed an online survey with demographic, perception and nutrition knowledge questions. Analysis of the data showed a significant difference in perceptions of the vegetarian diet between males and females, as well as non-vegetarians and vegetarians (p< 0.05).Females had a more positive perception compared to their male counterpart, while vegetarians had a more positive perception than non-vegetarians.

However, there were no significant results regarding nutrition knowledge between either gender or diet. Future studies with a larger sample size and questions with a stronger emphasis on vegetarianism are needed to confirm the results of this study.

ACKNOWLEDGEMENTS

I would like to thank Dr. Natalie Caine-Bish for her guidance and advice throughout this process. When starting graduate school, the abstract idea of a thesis can be daunting. However, with the help of Dr. Bish, I started to understand how the writing process might be broken up into attainable goals. Once I started researching, I could even see how it would be enjoyable. Now, I look forward to the research I’ll do as part of career because this has been such a rewarding experience. Dr. Bish has taught me a great deal about research methods, and I appreciate the time and effort she’s put into guiding me.

I would also like to thank Dr. Karen Gordon and Dr. Amy Miracle for their help and advice. Without their instruction and vast knowledge of the research process, I would have not been able to expand my personal knowledge or my methods of research.

Additionally, I would like to express gratitude toward the undergraduate students at Kent State University who have participated in the survey I distributed. Without their participation, data collection would have been greatly hindered.

Lastly, I am very grateful for the help and support I received from Peter Pribis during the survey development process. He was very supportive and willing to offer any assistance he could in the creation of a survey that fit the needs of my thesis.

iv TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS………………………………………………………………………iv

LIST OF TABLES.……………………………………………………………………………..viii

CHAPTER

I. INTRODUCTION…………………………………….…...….………………...... 1 Statement of the Problem…………………………………………………….….....3 Purpose Statement………………………………………………………...... 5 Hypotheses………………………………………………………………………...6 Operational Definitions…………………………………………………………....6

II. REVIEW OF LITERATURE……………………………………………....…….7 What is a Vegetarian Diet?...... 7 Origins of the Vegetarian Diet.……………………………………..…...8 Different Types of Vegetarian Diets………..……………………….…11 Recommendations for Vegetarian Diets…………………………….…13 Epidemiology of Vegetarianism ……………………………………....17 Nutrition Benefits of Vegetarian Diets……………………………………...…18 Body Weight………………………………………………………..…..20 Mortality Rates...……………………………………………………….21 Cardiovascular Disease…………………………………………...…....22 Cancers.....……………………………………………………….…..…23 Type II Diabetes………………………………….…………….……....23 Other Diseased States.………………………………..……..…....…….24 Nutrition Concerns of Vegetarian Diets…….………………………………….25 Protein Needs…..………………...…………………………………….…25

Vitamin B12 Deficiency…..…………………………….…………….…..26 Iron Deficiency…………………………………………………….….…27 Calcium and Vitamin D Deficiency…..……………………………....….28 At-Risk Populations…………………………………………………...…29 Pregnant Women………………...……………….…………...29

Breastfeeding Women and Infants..……………………..…..31 Children………………………………………………………32 Eating Behaviors of Vegetarians...…………………………………………..….33 Reasoning for Practicing a Vegetarian Diet…….……………………………....34 Current Trends in Dietary Intake and Behavior in College Students…………..37 Lifestyle Behaviors in College Students……………..………..………..38 Health Concerns for College Students….……………..…………..……40 Prevention and Interventions………...………………………………….42 Current Nutrition Knowledge in Men and Women College Students……….…45 Current Perception of Vegetarian Diets in Men and Women…………………..49 Gender Differences in Dietary Intake and Behavior…..…………………….....52

III. METHODOLOGY……………………………………………………………....55 Overview….……………………………………………………………………..55 Participants.……………………………………………………………………...55 Instrumentation…….………………………………………………………….…56 Survey Development…………..………………………………………...56 Survey Components……………………………………………………..57 Part I: demographics.……………………………………………58 Part II: perceptions toward vegetarianism.…..………………….59 Part III: general nutrition knowledge...………………...………..59 Data Collection Procedures….………………………………………………….60 Data Analysis Procedures…….…………………………………………………61

IV. JOURNAL ARTICLE…………………………………………………………..63 Introduction…………………………………………………………………....63 Methodology………………………………………………………………...…66 Instrumentation....…………………………………………………...….67 Data Collection Procedures……………………………………………..68 Data Analysis Procedures……………………………………………….69 Results………………………………………………………………………....70 Demographics…..……………………………………………………….70 Perceptions toward Vegetarianism……………………………………...72 General Nutrition Knowledge…………………………………………..79 Discussion……………………………………………………………………...88 Characteristics of Study Population……………………………………..88 Perceptions of Vegetarianism………………………………………..….89

vi Knowledge of General Nutrition……………………………………...... 92 Limitations……………………………………………………………………...94 Applications………………………………………………………………….…95 Conclusion………………………………………………………………..….…97

APPENDICES………………………………………………………………………………….99 APPENDIX A. NUTIRITION KNOWLEDGE AND PERCEPTION SURVEY…….....100 APPENDIX B. RECRUITMENT E-MAIL………….…………………………………..115 APPENDIX C. STUDY CONSENT FORM…………...………………………………..117 APPENDIX D. SURVEY BY PETER PRIBIS.…………………………………………119 APPENDIX E. SURVEY BY DR. AMY MIRACLE…………………………………...125

REFERENCES…………………………………………………………………………………130

vii LIST OF TABLES

Table Page

1. Demographics of Undergraduate College Students Surveyed at a Midwestern University on Nutrition Knowledge and Perception of the Vegetarian Diet (N=1,191)……… ………...…………………………………...…………………...... 71

2. Perceptions of Vegetarianism of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)……………...……………………..72

3. Perceptions of Vegetarianism of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191)…….……….…...75

4. Perception Scores of Vegetarianism of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)…………………...……...78

5. Perception Scores of Vegetarianism of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191)………………….79

6. General Nutrition Knowledge of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)…...………...……………………...80

7. General Nutrition Knowledge of Male and Female Undergraduate College Students Surveyed Using Fill-in-the-Blank Question at a Midwestern University (N=1,191)...83

8. General Nutrition Knowledge of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191)…...…...………...83

9. General Nutrition Knowledge of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed Using Fill-in-the-Blank Question at a Midwestern University(N=1,191)………...…………………………………...………………...... 86

10. Comparing General Nutrition Knowledge of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)….…………………..…...87

11.Comparing General Nutrition Knowledge of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University(N=1,191).....88

viii

CHAPTER I

INTRODUCTION

Vegetarianism is most commonly known as a diet that excludes the consumption of meat, including fowl, seafood and other products containing those foods (Craig and

Mangels, 2009). The vegetarian diet is as healthy as an omnivore diet, though both require a certain degree planning to ensure they are well-balanced (Marsh, Zeuschner and

Saunders, 2012; Craig and Mangels, 2009; Murphy, 2002; Harvard Women’s Health

Watch, 1996). The vegetarian diet is continuing to grow in popularity in the United

States, and approximately four percent of the population identifies as vegetarian

(Leitzman, 2014). College students aged 20 to 29 most frequently explore this diet, as they have just begun to explore their independence (Haddad and Tanzman, 2003).

Vegetarian diets can be considered for many different reasons and practiced in many different ways, but it is important for individuals considering this diet to be well- informed.

Vegetarian diets are associated with decreased mortality rates when compared to people who practice a non-vegetarian lifestyle (Orlich et al., 2013). These mortality rate decreases are more significant in male vegetarians than female vegetarians. Additionally, decreased mortality rates are significant in vegetarian individuals who are older, likely due to them practicing for a longer duration and their tendency to drink less, smoke less, exercise more and have an appropriate body weight for their gender, height and age

(Orlich et al., 2013). Therefore, it would be most beneficial to have a positive perception

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and strong knowledge base of this diet at a young age, such as when an individual is in their college years and exploring new dietary patterns that will likely be carried with them into adulthood.

Since most college students are young and exploring their independence, they have very different dietary patterns compared to other populations. The average diet of a college student lacks variety and they tend to skip meals frequently while snacking on a lot of unhealthy foods (Brunt, Rhee and Zhong, 2008; Huang, Harris, Lee, Nazir, Born and Kaur, 2003). College students also fail to meet recommended daily doses of fruits, vegetables and fiber, while exceeding the suggested amounts of added sugars and calorie- dense foods (Brunt, Rhee and Zhong, 2008;Huang, Harris, Lee, Nazir, Born and Kaur,

2003). The research is showing that the diet of a typical college student does not meet an individual’s nutritional needs.

College student’s perceptions of healthy eating include consumption of vegetables, fruits and meats, as well as limited amounts of dairy (Ligia María, José

Andrés and Marianela, 2013). As for the vegetarian diet, college students are considering it an extreme option in respects to eating healthier (Ligia María, José Andrés and

Marianela, 2013; Brunt, Rhee and Zhong, 2008). Therefore, a limited number of undergraduate college students, approximately seven percent, are practicing this diet in the United States (Brunt, Rhee and Zhong, 2008). College students perceive vegetarianism as being associated with fruits, vegetables, thinness, weakness and extremity, while health is perceived as having energy, consuming meat and consuming a

balance of nutrients by both men and women (Ligia María, José Andrés and Marianela,

2013; Hoek, Luning, Weijzen, Engels, Kok and Graaf, 2011; Ruby, 2012). However, female undergraduate students tend to see vegetarianism in a more positive way than males (Rothgerber, 2013).

In addition to unfavorable perceptions of vegetarianism, undergraduate college students have limited knowledge regarding healthy eating behaviors, nutritional requirements for their body types, how to interpret information on food labels and the groups of foods in the food pyramid (Cousineau, Franko, Ciccazzo, Goldstein and

Rosenthal, 2006). Students also have little to no understanding of metabolism and energy expenditures (Cousineau, Franko, Ciccazzo, Goldstein and Rosenthal, 2006). Graduate students, on the other hand, had more than basic nutrition knowledge when compared to their undergraduate counterparts (Poobalan, Aucoff, Clarke and Smith, 2014). Students in college do not get formal nutrition education unless the curriculum suggests it. Taking a nutrition course is not mandatory for everyone and only two percent of college students seek formal education on the subject (Barzegari, Ebrahimi, Azizi and Ranjbar, 2011).

Those with a strong foundation of nutrition education had regular meal patterns, an adequate intake of fruits and vegetables per day and lower levels of snacking than those without formal nutrition education (Poobalan, Aucoff, Clarke and Smith, 2014).

Statement of the Problem

Even college students open to practicing the vegetarian diet don’t have the knowledge necessary to maintain it healthfully. Of 428 college students surveyed, 59 of

them were following a vegetarian diet and started doing so when they got to college

(Smith, Burke and Wing, 2000). Health, animal welfare and finding meat unappealing were the main reasons these individuals adopted the diet. Of the vegetarians surveyed,

62% of them remained on their diet for a least a year, but most of these individuals, about

64% of them, started to eat meat again after a year. The reasons for returning to an omnivore diet included missing meat, finding vegetarianism inconvenient or feeling as though they were not receiving adequate nutrients (Smith, Burke and Wing, 2000).

Students who opted not to explore vegetarianism would cite a fear that they would become deficient in multiple nutrients as the reason. This fear stems from their lack of knowledge on how to combat this issue (Harvard Medical School, 2004). All this research shows that a negative perception keeps college students from pursing or maintaining a vegetarian diet.

The vegetarian diet is a viable option for college students to have and practice. It can provide students with all the nutrients they need to consume a well-balanced, healthy diet (Marsh, Zeuschner and Saunders, 2012; Craig and Mangels, 2009). The vegetarian diet can help students to live a longer life free of chronic illness, especially if established in their college years (Orlich et al., 2013). Therefore, college students would ideally have a strong foundation of nutrition knowledge and individual’s perceptions of a vegetarian diet would be positive in men and women, as well as vegetarian and non-vegetarian college students (Ligia María, José Andrés and Marianela, 2013; McEvoy, Temple and

Woodside, 2012) . However, many college students are not taking advantage of this diet and the many benefits it can provide due to their lack of knowledge and negative attitudes

toward a diet without meat consumption (Ligia María, José Andrés and Marianela, 2013;

Brunt, Rhee and Zhong, 2008; Cousineau, Franko, Ciccazzo, Goldstein and Rosenthal,

2006).

Despite the research outlined above, there is still not enough information on the perception and nutrition knowledge of vegetarian diets within college students. There is also limited research regarding differences between male and female nutrition knowledge and their perception of vegetarianism. Males and females seem to have similar opinions and intentions to commit to a healthy diet, but it is unsure what each gender knows and understands (Deshpande, Basil and Basil, 2009). Collecting more data from this sample of students about their perception and understanding of vegetarianism can equip dietitians with the information required to meet college students’ needs in this area, as well as help them counsel according to the potential differences between genders. They will be able to present a healthy alternative to students who are interested in exploring new diets by building on to what college students already know. Additionally, having access to students perceptions of this diet, and not just their nutrition knowledge, will help health professionals understand what students feel a vegetarian diet can be used for and their thoughts on what foods are appropriate for a well-balanced vegetarian diet.

Purpose Statement

Hypotheses

H1: There is a difference in nutrition knowledge between male and female college students.

H2: There is a difference in perception of vegetarian diets between male and female college students.

H3: There is a difference in nutrition knowledge between vegetarian and non- vegetarian college students.

H4: There is a difference in perception of vegetarian diets between vegetarian and non-vegetarian college students.

Operational Definitions

Nutrition Knowledge- the level of health conciseness an individual has about nutrition and a person’s awareness of calories, fat, protein and carbohydrates and how these nutrients contribute to a person’s overall health status (Hwang and Cranage, 2015) as measured by an electronic survey adapted from a previously validated study (A.

Miracle, personal communication, December 11, 2017).

Perception- the attitude one has toward vegetarian diets (Corrin and

Papadopoulos, 2017) as measured by an electronic survey adapted from a previously validated study (Pribis, Pencak and Grajales, 2010).

CHAPTER II

REVIEW OF LITERATURE

What is a Vegetarian Diet?

Currently, there is no universally accepted definition for the term “vegetarianism”

(Haddad and Tanzman, 2003; Marsh, Zeuschner and Saunders, 2012; Craig and Mangels,

2009). Generally speaking, the term can be described as a dietary pattern or lifestyle that emphases the consumption of plant-based foods such as legumes, fruits, nuts, seeds, grains and vegetables and avoids flesh- or animal-based foods like meat, poultry and seafood. The diet can still include the ingestion of eggs and/or dairy products. This general description can also be used to describe a vegan lifestyle, which is a vegetarian who avoids all animal products, including dairy, eggs and honey (Haddad and Tanzman,

2003; Marsh, Zeuschner and Saunders, 2012). The Academy of Nutrition and Dietetics defines a vegetarian diet in the position statement for vegetarian diets in 2009 as “one that does not include meat (including fowl), seafood, or products containing those foods”

(1266). A vegetarian diet that is well planned and thought out by the person consuming the diet can be healthy, nutritionally adequate and beneficial for treating or preventing a chronic disease (Craig and Mangels, 2009).

Vegetarian diets are given two definitions in the Evidence Analysis Library

(EAL) of the Academy of Nutrition and Dietetics (AND). The first refers to a vegan diet which is devoid of all flesh foods. Vegans can also avoid the use of honey (Craig and

Mangels, 2009; Murphy, 2002). The second definition frames a vegetarian diet as one

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that is devoid of flesh foods, as well, but can include the consumption of eggs and/or dairy (Craig and Mangels, 2009).

Origins of the Vegetarian Diet

The history of vegetarianism dates back to the 1700s when Sir Isaac Newton debated whether or not it would be acceptable for people to eat the blood from an animal and whether eating the blood of the slaughtered animal was cruel (Shapin, 2007). This debate went to trial in 1727, where it was decided that the blood should be drained and never eaten. Through most of history up to this point, eating the blood of an animal was not an issue because the commoners did not have access to meat due to its expense and scarcity. If someone at this time decided to avoid eating meat on purpose, it was usually due to one of three reasons: religious, medical or philosophical. Keeping a vegetarian diet has always had little to do with the importance of eating more plants and everything to do with why someone should not eat meat. In fact, during the middle ages, people believed that vegetarianism was one of the only ways to avoid cannibalism and being suspected of pagan beliefs (Shapin, 2007; Whorton, 1994).

In general, vegetarianism was much more prominent in American culture than in

England during the 1700s (Laws, 1994). The Plains Indians practiced the diet by mainly eating corn, beans and squash. Vegetarianism was incorporated not only into their eating habits, but their living habits. Plains Indians’ homes were made from wood, mud and bark, as opposed to animal’s skin. Additionally, animals were kept alive and treated with the same respect as tribe members (Laws, 1994).

During the same time, vegetarian was on the rise in Greece (Avey, 2014). The

Pythagoreans were the first self-proclaimed vegetarians in history. They got their name from the prominent philosopher, Pythagoras, though it is unclear whether he kept a vegetarian diet himself or ate meat occasionally. It is thought that he may have consumed fish on a daily basis, but he believed that a meatless diet aided in longevity and a healthy lifestyle. He wrote a book that included arguments for transitioning to a meatless diet that are still used in today’s society. Despite his contributions to the practice, his name was later replaced with the term “vegetarianism” in the 1800’s when the first vegetarian society was formed (Avey, 2014).

Throughout the Enlightenment period, people started to feel sympathy for animals and the suffering they would endure (Shapin, 2007). This sympathy was possibly born of urbanization and the lack of people experiencing the slaughter themselves. In urban settings, individuals no longer had an active hand in food production and could instead imagine the process, where before, people were doing it out of survival without thinking

(Shapin, 2007). Conversations about sustainability also became popular during this time thanks to factory farming. Though many people participated in the dispute, they were ultimately not deterred from consuming meat (Shapin, 2007; Whorton, 1994).

Indians were still following a mostly vegetarian diet by the 1840s. This can be attributed to their held beliefs that men who ate meat would become aggressive and that animals kept themselves protected from human consumption by having the ability to cause sickness while plants were medicinal and helped combat diseases (Laws, 1994).

Even the children in this culture remained 100% vegetarian until the age of ten so they could live happy and healthy lives (Laws, 1994). The idea that vegetarian was the solution to ailments, especially for people who lived weak and sedentary lifestyles, continued to gain purchase in the late 1800s and early 1900s (Shapin, 2007; Whorton,

1994). However, unlike in the Indian culture, there was a widely held belief that strong men needed to consume meat because vegetables would cause weakness and inefficiency.

Therefore, vegetarianism was not advised for long-term consumption (Shapin, 2007;

Whorton, 1994).

As time progressed into the 1900’s, the Food and Drug Administration was born.

Upton Sinclair helped bring about the organization with his writings, which shed light on the unsanitary conditions surrounding meat production and packaging (Avey, 2014).

Another prominent vegetarian supporter in the 1900’s was John Harvey Kellogg, who advocated for the benefits of a vegetarian diet and had created a meat-substitute called protose. Later on in this century, cookbooks for vegetarian diets became more prominent, and protose was a popular item to find in the recipe books. During the 1970s, cookbooks started to address protein consumption in vegetarianism and had examples of plant-based foods high in protein. In 1972, cookbooks and vegetarian advocates started to talk more about the use of vegetarian foods and started to steer away from using meat-substitutes

(Avey, 2014). This is when vegetarianism really started to be celebrated and considered as a healthy alternative to the omnivore diet

Different Types of Vegetarian Diets

There are four main types of vegetarian diets including the lacto-ovo-vegetarian, the lacto-vegetarian, the ovo-vegetarian and the vegan diet (Craig and Mangels, 2009;

Marsh, Zeuschner and Saunders, 2012; Frey, 2008; EBSCO CAM Review Board, 2016).

The lacto-ovo-vegetarian consumes dairy products and eggs in addition to other vegetarian foods, but no meat, poultry or seafood. Lacto-vegetarians eat dairy products, but exclude eggs from their diet as well as meat, fish and fowl (Craig and Mangels, 2009;

Marsh, Zeuschner and Saunders, 2012). An ovo-vegetarian, also known as eggetarians, consume a plant-based diet with the addition of eggs, while avoiding red meat, poultry, fish, cow’s milk and milk-based foods like cheese and yogurt (Frey, 2008). An ovo- vegetarian diet is commonly used for a person who is lactose intolerant and wants to practice a vegetarian diet that includes eggs as a source of protein (Frey, 2008). A vegan diet, also known as a total vegetarian diet, excludes eggs, dairy and all other animal products such as meat, fish and honey and may even exclude the use of wool, leather, silk or pearls in clothing and jewelry (Craig and Mangels, 2009; EBSCO CAM Review

Board, 2016).

The vegetarian diet is often compared to other diets but can differ in many ways.

The macrobiotic diet differs from a vegetarian diet due to fish consumption, the raw foods diet differs due to occasional consumption of unpasteurized dairy products and possible consumption of raw meat or fish (Frey, 2008; EBSCO CAM Review Board,

2016). It is also different from the fruitarian diet which is defined as a diet with no

vegetables, just fruits, nuts and seeds (EBSCO CAM Review Board, 2016). The semi- vegetarian diet is dissimilar as well because it is a diet where a person can consume fish or chicken (Craig and Mangels, 2009).

None of the variations of vegetarianism, including veganism, have a common diet plan to follow, but many existing diets can be adjusted to create a well-balanced vegetarian diet (EBSCO CAM Review Board, 2016). The Mediterranean diet can be adjusted to fit an ovo-vegetarian diet plan and the raw-foods diet, or the macrobiotic diet, can be modified to fit the nutritional needs of a vegan. The raw-foods diet can be seen as unhealthy but provides a good baseline to forming a vegan diet (Frey, 2008; EBSCO

CAM Review Board, 2016). There is also an alkaline diet that can be seen as similar to a vegetarian diet (Schwalfenberg, 2012). This diet requires eating plenty of fruits and vegetables, nuts, seeds, beans and legumes, while avoiding the consumption of high- sodium foods, processed grains and sugars, meat, fish and dairy products, especially dairy milk. It can be considered healthy if executed properly and can fit the guidelines of a vegetarian diet well (Schwalfenberg, 2012). However, if done improperly, any of the above diets could be considered unhealthy or even unsafe.

There are many vegetarian diets to consider avoiding for health reasons, including the fruitarian diet, the mono-food diet and the juicing diet, also known as the detox diet.

The fruitarian diet consists mainly of fruit (MacDonald, 1987). This diet can put people at nutritional risk and is a very unhealthy practice. While some people do eat vegetables, cereals, nuts and seeds while following this diet, it still does not have enough nutrients to

be accepted as a long-tem, healthful option and should not be practiced in replace of a planned vegetarian diet (MacDonald, 1987).

The mono-food diet is another vegetarian diet that can put people at risk of nutrient deficiencies. The simple plan of this diet appeals to people, as individuals keeping it eat only one type of food for several weeks at a time (Sinicki, 2017). When followed long-term, the mono-food diet causes nutritional deficiencies because a single food does not have all the nutrients the human body needs to thrive and toxicity due to an overabundance of one nutrient (Sinicki, 2017).

Lastly, the juicing diet, also known as the detox diet, meets the guidelines of being vegetarian but has multiple risks involved (Klein and Kiat, 2015). This diet consists of long-term fasting by consuming only juices. The goal of this diet is advertised as eliminating toxins from the body and losing weight. Not only is the elimination of toxins unnecessary because of the body’s ability to self-regulate, this diet is dangerous for its inability to meet daily protein needs. Additionally, this diet can increase stress levels and elevate cortisol, which will lead to an increase in appetite and a difficulty losing weight.

Lastly, this diet can lead to overdosing of various vitamins and minerals (Klein and Kiat,

2015).

Recommendations for Vegetarian Diets

The dietary guidelines for Americans rely heavily on epidemiology to make proper recommendations to Americans about what is appropriate to eat (Jacobs, Haddad,

Lanou and Messina, 2009; Craig and Mangels, 2009). Vegetarianism is becoming more

popular, although there are still issues regarding the recommendations being made by the

USDA. In 2005, the dietary guidelines started to become more favorable to vegetarians but failed to make appropriate serving size recommendations regarding common foods like beans, lentils and seeds because they are seen as a snack or a side on the dietary guidelines instead of a main dish (Jacobs, Haddad, Lanou and Messina, 2009). The guidelines do not fulfill important vitamin needs for a vegetarian diet including Vitamin

E, C, A, calcium, magnesium, potassium and fiber and commonly suggested an increase in milk to make up for these nutrient deficiencies, which is inappropriate for various vegetarians and could be an inaccurate guide for individuals planning a vegetarian diet

(Jacobs, Haddad, Lanou and Messina, 2009).

Resources that can provide accurate guidelines for keeping a vegetarian diet include information created by the Vegetarian Resource Group, the 7th-day Adventists and the World Health Organization. The Vegetarian Resource Group offers basic information on healthfully making the change from an omnivore diet to a vegetarian diet, such as the definition of vegetarianism, reasons one might practice this diet and how to remain healthy when creating a diet plan (2017). The main focus of making the transition is meeting all the basic food groups: fruits, vegetables, whole grains, nuts, seeds and legumes. Additionally, these guidelines touch on the fact that sweets and fats should be limited (The Vegetarian Resource Group, 2017). Next, they talk about having two options when it comes to transitioning to a vegetarian diet. An individual can chose to stop eating meat and fish instantly or they can gradually progress toward a vegetarian diet

(The Vegetarian Resource Group, 2017). Then they touch on the nutritional needs of a vegetarian and how to meet these needs properly.

Since it’s often a topic of concern when considering a vegetarian diet, the

Vegetarian Resource Group starts by addressing how to meet the body’s need for protein without consuming meat (2017). They state that vegetarians easily get enough protein and essential amino acids from beans, lentils, tofu and nuts. There is also protein in greens, potatoes and breads that can add up throughout the day. Next, they suggest meeting iron needs by increasing absorption through a higher vitamin C intake. Calcium and B12 are also discussed. The Vegetarian Resource Group suggests consuming fortified foods on a regular basis to limit B12 deficiencies. They encourage individuals to explore nutrition labels on their own to learn more information (The Vegetarian Resource Group,

2017).

The next section includes information on products to use in place of non- vegetarian items. They discuss meat substitutes including tempeh and tofu (The

Vegetarian Resource Group, 2017). They also make suggestions for egg replacers and dairy substitutes like soymilk, rice or nut milks and almond or soy yogurt. Furthermore, they touch on how flaxseed, canola oil, walnuts and soybeans contribute omega-3 fatty acids to a vegetarian diet. There is also a section on cholesterol and saturated fat and using products like cheese and eggs carefully, as well as watching coconut and palm oil consumption due to the fat content. Lastly, they discuss common vegetarian foods such

as spaghetti, eggplant, bread, yogurt, nut butters, soup, salad, burritos and grilled cheese

(The Vegetarian Resource Group, 2017).

The Vegetarian Resource Group also created a handout on a Vegan My Plate

(Mangels, 2017). This plate includes a fourth of fruits, vegetables, grains, protein and a side of calcium. The vegetables suggested include broccoli, peppers, carrots, corn and tomatoes, while the fruits section suggests bananas, blueberries, oranges and grapes. The grains suggested are bread, pasta and tortillas. The proteins offered were tofu, black beans, kidney beans and peanuts and the calcium options were nut milks or soy milks and leafy greens. The tips included on the handout involve choosing whole grains, eating a variety of foods and consuming enough Vitamin D and iodine, as well as Vitamin B12

(Mangels, 2017).

Seventh-day Adventists follow a vegetarian diet plan that can be transferred to any individual (Hinzey, 2017). It consists of avoiding meat but consuming legumes, whole grains, nuts, fruits and vegetables. Vegetarians following this plan could either be considered lacto-ovo or vegan. Under the Seventh-day Adventists guidelines, individuals must also refrain from tobacco, alcohol, coffee, tea and other caffeinated beverages. They are encouraged to follow a diet plan that has been modified from the original My Plate concept and aim toward eating six ounces of grains, two and half cups of vegetables, two cups of fruit, three cups of dairy and five and half ounces of legumes and nuts per day.

This diet plan also encourages individuals to pay special attention to their calcium,

Vitamin B12, iron, zinc and protein intake (Hinzey, 2017).

The last resource that can be utilized as a positive resource for vegetarianism comes from the World Health Organization. This resource puts an emphasis on beans, lentils and chickpeas as plant-based protein sources for vegetarians (Leterme, 2002).

They advise individuals on how to avoid meat-based products and what they can use for substitutes to these products. In addition, to suggesting beans, lentils and chickpeas, they also suggest nuts and some seeds be included in the diet. Like the other two sources, the

World Health Organization, advises individuals following this diet to lookout for deficiencies in calcium, iron, zinc and Vitamin D and B12. Additionally, they suggest the consumption of brown rice, whole grain bread, potatoes, low-fat dairy products and plenty of fruits and vegetables (Leterme, 2002).

Epidemiology of Vegetarianism

Multiple censuses were evaluated for information on vegetarianism and it was found that among 320 million people in the United States, 12.1 million people self- identify as a vegetarian, which amounts to four percent of the population (Leitzmann,

2014). Approximately ten percent of vegetarians reported identified as a vegan and the number of vegans in the United States continues to grow faster than the number of people who are vegetarians. India has the most vegetarians at 35% oftheir population, while

Switzerland has the lowest ratio of vegetarians to non-vegetarians at less than two percent of the population. Vegetarianism seems to be growing internationally, but in the United

States, meat consumption is still rapidly increasing (Leitzmann, 2014). In a nationwide survey conducted in 2009 by the Vegetarian Resource Group, three percent of United

States residents were vegetarian and one percent was vegan (Marsh, Zeuschner and

Saunders, 2012). Vegetarianism remains the minority everywhere in the world expect

India, but the awareness of the health benefits associated with a vegetarian diet are on the rise and the long-term effects of this diet are becoming more recognizable to people in the United States (Leitzmann, 2014).

The United States Department of Agriculture conducted a survey as part of the national nutrition monitoring program and found that, of about 13,000 people, two and a half percent were vegetarians at six years of age or older (Haddad and Tanzman, 2003).

Within the 334 people that self-reported to be vegetarians, 214 of them reported that they consume some meat. The age range of 20 to 29 years of age was the group with the largest amount of vegetarians. The age group of 60 to 69 was the age group with the lowest amount of vegetarians (Haddad and Tanzman, 2003).

Nutrition Benefits of Vegetarian Diets

During the 1980s, researchers started to conduct numerous epidemiological studies about the benefits of this diet and other plant-based diets, including the reduction on many degenerative, non-communicable diseases like obesity, ischemic heart disease and cancers (Leitzmann, 2014). The total mortality rate was also looked at over a greater length to determine how this diet can increase longevity. Many people still had skepticism about this diet and did not start to accept these benefits until the 20th century

(Leitzmann, 2014). The main health benefits of the vegetarian diet include low levels of saturated fat and cholesterol, high fiber, phytochemicals and antioxidants as well as a

high intake of fruits, vegetables, whole grains, nuts, seeds, legumes and cereals, while also obtaining higher energy levels compared to non-vegetarians (Craig and Mangels,

2009; Sabaté, 2003; Murphy, 2002; Harvard Women’s Health Watch, 1996). All of the types of vegetarian diets have benefits to them. The lacto-ovo, lacto and vegan diets are all appropriate for pregnant women, breastfeeding women, infants, children and adolescents. Each diet has the ability to promote normal growth and fulfil all nutritional needs (Frey, 2008). Although these characteristics are consistent with most vegetarian diets, the vegetarian diet can vary greatly from person to person due to the eating patterns being a heavily fluctuating variable but each diet has a functional purpose in that they can prevent disease. These diets also have the ability to fulfill ethical needs in regards to animal rights issues and can allow for a varying degree of animal rights activism within the amount of variability each diet contains (Frey, 2008; EBSCO CAM Review Board,

2016).

The most commonly documented health advantages of a vegetarian diet, in research journals, consists of low blood lipid levels, decreased risk for degenerative diseases such as heart disease, lower blood pressure and hypertension, decreased chances for acquiring type II diabetes and decreased risk for cancer, as well as a decreased risk for obesity and lower cholesterol levels, which is especially true for vegan diets because they are typically higher in fiber than any other diet and result in lower LDL cholesterol

(Craig and Mangels, 2009; Sabaté, 2003; Harvard Medical School, 2004). There is also evidence to suggest a vegan diet helps patients with arthritis symptoms (EBSCO CAM

Review Board, 2016). Compared to non-vegetarians, vegetarians have 25 percent less

deaths from heart related issues and 40 percent less deaths from cancer with an emphasis on breast and colon cancers (Murphy, 2002; Harvard Women’s Health Watch, 1996). The data on vegetarian diets show that people who consistently practiced this diet tend to have fewer diet-related diseases and lived a longer life than their counterparts (Leitzmann,

2014).

Haddad and Tanzman, (2003), conducted a three-day food recall on vegetarian and non-vegetarian individuals. Within the food recalls, it was found that vegetarians had lower levels of protein, higher levels of carbohydrates and lower levels of fat. They also had more vitamin E intake, vitamin C, folate, calcium, magnesium, copper and fiber than people who reported to consume meat. Vegetarians also consumed more fruit, vegetables, grains, nuts and seeds, but were reported to consume less Vitamin B12, niacin and zinc than meat-eaters. It was also reported that vegetarians consumed less juice, fried potatoes and white potatoes in total than those who consumed animal products (Haddad and

Tanzman, 2003).

Body Weight

Most vegetarians have a lower body weight, especially in people who practice a vegan diet (Le and Sabaté, 2014; Marsh, Zeuschner, and Saunders, 2012; McEvoy,

Temple, and Woodside, 2012). In 2014, it was found that vegetarian individuals have a

BMI that is between an average of two and four points lower than a non-vegetarian individual and vegans had a BMI that is between an average of three to five points lower than non-vegetarians (Le and Sabaté, 2014). This attribute of the diet can help lower

someone’s risk for cardiovascular disease (CVD), hypertension, type II diabetes, certain cancers, gallstones, kidney disease, constipation and diverticulitis, which is a disease that causes the bowel to be strained from bulging in the colon (McEvoy, Temple, and

Woodside, 2012). Vegetarian diets provide foods high in fiber, phytochemicals and antioxidants which are all dietary components that can contribute to the alleviation of some diseases (Marsh, Zeuschner, and Saunders, 2012; McEvoy, Temple, and Woodside,

2012).

Mortality Rates

Vegetarian diets were found to decrease mortality in many chronic diseases

(Orlich et al., 2013). Vegetarians in this study were of an older age than their non- vegetarian counterparts, suggesting that vegetarians consistently experienced first-time issues with chronic diseases later in life compared to people who do not practice a vegetarian lifestyle. The vegetarians were also non-smokers, consumed little to no alcohol, exercised frequently and had a healthy body weight. Vegans and lacto-ovo vegetarians had the lowest mortality rates among everyone. Lower mortality rates were documented for people who experienced a stroke, cardiac issues, renal disease, cancers

—specifically a decreased risk of female-specific cancers and gastrointestinal cancers, — and endocrine mortality rates. The people who consumed a vegetarian diet also had a decreased risk for diabetes, hypertension and metabolic syndrome (Orlich et al., 2013).

Cardiovascular Disease

Vegetarianism can help reduce the risk of CVD by 24% and the lowered risk is more common for those who have followed the diet for five years or longer and started practicing a vegetarian diet at a younger age (McEvoy, Temple, and Woodside, 2012).

The risk for CVD is lower due to the lower levels of LDL cholesterol in vegetarians, as well as lower BMI’s and a low blood pressure which results in reduced risk for hypertension (McEvoy, Temple, and Woodside, 2012). It was also found that whole grain consumption is associated with lower incidence of cardiac disease in addition to legumes having an impact on cardiovascular health, although whole grains have a more positive impact than legumes. The higher intake of fruits and vegetables that is assumed with vegetarianism helps to protect against CVD as well because they provide phytochemicals, antioxidants and fiber to the diet (McEvoy, Temple, and Woodside, 2012). Nuts also protect against CVD by shielding against inflammation and the oxidation of lipids while providing various vitamins and minerals high in antioxidants (Marsh, Zeuschner, and

Saunders, 2012; McEvoy, Temple, and Woodside, 2012). People who practice a vegetarian diet are also at a decreased risk for high blood pressure. With this diet, systolic and diastolic blood pressures are lower. People who practice vegetarianism in some form are also 75% less likely to be treated for hypertension (Marsh, Zeuschner, and Saunders,

2012).

Cancers

Red meats and processed meats can lead to colon cancers but with an increase in fiber, due to a vegetarian diet, the risk of colon cancer decreases (McEvoy, Temple, and

Woodside, 2012). The risk for breast cancer can be decreased due to the lower levels of blood estrogen since processed meat consumption is eliminated while an increase in soy protein can also help to protect again breast cancer (McEvoy, Temple, and Woodside,

2012). Although the risk is decreased in colon and breast cancer with the use of vegetarian diets there is inconsistent evidence with vegetarian diets decreasing the risk for lung, stomach and prostate cancers (McEvoy, Temple, and Woodside, 2012; Marsh,

Zeuschner, and Saunders, 2012 ).

Type II Diabetes

The risk for type II diabetes will fall with a vegetarian diet because of lower saturated fat levels as well as, increased fiber intake, which can lower blood sugar

(Harvard Medical School, 2004). Whole grain consumption and legume and nut consumption, in addition to higher fruit and vegetable consumption can also contribute to the decreased risk of type II diabetes. There is also evidence that this diet decreases fasting blood sugar, cholesterol levels and triglycerides (McEvoy, Temple, and

Woodside, 2012).Cholesterol levels can be decreased through the consumption of nuts, soy, legumes and whole grains, which is good for diabetic prevention since low cholesterol can protect against heart diseases, something that is more prevalent in diabetic patients (Harvard Medical School, 2004). A vegan diet will decrease the risk for type II

diabetes by 50% and a vegetarian diet before and during pregnancy will decrease the women’s risk for gestational diabetes (Marsh, Zeuschner, and Saunders, 2012).

Other Diseased States

Regarding diseased states and vegetarianism, it was found that people are consuming less whole plant foods and more meat products, causing higher obesity rates, lower levels of HDL cholesterol, increased triglyceride levels, glucose intolerance and metabolic syndrome (Singh et al., 2014). Non-vegetarian individuals have coronary events occur for the first time at a younger age than those who practice vegetarianism, as does insulin resistance. People are consuming more refined carbohydrates, using cooking oils rich in saturated fats and consuming fast food more frequently. Lacto-ovo- vegetarians and vegans have a lower prevalence of obesity and individuals on these diets tend to have a lower BMI and very few incidents of heart disease or insulin resistance

(Singh et al., 2014)

Other diseases can be alleviated with the use of a vegetarian diet, including gall stones, kidney disease, gout and arthritis (Marsh, Zeuschner, and Saunders, 2012). Gall stones are decreased through the high fiber content from the increased consumption of fruits and vegetables. Kidney disease can be decreased through the low amount of blood fat levels and the decreased urinary creatinine output as well as a decreased risk for proteinuria. Occurrences of gout are reduced by the elimination of red meats and seafood because these foods increase the risk for uric acid crystallization. Lastly, due to the

decrease in inflammation as a result of a vegetarian diet, arthritis can be decreased

(Marsh, Zeuschner, and Saunders, 2012).

Nutrition Concerns of Vegetarian Diets

When planning for a well-balanced vegetarian diet, some nutrients can be hard to obtain. The necessary vitamins and minerals should be monitored by the individual to prevent deficiency (Craig and Mangels, 2009). Nutrients to consider are protein, iron, zinc, iodine, calcium, and Vitamin D and Vitamin B12 because it is common to not consume enough of these core macro- and micronutrients while practicing a vegetarian or vegan lifestyle (Craig and Mangels, 2009; Sabaté, 2003). Calcium is commonly found in leafy vegetables, tofu, orange juice and nut milks. Iron can be found in beans, lentils and greens, while Vitamin C can be found in orange juice, strawberries and broccoli. Zinc and Vitamin B12 can be increased with legumes, nuts, seeds and whole grains (Murphy,

2002). While there are some risks to the vegetarian diet, scientifically, the risks seem to be outweighed by the benefits for most demographics. Additionally, some risks can be alleviated by consumption of the proper nutrient-dense foods.

Protein Needs

Nutritional aspects to consider when switching from a non-vegetarian diet to a vegetarian diet include one’s ability to consume adequate protein (Harvard Medical

School, 2004; Marsh, Zeuschner and Saunders, 2012; Murphy, 2002). Although most people keeping a vegetarian diet either meet or exceed protein recommendations, vegans can have some issues due to the lack of dairy and eggs. Therefore, they need to consider

consuming soy, nuts and beans as additional sources to vegetables (Harvard Medical

School, 2004; Marsh, Zeuschner and Saunders, 2012). Vegetarian diets, on average, provide 50 grams of protein per day from sources like beans, dairy, eggs, nuts, seeds and soy products (Harvard Medical School, 2004). If protein levels are low, they can be increased by higher consumption of beans, breads, nuts, nut butters, tofu, soy milk or other nut milks and vegetables like spinach or broccoli (Murphy, 2002).

Vitamin B12 Deficiency

Nutrient deficiencies are one of the most common concerns that cause individuals to not want to switch from an omnivore diet to a vegetarian diet (Harvard Medical

School, 2004). Vitamin B12 is one of the most frequently questioned vitamins for vegetarians and although the human body does not require large amounts of this nutrient it is still necessary for a well-balanced diet. This vitamin comes from animal products only so it is easy for vegetarians to become deficient in this nutrient, although symptoms might not start to show for years after this diet has been adopted. There are some plant- based foods that have been found to have trace amounts of B12, but there is not enough of this vitamin in those foods for people to get all they need. These foods can include mushrooms, tempeh, miso and sea vegetables such as seaweed, however these foods contain the inactive form of B12 so the body does not absorb them as efficiently (Marsh,

Zeuschner and Saunders, 2012; McEvoy, Temple and Woodside, 2012). It was found that

Vitamin B12 was improved with regular dairy milk consumption, but since this is not an option for vegans, supplementation is recommended to improve serum B12 (Woo, Kwok

and Celermajer, 2014). Supplementation is highly suggested since vegetarians are at risk for deficiency or the consumption of fortified foods such as soy milks or cereals to reach dietary needs of this nutrient (Marsh, Zeuschner, and Saunders, 2012; McEvoy, Temple, and Woodside, 2012; Harvard Medical School, 2004).

Iron Deficiency

Iron should also be monitored since non-heme iron, which comes from plant sources, is not as readily absorbed in the body, while heme iron is but can only come from animal sources (Marsh, Zeuschner, and Saunders, 2012). It is recommended that iron intake is higher in vegetarians and vegans for this reason; women should especially be aware of this issue due to women’s predisposition of low iron stores. This is the main reason that women who live a vegetarian lifestyle are at risk for iron-deficiency anemia and should try to consume Vitamin C with their iron to increase the absorption rate in the body. There is evidence to support that the body will adapt over time to the different type of iron in the body and lower body stores are created which will increase absorption of the non-heme iron, helping the issue of low iron stores in vegetarians. Nonetheless, vegetarians should consume whole grains, legumes and dark leafy vegetables to accumulate enough iron (Marsh, Zeuschner, and Saunders, 2012; McEvoy, Temple, and

Woodside, 2012). Zinc is similar to iron in the sense that its absorption rate depends on the amount of stores the body has, so it is important for vegetarians to eat foods rich in zinc, such as nuts, seeds and whole grains, to maintain adequate levels of zinc in the body

(Marsh, Zeuschner, and Saunders, 2012).

Calcium and Vitamin D Deficiency

Calcium can also be a nutrient that vegetarians are deficient in, although this is more common in veganism than in any type of vegetarianism (Marsh, Zeuschner, and

Saunders, 2012; McEvoy, Temple, and Woodside, 2012). Vegans should obtain calcium from fortified foods such as tofu and soy milk. They can also consume plant sources such as leafy greens and almonds but the bioavailability is lower. Vegans should also take into consideration that Vitamin D can help to increase calcium absorption so pairing sources of both these nutrients would be most beneficial to them (Marsh, Zeuschner, and

Saunders, 2012). Vitamin D is also beneficial to consume as it is a common deficiency for most Americans. This nutrient can be found in plant and animal sources such as mushrooms and eggs but is also added to many dairy products. Vegans living in areas with little sun-exposure are at an especially high risk for deficiency of this nutrient.

Fortified foods are one of the only sources vegans have for Vitamin D so they should be sure to consume soy milks or cheeses to get the adequate amount they need (Marsh,

Zeuschner, and Saunders, 2012; McEvoy, Temple, and Woodside, 2012).

Osteoporotic people may be at risk if they chose to consume a vegetarian or vegan diet on a regular basis. Bone density has been linked to being lower in people who adhere to a vegetarian or vegan lifestyle (Lanham-New, 2009). However, this study did not account for the body weight of the person in question, nor was physical activity level or smoking habits of the individuals assessed. Ethnicity was not collected from participants either. A vegetarian diet is such a large variable that conclusive results on vegetarianism

relating to osteoporosis could be hard to gather. Each type of vegetarianism would need to be looked at separately since some types of vegetarianism can include dairy products, which means there is a steady consumption of calcium and Vitamin D. Although, bone density was lower in vegetarians than non-vegetarians, the individuals were not at a serious risk for developing osteoporosis. The study also suggested that Vitamin D and

Vitamin K might be a factor in developing osteoporosis (Lanham-New, 2009).

At-Risk Populations

While concerns can arise when practicing any of the vegetarian diets, they should be appropriate for all stages of life including children, infants, pregnant women and individuals in diseased states such as renal failure and people who are osteoporotic as long as there is a balance of nutrients and the types of foods being consumed (Murphy,

2002; McEvoy, Temple, and Woodside, 2012). Athletes and teens should also be able to practice this diet as long as calcium levels are monitored (Murphy, 2002; McEvoy,

Temple, and Woodside, 2012). Although this diet could be inappropriate for patients who are in renal failure due to plants causing high protein levels, this is just as likely in animal protein sources. Vegetarianism may also be inappropriate for patients with severe osteoporosis due to the lack of calcium the diet supplies (Craig and Mangels, 2009).

Pregnant women. Pregnant women can consume a vegetarian or vegan diet and have it be nutritionally adequate (The Cleveland Clinic Foundation, 2015), but there are risks for both the pregnant woman and fetus (Piccoli et al., 2015; The Cleveland Clinic

Foundation, 2015; King, Stein and Doyle, 1981; Koebnick et al., 2004). There is

evidence to suggest that vegetarian or vegan diets can lead to hypertension during pregnancy but there is no evidence to support this leading to pre-eclampsia or eclampsia

(Piccoli et al., 2015; Koebnick et al., 2004). Some women practicing a vegetarian diet experienced a lower pregnancy BMI than women who ate an omnivore diet but weight gain was not a dire issue (Koebnick et al., 2004). The fetus of a vegetarian woman can be at risk for neural tube defects during pregnancy and cognitive delay and failure to thrive after birth (Piccoli et al., 2015; Koebnick et al., 2004).

Nutritional inadequacies are also a concern for pregnant women and their fetuses.

Vitamin B12, iron and zinc deficiencies are most prominent (Piccoli et al., 2015; King,

Stein and Doyle, 1981). Vitamin B12 deficiencies are especially probable in vegan pregnant women, but are generally less of an issue for women who consume a lacto-ovo vegetarian diet (Piccoli et al., 2015; Koebnick et al., 2004). However, women who consume a vegetarian diet have higher levels of magnesium and folate than women who consume meat during their pregnancy (Piccoli et al., 2015). Infants are at risk for developing a Vitamin B12 deficiency if born to a women adhering to a strict vegetarian diet, but most women meet these nutrition needs if they consume dairy throughout their pregnancy. Therefore, vegan diets are the most risky vegetarian diet to peruse when pregnant (Koebnick et al., 2004).

As for food recommendations for pregnant women, women should try to consume four servings of calcium per day, three servings of iron per day and one serving of

Vitamin C, folic-acid, Vitamin A and Vitamin B12 (The Cleveland Clinic Foundation,

2015). Following this plan will allow women to maintain a nutritionally-adequate vegetarian diet while pregnant. Pregnant vegetarians should also consider the food safety components of their diet just as any other pregnant woman should. There are food safety concerns for women practicing the ovo-vegetarian diet due to the possibility of consuming raw or partially cooked egg, so this should be taken into consideration (Frey,

2008). There are also concerns regarding produce, which should be washed properly to avoid contracting any bacterial infections or foodborne illnesses. Additionally, pregnant women should avoid consuming raw, sprouted grains like sprouted bread and should also avoid unpasteurized juice (The Cleveland Clinic Foundation, 2015).

Breastfeeding women and infants. There are concerns for low DHA in breastmilk produced by vegetarian women due to the lack of omega-3 fatty acids in the diet. This can be combated by consuming alternative sources of omega-3 fatty acids such as walnuts and flax seeds (Harvard Medical School, 2004). However, the child being breastfed by a vegetarian or vegan woman puts the baby at risk for growth failure, iron- deficiency anemia and possible developmental issues if the mother is not consuming enough vegetarian omega-3 fatty acids (Koebnick et al., 2004). Although, there is evidence to support vegetarian mothers have more desirable breastfeeding patterns, which means vegan and vegetarian women breastfeed children longer, on average, than their meat-eating counterparts. Still, breastfeeding while on this diet can be cause for concern if done improperly (Pawlack, Ding and Savyanhadi, 2015).

Children. The vegetarian or vegan diet can be appropriate and nutritionally adequate for a child, but there are numerous variables to consider when deciding if this diet should be consumed regularly by children (Jacobs and Dwyer, 1988). The stricter the plan, the harder it is for a child to maintain a nutritional, well-balanced vegetarian diet

(MacLean and Graham, 1980). The lacto-vegetarian diet and lacto-ovo vegetarian diet are the safest and healthiest vegetarian option for children (Jacobs and Dwyer, 1988). Still, the vegetarian diet, no matter which type, comes with a risk of deficiency for children, just as it does for adults. These deficiencies include Vitamin D, B12 and iron. However, this diet can help children to maintain an appropriate weight and cholesterol level throughout childhood and into adulthood (Dwyer, Dietz, Andrews and Suskind, 1982).

Vegan diets in children come with more risks than vegetarianism (Craig and

Mangels, 2009; EBSCO CAM Review Board, 2016; Marsh, Zeuschner, and Saunders,

2012; Dwyer, Dietz, Andrews and Suskind, 1982). Vegan children have higher protein needs than children who consume animal products due to the absorption rates and digestibility of plant-based protein sources, but this can easily be compensated for with more plant-based protein. Vegan children also tend to have lower B12 levels than vegetarians, which can be treated with supplementation (Craig and Mangels, 2009;

EBSCO CAM Review Board, 2016; Marsh, Zeuschner, and Saunders, 2012). Similarly, iron, Vitamin D and calcium deficiencies might be more prominent when following a strict vegan diet as opposed to a vegetarian diet (Dwyer, Dietz, Andrews and Suskind,

1982).

Teenagers can also be at risk when following a vegetarian diet. The nutritional concerns are the same for teenagers as they are for younger children (Bas, Karabudak and

Kiziltan, 2005). Although there could be a possibility for weight inconsistency during this time, the vegetarian diet does not significantly impact height or weight for a teenager.

Teenagers who consume meat are of similar heights and weights to those who consume vegetarian diets and most vegetarian teenagers maintain a normal weight for their height and age. Nevertheless, vegetarian or vegan teenagers are more likely to display disordered eating behaviors than teenagers who consume an omnivore diet (Bas,

Karabudak and Kiziltan, 2005).

Eating Behaviors of Vegetarians

There is evidence to suggest that practicing a vegetarian lifestyle can lead to disordered eating patterns (Robinson-O'Brien, Perry, Wall, Story and Neumark-Sztainer,

2009). Surveys and food recalls were distributed in the state of Missouri to males and females between the ages of 15 and 23 years old. Of the participants, four percent of them were vegetarians and ten percent of them were former vegetarians. The remainders were not vegetarian and had never practiced a vegetarian diet. The people who were currently vegetarians had healthier eating behaviors than the other two groups and consumed more fruits, vegetables and had a healthier intake of fat than their counterparts. They were also less likely to be overweight. The former vegetarians were the group that reported to have binge eating behaviors and were most likely to engage in extreme dieting behaviors

(Robinson-O'Brien, Perry, Wall, Story and Neumark-Sztainer, 2009).

Vegetarians who live a sedentary lifestyle while consuming more ready-to-eat foods and processed foods are more likely to become obese due to the high amounts of fats, sugars and salts in these types of foods (Leitzmann, 2014). If a vegetarian is eating within the technical guidelines of vegetarian diet but eating mass amounts of highly processed foods that are calorie dense but lack nutrient density then they could be at risk for diabetes, heart disease and obesity (Leitzmann, 2014). Nutrient deficiencies could arise if the person converting to this diet is uneducated about the proper foods to eat. For example, food such as breads and pastas can either hurt the individual’s nutritional status or better it. If they are consuming white breads that are highly processed instead of whole grain bread they would be consuming less fiber as well as less nutrients since this process causes the loss of nutrients (Leitzmann, 2014).

Reasoning for Practicing a Vegetarian Diet

The main reasons for a person to consume a vegetarian diet are due to environmental issues, health concerns, animal welfare, economical issues, ethical issues, world hunger concerns and religious concerns (Craig and Mangels, 2009). While these are all possible considerations the most highly documented are ethical and environmental concerns as well as, religion and philosophical issues (Murphy, 2002; Harvard Women’s

Health Watch, 1996). Awareness of vegetarianism is growing and more people are interested in the various reasons for becoming a vegetarian. One group of reasons people want to convert to this lifestyle is for ethical, moral, religious and spiritual reasons. There are many people who do not want animal suffering to continue to benefit someone’s

appetite and many people are supporting organic farming for animals. Ecologic, economic and political reasons are also increasing because people do not want to continue to lessen the life of the planet or contribute to global climate change.

Additionally, people want food waste to be kept to a minimum and vegetarianism can help to reach that goal. People also practice this diet for health reasons and hygienic reasons which are currently the most popular reasons for practicing this lifestyle

(Leitzmann, 2014; Marsh, Zeuschner, and Saunders, 2012). If people have the option to avoid diseases through a nutrient dense diet, like vegetarianism, they tend to prefer that option to living with life-long health concerns. Lastly, there are people who practice this diet for sustainability reasons because they want future generations to have the ability to live a high quality life (Leitzmann, 2014).

Many people experience an internal conflict with meat consumption and animal welfare. This conflict is called the “meat-paradox” (Piazza et al., 2015), which applies to a person or people who feel badly for animals and the suffering they go through to be slaughtered for food but, at the same time, they enjoy eating meat. People are forced to pick a side of this conflict and since eating meat is more popular, it is the side that is more commonly adapted. Since meat eating is the norm in most societies, it is also common for vegetarians to be conceived as admirable for their moral decision while also perceived as a threat to meat eaters who feel they have to defend their choice to continue consuming meat (Piazza et al., 2015).

There are three reasons that are used to justify meat consumption, known as the three N’s: natural, normal and necessary (Piazza et al., 2015). People argue that meat consumption is natural because we are biologically set up to be able to consume meat, we crave meat and we, as humans, have evolved to be able to eat meat. Normalcy is argued because it is what the majority of civilized societies participate in and it is expected of us to consume meat. Lastly, meat being a necessity is argued because people feel we need meat for survival and it makes people stronger and fully healthier, meaning a healthy diet needs to include meat to be complete. There is a possible fourth “N” that has been debated, and that is “nice” which helps to justify meat consumption because it is enjoyable for people and people like the way it tastes (Piazza et al., 2015). Piazza et al. found that the four N’s accounted for 83% of college students justification for meat eating, with “necessary” being the highest at 42% and “normal” being the lowest at 10%.

The students had the option to write in any responses they wanted because the survey was open-ended. The remaining responses that were not the four N’s, consisted of “humane slaughter”, religious reasons and sustainability reasons (Piazza et al., 2015).

Individuals’ morals and how they connected to meat consumption was evaluated and 93% of participants were found to be meat eaters while the rest were vegetarians, semi-vegetarians or pescaterians (Graça, Calheiros, and Oliveira, 2016). The majority of the participants were college students; they accounted for 60% of the total participants.

The most repeated responses for meat consumption justification included: humans need meat to survive, it keeps a balance in the food chain and in our dietary consumption, the problems associated with meat consumption can be associated with other foods as well

and one person cannot make a difference by discounting meat consumption so there is no reason to stop. People also wrote that if they had to see the animal being slaughtered or had to slaughter the animal themselves they would probably stop eating meat permanently. People also recognized that there are considerable environmental impacts but do not feel it is a reason to stop their consumption. Many participants mentioned that they felt as though there are solid options for meat alternatives out there for those who to choose to practice a vegetarian diet (Graça, Calheiros, and Oliveira, 2016).

Current Trends in Dietary Intake and Behavior in College Students

When looking at the dietary patterns of college students, it was found that their diets lack the intake of fruits, vegetables and dairy while containing an overabundance of fat, sodium, sugar, fast food and snacks (Brunt, Rhee, and Zhong 2008). This population also tends to skip meals and consume sugary drinks frequently while failing to consume a varied diet; instead consumption is similar each day (Brunt, Rhee, and Zhong 2008;

Poobalan, Aucott, Clarke and Smith, 2014). The average fruit and vegetable consumption was two servings of fruits or vegetables per day, which is lower than the recommendation of five servings of each per day (Huang, Harris, Lee, Nazir, Born and Kaur, 2003;

Deshpande, Basil, and Basil, 2009). Fiber consumption was below the recommended value of 20 grams, at less than six grams of fiber on average each day. Over 70% of the students consumed less than the recommended intake for fruits, vegetables and fiber

(Huang, Harris, Lee, Nazir, Born and Kaur, 2003). Typical eating behaviors in the age group of 18-25 year olds were looked at and it was found that 18 and 19 year olds are

more likely to snack than any other age group. No correlation was found between age group and fruit and vegetable consumption. However, the group with the highest intention of eating healthy was the 20-22 year olds (Poobalan, Aucott, Clarke and Smith,

2014).

College students frequently experiment with new things, including their diet.

Vegetarianism and veganism can become appealing options to college students who want to try a different, healthy diet (Smith, Burke and Wing, 2000). Vegetarianism has become more popular over the years. The college students who decided to initiate a vegetarian diet during their first year of college had various reasons, the main ones being health, a disinterest in meat and meat products or animal welfare. Some students started this diet with a mixture of these reasons in mind while some chose this diet for one specific reason, but 62% of the students who had initiated this diet remained on it for at least a year. However, it was found that most students who initiated the diet did not follow vegetarianism strictly and instead kept a semi-vegetarian diet. Of the 62% of students who followed the diet for at least a year, 64% of them started eating meat again. Most of them missed the taste of meat, but a handful of others stopped because they felt it was inconvenient and nutritionally inadequate (Smith, Burke and Wing, 2000).

Lifestyle Behaviors in College Students

College students were evaluated for their behavior patterns in relation to food and lifestyle choices over the course of various studies (Huang, Harris, Lee, Nazir, Born and

Kaur, 2003; Deshpande, Basil, and Basil, 2009; Brunt, Rhee and Zhong, 2008). Among

the college students tested, 15% were currently dieting. Within the last three days of the study being conducted, 40% of the students had consumed alcohol and 14% of them had smoked. In regards to food consumption, 95% of the students consumed at least two servings of sweets or high fat foods, 33% of people consumed less than one serving of fruits or vegetables, while nine percent of people consumed less than one serving of grains (Huang, Harris, Lee, Nazir, Born and Kaur, 2003; Deshpande, Basil, and Basil,

2009; Brunt, Rhee and Zhong, 2008). Seven percent of the college students abstained from meat within the last three days. The obese individuals looked at were more likely to consume pork, lamb or veal than the students with a healthy weight (Brunt, Rhee and

Zhong, 2008).

College students tend to engage in risky behaviors, including dieting, whether good or bad, strenuous physical activity, erratic sleep patterns, tobacco use, alcohol consumption, and unsafe sex (Laska, Pasch, Lust, Story and Ehlinger, 2009). In the age group, 18-25 years, males and females need improvement in healthy diet behaviors and appropriate amounts of physical activity. Most individuals in this age range are consuming little to no fruits or vegetables and too much fast food. It was also found that the higher levels of stress an individual has, the more risky behaviors they take part in, but males are more likely to participate in risky behavior than females are at this age.

Males eat more fast food, smoke more cigarettes, drink more alcohol and participate in risky sexual behaviors more often than females. Males also gain more weight in college than females do (Laska, Pasch, Lust, Story and Ehlinger, 2009).

There is also evidence to suggest that an increase in stress causes greater credit card debt, higher consumption of energy drinks and less sleep during the night (Miller,

2008; Nelson, Lust, Story, Ehlinger, 2008). An increase in energy drink consumption also leads to other risky behaviors such as increased use of marijuana, increased possibility of fighting another person, increased chances of not using a seatbelt in the car and an increase in sexual risks (Miller, 2008). Although males are more likely to participate in risky behaviors, females are more likely to have credit card debt than males. It is worth noting that people who are further along in school tend to have more credit card debt regardless of their gender (Nelson, Lust, Story, Ehlinger, 2008).

Health Concerns for College Students

Obesity is a prominent issue among college students that leads to obese adults so it is critical to educate this population before the transition into adulthood starts (Brunt,

Rhee, and Zhong 2008). Within the college students tested, 35% are overweight or obese.

The individuals who live off campus were more likely to be overweight or obese compared to the students who either lived with their parents or lived on campus (Brunt,

Rhee and Zhong 2008; Deshpande, Basil and Basil, 2009). A sample of individuals, ranging from 18 years to 27 years old, was evaluated to assess the diet of college students. It was found that students who were 20 years or older were more likely to be overweight or obese than students aged 19 or younger (Huang, Harris, Lee, Nazir, Born and Kaur, 2003).

Eating disorders are another prominent issue among college students. In a random sample of college students, it was found that eating disorders are directly correlated to depression, anxiety disorders, self-harm and substance abuse (Eisenberg, Nicklett,

Roeder and Kirz, 2011). Many students let eating disorders go untreated due to the stigma attached to them and the other mental illnesses eating disorders are associated with. Of the college students who get tested for an eating disorder, only ten percent of those individuals will have had treatment and been formally diagnosed. Eating disorders are more prevalent in women and those women are more likely to partake in intense physical exercise and binge drink. Men are the opposite, as they will abstain from drinking and physical activity when battling an eating disorder (Eisenberg, Nicklett, Roeder and Kirz,

2011). Overweight individuals with an eating disorder are more likely to have a fear of bingeing on food, have a greater desire to be thinner and are more likely to participate in extreme diets compared to healthy weight individuals (Desai, Miller, Staples, Bravendar,

2008).

Lastly, mental illness is prevalent on college campuses. In fact, one in three

American undergraduate students are depressed and one in ten undergraduate students are suicidal (Hunt and Eisenberg, 2010). Although, undergraduates are at higher risk for both of these, graduate students also have significant psychological problems (Hunt and

Eisenberg, 2010; Cranford, Eisenberg and Serras, 2009). Undergraduate students in minority races, ethnicities or socioeconomic statuses are at higher risk still for mental illness. Additionally, undergraduate males are at higher risk of suicide, while undergraduate females are at a higher risk for depression (Hefner and Eisenberg, 2009;

Cranford, Eisenberg and Serras, 2009). Mental illness is also more prominent in individuals who have been victims of sexual assault and have low social support from family or friends (Hunt and Eisenberg, 2010). Mentally ill individuals have a greater risk of becoming addicted to drugs and alcohol, which is greater in males than in females and is directly related to age; the older the individual gets, the less likely they will binge drink and smoke marijuana (Cranford, Eisenberg and Serras, 2009). Mental illness is on the rise in college students and there has been a significant increase in psychological problems over the years. Untreated mental illnesses are highly prominent and college campuses are working to decrease this prevalence (Hunt and Eisenberg, 2010).

Prevention and Interventions

College campuses, no matter the size or type of programs offered, make many resources centered on educating students about nutrition concerns and health status available. When comparing two-year colleges to four-year universities, both put an emphasis on wellness programs. 65% of the two-year colleges and 79% of the four-year universities had wellness-programs and a recreation center available to all students

(Strand, Egber and Mozumdar, 2010). College campuses not only offer wellness- programs to students, but to facility and staff as well (Kupchella, 2009). Many colleges also offer classes about health sciences, physical activity, health policy, healthcare and the economics of the healthcare system if students chose to take part. Most schools will offer health screening for health concerns related to mental illness and suicide, alcoholism, eating disorders and other issues like sexually transmitted infections, as well.

Additionally, most college campuses are smoke-free to help promote a healthy learning environment and to encourage students to avoid smoking (Kupchella, 2009).

In 2013, a Recreation and Wellness Benchmark Survey was conducted on 38 different colleges and universities in the United States to explore students’ thoughts on and utilization of their campus wellness programs (Forrester, 2014). Of the 33,500 students that participated in this study, 75% said they utilized the wellness programs that were offered at their school and of those students, 80% of them used these programs at least once a week. The recreation center was the most utilized resource of all the programs and wellness opportunities provided, and 90% of the students that went to the recreation center would stay for at least 30 minutes each visit. Students stated that all the programs offered gave them a sense of wellbeing and felt they improved their overall health status, fitness level, time management skills, academic performance and ability to develop friendships. In fact, the main reason people participated in the wellness programs was to meet new people. Other common reasons included having fun, relieving stress and improving their health (Forrester, 2014).

Despite the positive student response, there are ways college campuses can improve upon their wellness programs. For example, colleges could offer more nutrition and physical education courses in the curriculum and should consider making these classes mandatory for all students who attend the school (Centers for Disease Control,

2013). Campuses could also try to make these programs more accessible to students who want to participate. Furthermore, schools should be promoting physical activity more

prominently, such as endorsing walking to school if the student lives under a certain mileage from the campus. They could also increase the opportunities for clubs and intermural sports by making them more abundant. Finally, colleges can improve on the dining options offered by making the food choices in dinning halls more appealing and nutritionally adequate for students, as well as making healthier foods more accessible by offering them in vending machines around the campus (Centers for Disease Control,

2013).

Many different types of interventions have been explored to help college students make sound eating decisions, such as wellness promotion classes, education seminars or long health programs, behavior change courses and weight management lessons

(Plotnikoff et al., 2015). When these methods were conducted on college students, these interventions, in combination with each other, helped 50% of the people decrease fat and calorie intake, as well as increase fruit, vegetable and whole grain consumption. This is the demographic that is most susceptible to change and the professional world should continue to work with this population to make health choices particularly since dietary habits from the first year or two of college are likely to carry over into adulthood if gone untreated (Plotnikoff et al., 2015; Deshpande, Basil and Basil, 2009; Poobalan, Aucott,

Clarke and Smith, 2014). The students who participated in the interventions, not only learned the tools for practicing a healthier diet, but also were happy with the results and their increase in diet quality (Plotnikoff et al., 2015).

While looking at diet behaviors in students transiting from childhood to adulthood, education of nutrition concepts were evaluated. This population, aged 18-25, are college students or recent college graduates transiting into adulthood and living an independent lifestyle (Poobalan, Aucott, Clarke and Smith, 2014). The use of the “5-a- day” campaign was looked at to assess this age groups feeling toward the campaign. The

“5-a-day” campaign spread knowledge regarding the recommended fruit and vegetable intake of five servings per day. Of the people evaluated, 85% had a positive attitude toward the education platform and felt it was healthy and 75% of the participants felt it was a clever teaching tool (Poobalan, Aucott, Clarke and Smith, 2014).

Current Nutrition Knowledge in Men and Women College Students

The food college students select in their young adult life is important for their long term health (Barzegari, Ebrahimi, Azizi and Ranjbar, 2011; Deshpande, Basil and

Basil, 2009). A strong foundation of nutrition knowledge allows students to make appropriate nutrition decisions in a time in their life where they are becoming independent from their parents or guardians (Barzegari, Ebrahimi, Azizi and Ranjbar,

2011; Deshpande, Basil and Basil, 2009). There is lack of in-depth nutrition knowledge, in general, for college students, which causes them to look elsewhere for information from inappropriate sources, such as television shows and social media platforms, that could possibly be giving them wrong information (Poobalan, Aucott, Clarke and Smith,

2014). It is also important to consider each diseased state when dispensing nutrition information because tips for keeping a healthy diet are not the same for a diabetic person

versus the general public. (Barzegari, Ebrahimi, Azizi and Ranjbar, 2011; Deshpande,

Basil and Basil, 2009; Poobalan, Aucott, Clarke and Smith, 2014).

While assessing the factors that affect student’s decisions when choosing food, most of them said that taste is the most important consideration followed by cost, nutrition, convenience, pleasure and weight control (Deshpande, Basil and Basil, 2009;

Piazza et al., 2015). It was found that students are more likely to be influenced by barriers keeping them from eating healthy than the benefits of a healthy diet. Meaning, the price or availability of foods are the dominant reasons people are not eating healthy, which results in the benefits of a healthy diet being discounted. The barriers are outweighing the benefits for the college population (Deshpande, Basil and Basil, 2009).

There are many barriers that can prevent young adults, ages 18-25, from eating a healthy, well-balanced diet and following an exercise plan on a regular basis (Nelson,

Story, Larson, Neumark-Sztainer and Lytle, 2008; Silliman, Rodas-Fortier and Neyman,

2004; Greaney et al., 2009). The most frequently reported barriers include long-term high stress, poor sleeping habits and lack of time management skills (Nelson, Story, Larson,

Neumark-Sztainer and Lytle, 2008). Specifically, students barriers to eating healthy include a lack of time in their schedule, lack of money, taste preferences, lack of motivation, inconvenience, not caring enough to eat healthy and having to eat at the school cafeteria (Silliman, Rodas-Fortier and Neyman, 2004). The most common barriers included having a lack of time and preferring the taste of unhealthy foods. A lack of time was the most common answer among women, while men’s most common answer was

that they did not care to eat healthy. Also, students most popular barriers to exercising included a lack of time, a lack of motivation, a lack of willpower and a lack of interest in exercising. There was no difference in responses for barriers to exercising between males and females (Silliman, Rodas-Fortier and Neyman, 2004). Male and female college students also experience barriers when trying to maintain their weight. These barriers were predominantly due to lack of discipline, but also included temptations, social situations, time restraints and the convenience of fast foods (Greaney et al., 2009).

When looking at nutrition knowledge of college students, the attitudes and behaviors toward nutrition and education were assessed. Knowledge was found to be higher in males compared to females within this college population (Barzegari, Ebrahimi,

Azizi and Ranjbar, 2011). Amongst these individuals, only two percent had formal nutrition education, while the remaining population had never had any and only obtained information from media sources. Although most of these individuals lacked education, they were enthusiastic about the prospect of education and had a positive attitude toward receiving formal nutrition information. Of the total individuals surveyed, 63% of them said the lack of awareness of nutrition was due to a lack of distributed information from reputable sources. This lack of awareness in individuals can cause a high consumption of calorie dense foods that are low in nutrients. Nutrition knowledge has a direct relation to dietary intake within college students. Hwang and Cranage show that individuals aware of the nutritional value, or lack thereof, in fast food have a higher level of nutrition knowledge in general (2015; Barzegari, Ebrahimi, Azizi and Ranjbar, 2011). The

correlation found between college students who consume fast food on a weekly basis and have a shortage of nutrition knowledge was significant (Hwang and Cranage, 2015).

In regard to nutrition knowledge among age groups, postgraduates had a higher level of understanding of nutrition (Poobalan, Aucott, Clarke and Smith, 2014). College students with a nutrition related major had an even stronger foundation of healthy eating patterns, as well as regular meal patterns and adequate intake of fruits and vegetables

(Poobalan, Aucott, Clarke and Smith, 2014). To increase nutrition education in college students with a limited nutrition background, focus groups were tested and the impact focus groups have on nutrition knowledge was evaluated (Barzegari, Ebrahimi, Azizi and

Ranjbar, 2011). The focus groups looked at diet behaviors and the influences of these behaviors, knowledge, sources of information, attitude and readiness to change behaviors.

Most people felt they needed the nutrition knowledge now more than ever because their eating habits started to decline when they became independent and responsible for their own eating habits. Individuals with an interest in further education want most of their information in the form of a brochure or a hand-out with the next preferred form of delivery being the news on the T.V. or radio shows (Barzegari, Ebrahimi, Azizi and

Ranjbar, 2011; Poobalan, Aucott, Clarke and Smith, 2014). These classes made people realize that there is limited access to accurate nutrition information but they also feel that too much education can cause people to feel overwhelmed and think their nutrition goals are unattainable. They also stated that there is too much misinformation in the media and they would be happy to see more information readily available (Poobalan, Aucott, Clarke and Smith, 2014). Those individuals who had basic nutrition education were more likely

to crave fruits and vegetables and avoid high fat foods. These individuals were also more likely to go to a sit-down restaurant than a fast-food restaurant. Overall, it was found that individuals with a strong background in nutrition education ad a higher awareness of health and were more health conscious individuals (Hwang and Cranage, 2015; Poobalan,

Aucott, Clarke and Smith, 2014).

Current Perception of Vegetarian Diets in Men and Women

In the 1980s, vegetarianism was not easily accepted by society (Ruby, 2012).

Vegetarians were seen as pacifists, hypochondriacs, drug-users, and weight conscious, liberal people. Attitudes toward vegetarians took a shift in the early 2000s when people practicing vegetarian diets started to be seen in a more positive light. Though people higher in authoritarianism had negative opinions of vegetarians at this time, women displayed an enthusiastic and progressive attitude toward this diet (Corrin, and

Papadopoulos, 2017; Ruby, 2012). Omnivores generally started to see vegetarians as good people, while vegans were having an issue with vegetarian’s moral inconsistencies because they questioned why they couldn’t eat meat for moral reasons but still consumed dairy and eggs without concerns. Still, many people felt vegetarians were moral people but often felt threatened and would react by calling them weak for not eating meat (Ruby,

2012). Even though attitudes used to be negative, there seems to have been in shift through the years.

Generally, vegetarianism seems to be perceived in a positive way but people who consume meat have a hard time understanding why people would make the transition

from an omnivore diet to a vegetarian diet (Corrin, and Papadopoulos, 2017; Ruby,

2012). Perception was looked at by Corrin and Papadopoulos and it was found that meat eaters cannot understand vegetarianism due to the enjoyment they get from eating meat

(2017; Piazza et al., 2015). Some of the biggest barriers people expressed were health concerns related to a vegetarian diet and unwillingness to change their dietary habits.

Most people have concerns about getting adequate protein, zinc, iron and B-vitamins even though there are ways to consume adequate amounts of all these nutrients in a vegetarian diet. There is a lack of education in this area, so people feel vegetarianism can be dangerous. Marketplaces perceive vegetarianism negatively because they feel that, even though they account for a small portion of the population, they contribute to lost sales since meat is a top selling, high priced item. Most people do not have an intention of practicing a vegetarian diet because meat consumption is a regular occurrence and it would be too hard to steer away from it (Corrin, and Papadopoulos, 2017; Ruby, 2012).

People feel there is a stigma attached to meat alternatives, which influences their desire to continue eating meat and meat dishes (Hoek, Luning, Weijzen, Engels, Kok and

Graaf, 2011; Ligia María, José Andrés and Marianela, 2013). People feel that vegetarian

“meat” options are unattractive and unfamiliar, which means the likelihood of omnivores consuming these products are limited (Hoek, Luning, Weijzen, Engels, Kok and Graaf,

2011; Ligia María, José Andrés and Marianela, 2013). People are more likely to avoid trying new foods than they are to go out of their way to taste something new. Since meat alternatives are not widely used, people tend to have a disinterest. They also feel that the

meat alternative is usually unrecognizable because it does not resemble the meat dish it is replacing (Hoek, Luning, Weijzen, Engels, Kok and Graaf, 2011).

In this society, meat is usually associated with the center of a meal and is typically used as the dominant food in a dish or meal (Ligia María, José Andrés and Marianela,

2013; Ruby, 2012). Even looking at vegetarian meals, they are usually presented as meat and marketed as a meat alternative instead of a vegetable based dish, but vegetarianism has become increasingly acceptable in today’s society. Meat is seen as a symbol of power and dominance and is usually associated with masculinity, while vegetables and salads are linked to femininity. After testing college student’s association with meat, men and women used words like protein, delicious, beef and energy whereas vegetarian diets are associated with fruits, vegetables, lettuce, health, thinness, weak and extremist. When these questions were answered, women were more likely to be more descriptive with their words like lettuce while men had more abstract answers like vegetables. The word health was associated with the words fruit and vegetables, energy, meat and balance by both men and women participants (Ligia María, José Andrés and Marianela, 2013; Hoek,

Luning, Weijzen, Engels, Kok and Graaf, 2011; Ruby, 2012).

Thomas conducted a study regarding masculinity and vegetarianism (2016) since awareness of the theory that food consumption of any kind directly corresponds how a person is perceived has increased. This can include perception of moral issues, likeability and gender. The idea of masculinity and its relation to eating meat was tested. It was

found that men who consume a vegetarian diet are perceived to be less masculine compared to men who consume an omnivore diet (Thomas, 2016; Ruby, 2012).

Masculinity’s correlation with vegetarian diets has been tested multiple times by many different researchers. This correlation was looked at by Browarnik in 2012, where it was found that male vegetarians seem to be implemented into society but people did not always accept this in a positive way. Male vegetarians are more likely to be discriminated against when compared with their gender counterpart (Browarnik, 2012).

This theory was tested again by Rothgerber; where a correlation was seen between males being more likely to endorse a pro-meat attitude by justifying his meat consumption with hierarchy logic, religion, health reasons and human destiny theories (2013). Females were found to be more likely to dissociate with the animal she was going to consume by avoiding thinking about where meat comes from and the process of how it gets to her plate. They also were less likely to justify their eating habits compared to men because they want to think about it less. Males consumed more beef, chicken and pork than women, while females were more likely to consume a vegetarian meal than men

(Rothgerber, 2013).

Gender Difference in Dietary Intake and Behavior

Eating behaviors can be very different between men and women. There is evidence to suggest that female college students eat more high-fat foods than men do

(Deshpande, Basil and Basil, 2009). While protein consumption is more prominent in men, fruit and vegetable consumption seems to be equal among men and women, alike

(Deshpande, Basil and Basil, 2009; Poobalan, Aucott, Clarke and Smith, 2014). Men’s eating habits seem to be more influenced by peers, friends and the taste of the food whereas women are more influenced by the nutritional content of a food item and are motivated by weight concerns and the prices of foods. Although both men and women had a high intention to eat healthier, women’s is higher than that of men (Deshpande,

Basil and Basil, 2009).

An assessment was done on nutrition knowledge and diet behavior of college students (Poobalan, Aucott, Clarke and Smith, 2014). It was found that males were more likely to snack throughout the day compared to females. Males were also more likely to have irregular eating habits. Females had more of a positive attitude to national nutrition campaigns, such as the “5-a-day” campaign for fruits and vegetables (Poobalan, Aucott,

Clarke and Smith, 2014).

While looking at gender differences in dietary intake, Dunhagan explored consumption patterns in each gender and found that women are less likely to consume sugary beverages, including soda and iced teas (2003). Women consumed more carrots, salad, greens and fruit or vegetable juice, in addition to whole fruits when compared to men (Dunhagan, 2003; Blanck, Gillespie, Kimmons, Seymour and Serdula, 2008). Men consistently ate more potatoes and milk while women consumed more fiber rich foods.

Women were less likely to purchase super-sized portions than men and they also consumed more meals from home whereas men ate out more frequently (Dunhagan,

2003).

Men and women view meat differently and interact with meat in different ways, so the expectation is for both genders to feel differently about vegetarianism and have different meat consumption patterns (Ruby, 2012). Men seem to know less about the nutritional value of food, including meats and consume a higher intake of calories and eat less fruits and vegetables. Because of this, men have a more positive attitude toward meat consumption while women support animal rights more frequently and are less likely to support the use of animals for food and consume less red meat. Women perceive healthy, vegetarian meals as full of nutrients, pleasurable and convenient where men share a stronger connection to animal foods (Ruby, 2012).

CHAPTER III

METHODOLOGY

Overview

The purpose of this study was to determine the nutrition knowledge and perception of vegetarian diets between male and female vegetarian and non-vegetarian undergraduate college students at a Midwestern University. Data collection was executed with an electronic questionnaire sent via e-mail (Appendix A and B) that contained questions relating to perception and nutrition knowledge of a vegetarian diet. The independent variables of this study included gender and diet, while the dependent variables were nutrition knowledge and perception of vegetarian diets. This research was approved by the Institutional Review Board (IRB) at Kent State University.

Participants

The sample consisted of undergraduate college students at Kent State University enrolled in courses for the spring 2018 semester which equated to a total of 20,331 students being eligible for recruitment. Participants were either part-time or full-time status. The participants included males and females, as well as vegetarians and non- vegetarians, at all class levels, from freshman to senior level status. The sample was limited to undergraduate college students only to avoid the higher level of nutrition knowledge a graduate student might have had. Participants were of any ethnicity, age and major, as well as in any living situation, including living alone, with roommates, a

55 56

spouse, parents or living in a dorm room on campus. The sample was restricted to Kent

State’s Main Campus for the purpose of uniformity and similar locality of the individuals.

Anyone under the age of 18 years old was also excluded from participating in the survey.

Instrumentation

Data was collected with the use of a survey composed of demographic and nutrition knowledge questions, as well as questions regarding perception of vegetarianism (Appendix A). The survey was the only instrument used for this study.

This form of data collection was approved by the Kent State University Institutional

Review Board.

Survey Development

The questions in this survey were created with the help of former surveys used to do research on perception of vegetarianism and nutrition knowledge. Questions from each source were reworked to fit the purpose and content of this study. For questions regarding perception of vegetarianism, a study (Pribis, Pencak, and Grajales, 2010) that examined people’s reasoning behind choosing a vegetarian diet and the difference in beliefs and attitudes among generations helped shape the measurement of this data

(Appendix D). This study was conducted at a Seventh-day Adventist higher learning institution. The objective of the study was to find out if vegetarians’ reasons for practicing the vegetarian diet would change with age. One limitation of this study was the use of a population almost solely comprised of Seventh-day Adventists, who usually

practice a vegetarian diet for religious reasons. As such, religion was eliminated from the survey as a response (Pribis, Pencak, and Grajales, 2010).

The survey consists of four parts (Pribis, Pencak, and Grajales, 2010). The first part includes eleven questions about demographics. Part two is a food frequency questionnaire, consisting of a list of food items and a chart to fill in regarding how often the individual consumes each item. The third part of the survey is related to use of herbs and supplements. The fourth and final part of the survey involves nutrition and lifestyle questions, as well as various perception questions (Pribis, Pencak, and Grajales, 2010).

The other survey used for this study consisted of questions about general nutrition knowledge (Miracle, 2017). This survey was originally designed for the use of athletes and studies pertaining to college athletes, but was easily adjusted for more general use

(Appendix E). The survey is comprised of 40 questions in total and does not contain different sections. These questions are related to knowledge only and have three possible answers: agree, disagree and don’t know (Miracle, 2017).

Survey Components

Permission was received at the time of survey development from both authors.

Both surveys, from previously validated sources, were evaluated and then adapted to fit the needs of this study. The final result yielded 14 total questions that were created using

Qualtrics, an online survey program available to the public. The first section, Part I, consisted of demographics, such as age, gender, ethnicity, living status and class level.

This section also solicited information on the type of diet consumed, whether the

participant was a nutrition major at the time, and any additional formal nutrition education the participant had received at the collegiate level. The next set of questions,

Part II of the survey, asked for information regarding people’s perceptions of vegetarianism and other health related topics. Part III, the final section of the survey, centered on general nutrition knowledge (Appendix A).

Part I: demographics. Part I of the survey included a total of 11 questions regarding the demographics of the responding individual. The first of the 11 questions asked if the individual was 18 years of age or older and consented to participating in the study (Appendix C). If the individual answered “no” to being 18 years old or did not want to give consent to the study, the survey was terminated. They were immediately taken to the end and were not shown any further questions. The next question asked the individual about their status as a student. If the person stated they were an undergraduate the survey continued on to the next question, and if the person stated they were a graduate student, the survey was discontinued. Next were questions regarding gender, age, race and ethnicity, living status and student level, such as if the individual was a freshman, sophomore, junior or senior level student. Additionally, students were asked if they had ever completed a college level nutrition course and if they were currently a nutrition major (Appendix A).

Lastly, they were asked what foods they avoid and how long they had been following that particular diet. Within the context of this study, a vegetarian is defined as someone who checked off (in question 10 of the survey) that they “restrict or avoid”

poultry, red meat and seafood in their diet (Appendix A). All three of these responses had to be checked for the participant to be classified as a person currently practicing a vegetarian diet. Data collected from this section was analyzed using descriptive statistics, including means, standard deviations and frequencies.

Part II: perceptions toward vegetarianism. Part II of the survey included perception questions regarding nutrition and vegetarianism. The participants were prompted to indicate the extent to which they agreed or disagreed with the following statements by selecting an answer using a five point Likert-style scale. This scale was followed by an individual statement made about nutrition and/or vegetarianism. The scale ranged from (1) “Strongly agree” to (5) “Strongly disagree” with (3) indicating the individual had “no opinion” on the matter. Within this question, there were 31 statements total for the individual to answer at their own discretion.

Part III: general nutrition knowledge. Part III of the survey included nutrition knowledge questions. Participants were prompted to choose the option they felt best answered the statement. They had three options to choose from, including “agree”,

“disagree” and “I don’t know”. There were 39 statements to answer within this section.

The last question, both of the section and the survey as a whole, was to be answered using one of the three options: “Carbohydrates”, “Protein” and “Fat” (Appendix A); equaling a total of 40statements for the participants to answer within this section.

Data Collection Procedures

Upon IRB approval, the Kent State University’s Main Campus undergraduate students were recruited through their university e-mail which included an attachment of the survey, an explanation of the survey, why the survey was being conducted and the individual’s rights as a participant (Appendix B). E-mails were obtained through Kent

State University’s Registrar Office after approval from the IRB had been achieved. The survey was e-mailed to a total of 20,331 students using Qualtrics’s e-mailing system

(Appendix B). No compensation or incentive was provided for their participation.

Therefore, a convenience sample was utilized. Students were given four weeks total or 29 consecutive days to complete the survey, with one e-mail reminder at the end of the second week. This e-mail was sent on the 15th day of data collection.

Responses were collected through the electronic survey system, Qualtrics, of which the 2018 version was used. Difficulties were minimized through clearly written questions and simple instructions. Participants were also given a letter of consent to read so they understood their rights (Appendix C). The survey could have been started at any time and taken on any device that allows internet access. Some limitations could have occurred with the self-reported data: the participant could have taken the survey with another person, answered dishonestly or answered the questions from another individual’s point of view. Another issue with this data collection procedure was the possibility of participants being tempted to look up answers on the internet for the

nutrition knowledge questions. This was mitigated through anonymity and this survey having no bearing on the student’s grades.

Data Analysis Procedures

The data collected from the survey was organized and prepared for analysis. SPSS version number 24 was used to run statistical analyses. Analysis was conducted using descriptive statistics in regard to the demographics sections to find means, standard deviations and frequencies within that set of data. Analysis of perception and knowledge was conducted using a two by two factorial ANOVA design, with the two factors being the dependent variables, gender (with the levels being female and male) and diet (with the levels being vegetarian and non-vegetarian). p< 0.05 was considered statistically significant.

The perception questions were scored by coding the Likert-style scale using a 5 point scale, where strongly disagree was coded for as "1" and strongly agree as "5". The number or code "1" was equivalent to a negative perception and "5” was equivalent to a positive perception. If the person answered "1” or “disagree" to the following statements:

1, 3, 6, 10, 12, 16, 17, 19, 20, 21, 23, 24, 25, 26, 29 and 31, it would mean the person had a negative perception in regards to those individual statements. If the person answered

"1” or “disagree" to the following statements: 2, 4, 7, 8, 9, 13, 14, 18, 22, 27 and 28, it would mean the person had a positive perception in regards to those individual statements(Appendix A). Excluded from the scoring process were questions 5, 11, 15 and

30. These required responders to provide reasons they think someone chooses to be a

vegetarian and are related to individual beliefs as opposed to someone’s perceptions of the vegetarian diet. This resulted in 27 total perception questions scored.

For the nutrition knowledge questions, individuals who answered with “I don’t know” were considered to answer incorrectly and the response was marked as wrong.

This section was scored using an answer key, with answers to all 40 statements that had been obtained through the original author of the survey. Questions one through 31 were scored according to the person’s correct or incorrect answer, while questions 32-40 were behavior related questions and, therefore, reported as frequencies.

CHAPTER IV

JOURNAL ARTICLE

Introduction

The vegetarian diet is typically seen as one that excludes the consumption of meat and meat products, including fowl and seafood (Craig and Mangels, 2009). This type of diet is a healthy alternative to the omnivore diet if well-planned and balanced with the appropriate nutrients (Marsh, Zeuschner and Saunders, 2012). More and more people are considering this option, with four percent of the U.S. population practicing it. Currently, this diet is most common in college students aged 20-29 years old (Leitzman, 2014;

Haddad and Tanzman, 2003). It is of utmost importance that an individual considering a vegetarian diet is well-informed and has all the appropriate knowledge needed to execute it in a positive and healthful way (Murphy 2002; Harvard Women’s Health Watch, 1996).

Therefore, it is valuable to introduce the information while the students are in college so the individual can reap enhanced benefits (Olrich et al., 2013).

The vegetarian diet positively impacts health by improving the symptoms of chronic diseases, like cardiovascular disease or diabetes (Craig and Mangels, 2009;

Olrich et al, 2013; Marsh, Zeuschner, and Saunders, 2012; McEvoy, Temple, and

Woodside, 2012; Harvard Medical School, 2004; Singh et al., 2014). This type of diet can even go so far as to decrease mortality rates related to chronic illnesses (Olrich et al.,

2013; Marsh, Zeuschner, and Saunders, 2012; McEvoy, Temple, and Woodside, 2012).

Decreased mortality rates are more significant in individuals who have practiced this diet

63 64

for a long duration, so it is in a person’s best interest to have knowledge of this diet from a young age, such as while they are in college and likely establishing new eating patterns

(Olrich et al., 2013).

The college student population has a very unique set of dietary habits (Brunt,

Rhee and Zhong, 2008). Their diets typically lack variety and have a high concentration of unhealthy foods, such as those that are calorie-dense and high in sugar (Huang, Harris,

Lee, Nazir, Bron and Kaur, 2003). Fruit and vegetable intake is also very low considering the recommended amounts (Brunt, Rhee and Zhong, 2008; Haddad and Tanzman, 2003;

Huang, Harris, Lee, Nazir, Bron and Kaur, 2003). Research shows that college student’s typical eating habits do not meet their nutritional needs.

Both men and women college students perceive healthy eating to include meat consumption. Vegetarianism is associated with thinness and weakness and is seen as an extreme option with respects to eating healthy (Rothgerber, 2013; Ligia María, José

Andrés and Marianela, 2013; Hoek, Luning, Weijzen, Engels, Kok and Graaf, 2011;

Ruby, 2012). However, females tend to view vegetarianism more positively than males.

In addition to negative perceptions toward vegetarianism, college students appear to have the least amount of nutrition knowledge among all age groups studied, lacking familiarity with healthy eating behavior, nutrition requirements for their own body types and the way their body utilizes energy (Cousineau, Franko, Ciccazzo, Goldstein and Rosenthal, 2006).

This stems from undergraduate college students lacking in formal nutrition education

(Poobalan, Aucoff, Clarke and Smith, 2014; Barzegari, Ebrahimi, Azizi and Ranjbar,

2011). The perceptions of vegetarianism and nutrition knowledge of these individuals should be further evaluated since a strong foundation of nutrition knowledge and an open and positive attitude toward a healthy diet, such as vegetarianism, can lead to regular meal patterns, an adequate intake of macronutrients and limited consumption of sodium, sugar and fast food (Poobalan, Aucoff, Clarke and Smith, 2014; McEvoy, Temple and

Woodside, 2012).

The vegetarian diet is a practical option for college students to practice (Brunt,

Rhee and Zhong, 2008; Ligia María, José Andrés and Marianela, 2013). It can provide all nutrients a student needs and can help them live a longer life free of chronic illness, especially if established early in life. However, many college students are not taking advantage of this diet option due to their knowledge deficit and negative attitudes (Ligia

María, José Andrés and Marianela, 2013; McEvoy, Temple and Woodside, 2012; Brunt,

Rhee and Zhong, 2008; Cousineau, Franko, Ciccazzo, Goldstein and Rosenthal, 2006).

Even college students willing to practice this diet do not have the appropriate knowledge to execute it healthfully (Smith, Burke and Wing, 2000). With the vegetarian diet’s increasing popularity and exposure, it is becoming more accessible to students and resulting in a greater need for individuals to have an adequate understanding of this diet.

Further input regarding students’ perceptions and knowledge can help assist in the creation of ways to reach this population and discredit the misleading information about vegetarian diets that is currently circulating. Therefore, the primary purpose of this study was to determine the nutrition knowledge and perception of vegetarian diets between

male and female vegetarian and non-vegetarian undergraduate college students at a

Midwestern University.

During this current study, it was hypothesized that there would be differences between nutrition knowledge and perceptions of vegetarianism when comparing gender and diet type. Hypothesis 1 stated there is a difference in nutrition knowledge between male and female college students. Hypothesis 2 stated there is a difference in perception of vegetarian diets between male and female college students. Hypothesis 3 stated there is a difference in nutrition knowledge between vegetarian and non-vegetarian college students. Hypothesis 4 stated there is a difference in perception of vegetarian diets between vegetarian and non-vegetarian college students.

Methodology

Participants were undergraduate college students at Kent State University enrolled in courses for the spring 2018 semester. A convenience sample was utilized. The students could be part-time or full-time status. The goal for this study was to accumulate 200 participants (n=200). The participants included both males and females and vegetarians and non-vegetarians. The sample was limited to undergraduate college students to avoid the higher level of nutrition knowledge a graduate student might have had. Additionally, the sample was restricted to Kent State’s Main Campus for the purpose of uniformity and similar locality of the individuals. Anyone under the age of 18 years old or any graduate students were excluded from participating in the survey.

Instrumentation

A survey was created from previously validated surveys to include demographic and nutrition knowledge questions, as well as questions regarding perception of vegetarianism (Appendix A). The use of survey questions was the most appropriate way to collect data on this topic. This is the only instrument that was used for the study. The questions in this survey were created with the help of former surveys used to do research on perception of vegetarianism and nutrition knowledge (Pribis, Pencak, and Grajales,

2010; Miracle, 2017) (Appendix D and E). Questions from each source were reworked to fit the purpose and content of this study. Permission was received at the time of survey development from both authors. The final result yielded 14 total questions.

Part I of the survey was comprised of a total of 11 questions regarding the demographics of the individual answering (Appendix A). This included gender, age, race and ethnicity, living status and student level, level of formal nutrition education, information regarding current diet and the duration of time this diet has been followed.

Part II of the survey focused on perception questions regarding nutrition and vegetarianism (Appendix A). The participants were prompted to indicate the extent to which they agreed or disagreed with the following statements by selecting an answer using a five-point Likert style scale. Within this question, there were 31 statements total for the individual to answer at their own discretion. Part III of the survey included nutrition knowledge questions. The participants were prompted to choose the option they felt best answered the statement and were able to choose from three answers: “agree”,

“disagree” and “I don’t know”. The “I don’t know” responses were scored as incorrect responses. The last statement was to be answered using one of the three options:

“Carbohydrates”, “Protein” and “Fat” (Appendix A). There were 40 statements total in this section, including behavior questions that would not be scored.

Data Collection Procedures

This research was approved by the Institutional Review Board (IRB) at Kent State

University. The Kent State University’s Main Campus undergraduate students were recruited through their university e-mail. The e-mail included the survey attachment, an explanation of the survey, why the survey was being conducted and the individual’s rights as a participant (https://kent.qualtrics.com/jfe/form/SV_cUgyH6Xaw8TliPX)

(Appendix B). E-mails were obtained through Kent State University’s Registrar Office after approval from the IRB had been achieved. The survey was created using the website called Qualtrics, an online program available to the public, and was e-mailed to a total of

20,331 students. No compensation was provided for their participation. Thus a convenience sample was utilized. Students were given four weeks total, or 29 consecutive days, to complete the survey, with one e-mail reminder at the end of the second week; this e-mail was sent on the 15th day of data collection (Appendix B). Responses were collected using version 2018 of Qualtrics. The survey could have been started at any time and participants could have used any device with internet access. There was no incentive for the participant. Limitations of using self-reported data was alleviated through anonymity and this survey having no bearing on the students’ grades.

Data Analysis Procedures

The data collected from the survey was organized, prepared for analysis and ran through version 24 of the Statistical Package for Social Sciences (SPSS). Analysis was conducted using descriptive statistics in regards to the demographics sections to find means, standard deviations and frequencies within that set of data. Analysis of perception and knowledge was conducted using a two by two factorial ANOVA design, with two factors being the dependent variables, gender (with the levels being female and male) and diet (with the levels being vegetarian and non-vegetarian). P < 0.05 was considered statistically significant.

The perception questions were scored by coding for the five-point Likert-style scale, where strongly disagree was coded for as "1" and strongly agree as "5". The number or code "1" was equivalent to a negative perception and "5” was equivalent to a positive perception. Excluded from the scoring process were questions five, 11, 15 and 30 due to these questions being reasons someone chooses to be a vegetarian and were related to individual beliefs as opposed to someone’s perceptions of the vegetarian diet; which resulted in 27 total perception questions scored. The total value for each individual would be evaluated on a scale of 27 to a maximum of 135 with the assumption that a participant completed all 27 questions for scoring. The nutrition knowledge section was scored using an answer key, with answers to all 40 statements that had been obtained through the original author of the survey. Questions one through 31 were scored according to the person’s correct or incorrect answer and questions 32-40 were behavior related questions and therefore were not scored. The knowledge questions were scored out of a maximum

score of 31; one point was given for each correct response and zero points were given for incorrect answers, including the “I don’t know” response.

Results

Of the 20,331 students the survey was sent to, 1,882 students opened and started the survey, resulting in a 9.26% response rate. Students were eliminated from the analysis process if the person was under the age of 18 years old (n=8), did not give consent to participate in the study (n=4) or stated they were a graduate student (n=27). The remaining 1,843 participants continued through the additional two parts of the survey: the perception and nutrition knowledge questions. Additionally, students were eliminated if they did not complete at least 90% of the perception questions and 100% of the knowledge questions. Six hundred and fifty two incomplete survey responses were eliminated due to those guidelines. Based on those criteria, 1,191 participants’ surveys were used for data analysis, equating to a 64.6% completion rate.

Demographics

The demographics data pertaining to the participants of the study are shown in

Table 1. Survey participants’ ages ranged from 18 to 60 years old. The mean age of the sample was 21.34 years old (n= 1191). Additionally, 83% of participants were Caucasian, followed by African American, other, Asian/Pacific Islander, Hispanic and American

Indian/Native American. The majority of participants were freshman, female students living on-campus, who were majoring in something other than nutrition. About two percent of the total participants were nutrition majors. Approximately 30% of participants

reported participation in a college-level nutrition course. More than 18% of participants in this study follow a vegetarian diet, with the majority doing so for longer than five years.

Table 1 Demographics of Undergraduate College Students Surveyed at a Midwestern University on Nutrition Knowledge and Perceptions of the Vegetarian Diet (N=1,191) Demographics % n

Class level

Freshman 30.1 357

Sophomore 19.0 225

Junior 22.5 267

Senior 28.5 338

Gender

Female 80.7 961

Male 19.3 230

Living situation

On campus 39.3 466

Off campus, alone 7.5 89

Off campus with roommates 27.9 331

Off campus with parent/guardian 17.6 209

Off campus with spouse 7.8 92

College nutrition course

Yes 29.0 345

No 71.0 846

Diet

Vegetarian 18.2 217

Non-vegetarian 81.8 974

Perceptions toward Vegetarianism

The results from the assessment regarding perceptions of vegetarianism are displayed in Table 2 and Table 3, with a focus on gender and diet respectively. On a modified five-point Likert style scale, ranging from one (1) “strongly disagree” to five (5)

“strongly agree” with three (3) standing for “no opinion”, participants were able to indicate how they perceived certain concepts. Participants who stated they were female had a significantly higher, positive perception of vegetarianism (p< 0.05) than their male counterparts. Also, participants who indicated they were practicing a vegetarian diet had a significantly more positive perception of vegetarianism (p< 0.05) than participants who were classified as non-vegetarians.

Table 2

Perceptions of Vegetarianism of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Item Gender Mean ±SD % A/SA (n) % NOP (n) % D/SD (n)

“Organic Foods” are better for your health Male 3.01± 1.12 39.1 (90) 24.8 (57) 36.1 (83) because they contain more vitamins, Female 3.35± 1.13 54 (518) 17.9 (172) 28.2 (271) minerals and other important nutrients.

Today foods have so many vitamins added Male 4.07± 0.89* 6.1 (14) 13.5 (31) 80.4 (185) that people don’t have to worry about their Female 4.21± 0.76* 3.2 (31) 8.6 (83) 88.2 (846) nutrition.

It is healthy to eat a handful of nuts daily. Male 4.00± 0.75 81.2 (186) 14.8 (34) 3.9 (9) Female 3.96± 0.79 80 (769) 14.5 (139) 5.5 (53) Vegan lifestyle is extreme. Male 2.50± 1.25 57.4 (132) 17 (39) 25.7 (59) Female 2.96± 1.30 42.7 (410) 17.8 (171) 39.5 (380)

The main reason to choose a vegetarian Male 2.63± 1.19* 27.4 (63) 22.6 (52) 50 (115) lifestyle is that it is wrong to kill animals. Female 2.75± 1.15* 31.2 (299) 18.2 (175) 50.6 (486)

“Health foods” give people more energy Male 3.32± 1.14 50 (115) 23 (53) 27 (62) than “regular foods”. Female 3.61± 1.03 65.3 (627) 15.7 (151) 19 (182)

Table 2 (continued)

Perceptions of Vegetarianism of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Item Gender Mean ±SD % A/SA (n) % NOP (n) % D/SD (n)

Being vegetarian is too complicated in Male 3.70± 1.08* 14.7 (34) 19.6 (45) 65.6 (151) today’s society. Female 3.91± 1.09* 14.9 (143) 11.5 (110) 73.7 (707)

All fat is bad and we should consume as Male 4.44± 0.82* 4.4 (10) 3.9 (9) 91.7 (210) little fat as possible. Female 3.91± 1.09* 3.6 (35) 4.3 (41) 92 (885)

One effective way to lose weight is to eat a Male 3.25± 1.24* 32.6 (75) 19.6 (45) 47.8 (110) lot of protein and eliminate carbohydrates Female 3.12± 1.20* 39.5 (379) 16.8 (161) 43.8 (420) such as pasta and bread.

Vegetarian lifestyle is the healthiest option Male 2.21± 1.10* 15.6 (36) 17.4 (40) 66.9 (154) we have. Female 2.40± 0.99* 16.2 (156) 19.8 (190) 64 (615)

The main reason to choose a vegetarian Male 2.40± 1.10 17 (39) 23 (53) 60 (138) lifestyle is the fact that vegetarians live Female 2.51± 1.01 17.6 (169) 28 (269) 17.6 (169) longer and are less sick.

Flax seeds and fish are good sources of Male 4.09± 0.82 80.9 (186) 16.5 (38) 2.6 (6) omega-3 fatty acids. Female 4.10± 0.73 84.5 (810) 13.2 (127) 2.3 (22)

Vitamin B-12 is only found in foods of Male 3.31± 0.85 12.2 (28) 50.2 (115) 37.6 (86) animal origin. Female 3.36± 0.96 14.4 (138) 41.6 (399) 44 (422)

Milk consumption is the cause of many Male 3.52± 1.07* 16.9 (39) 29.6 (68) 53.5 (123) serious diseases. Female 3.29± 1.10* 23.9 (229) 27.4 (263) 48.7 (468)

The main reason to choose a vegetarian Male 2.80± 1.24* 31.4 (72) 23.6 (54) 45 (103) lifestyle is that it is much more protective Female 3.16± 1.09 40.9 (393) 284 (273) 30.7 (295) against the environment.

Manufactured vitamins are nutritionally Male 2.88± 1.04* 26.5 (61) 38.7 (89) 38.8 (80) inferior to natural vitamins. Female 3.01± 1.00 32.5 (311) 35.5 (340) 32.1 (308)

When I shop I read the food labels and Male 3.46± 1.27 61.7 (142) 10.4 (24) 27.9 (64) search for healthful foods. Female 3.72± 1.17 70.3 (675) 7.9 (76) 21.7 (208)

As long as appropriate weight is Male 4.18± 0.85* 4.4 (10) 6.1 (14) 89.5 (205) maintained a person doesn’t have to worry Female 4.25± 0.81* 5.2 (50) 4.7 (45) 90.1 (866) about nutrition.

Being vegetarian is cool. Male 2.67± 1.20* 20.4 (47) 42.6 (98) 37 (85) Female 3.35± 0.10 39.1 (376) 45.4 (436) 15.6 (149)

There are water-soluble and fat-soluble Male 3.87± 0.86 63.5 (146) 33.9 (78) 2.6 (6) vitamins. Female 3.92±0.78 68.1 (653) 31.1 (289) 0.8 (8)

Soy milk is good for your health. Male 3.13± 0.95 34.5 (79) 45.9 (105) 19.6 (45) Female 3.30± 0.88 43.8 (421) 40.6 (390) 15.6 (150)

Table 2 (continued)

Perceptions of Vegetarianism of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Item Gender Mean ±SD % A/SA (n) % NOP (n) % D/SD (n)

To be vegetarian you must have a strong Male 3.86± 0.99* 9.5 (22) 23.5 (54) 67 (154) personality. Female 3.97± 0.93* 7.9 (76) 17.1 (164) 75 (718)

Vegetable proteins are incomplete sources Male 3.17± 1.11 40.8 (94) 34.8 (80) 24.4 (56) of essential amino acids; thus vegetarians Female 3.07±1.06 35.9 (345) 34.9 (335) 29.1 (280) must be very careful in combining proteins from many sources.

In magazines I usually read the articles Male 2.57± 1.15* 23.9 (55) 25.7 (59) 50.5 (116) about nutrition. Female 2.86± 1.18* 36.7 (352) 18.3 (176) 45.1 (433)

The movie “Supersize Me” clearly Male 3.22± 1.18 46.9 (108) 25.7 (59) 27.4 (63) identified the reason for American Female 3.48± 1.04 55.2 (530) 25.7 (247) 19 (183) epidemic of obesity- fast food.

Nutrition is important and a person Male 4.41± 0.91 90.4 (207) 5.2 (12) 4.4 (10) shouldn’t be careless about it. Female 4.57± 0.63 96.6 (926) 2.3 (22) 1.1 (11)

Parents should not raise their children as Male 3.01± 1.11* 32.2 (74) 33.9 (78) 33.9 (78) vegetarians because of nutritional Female 3.43± 1.12* 22.3 (214) 26.6 (256) 51.1 (491) problems with vegetarian diets.

Most food additives are safe when used Male 3.37± 1.00* 22.2 (51) 30.4 (70) 47.4 (109) according to government regulations. Female 3.59± 0.98* 15.9 (153) 26.3 (252) 57.8 (555)

Vegans need to take a vitamin B-12 Male 3.46± 0.75 43.7 (100) 52.3 (121) 3.5 (8) supplement or use fortified food like soy Female 3.56± 0.84 51.3 (493) 41.5 (399) 7.2 (69) milk.

The main reason to choose a vegetarian Male 2.24± 0.93 3.5 (8) 44.3 (102) 53.2 (120) lifestyle is because it is part Adventist Female 2.35± 0.84 2.8 (27) 49.1 (472) 48.1 (462) beliefs and was recommended by E.G. White.

Excessive meat consumption is causing Male 2.68± 1.43* 33.2 (76) 16.6 (38) 50.3 (115) global warming. Female 3.05± 1.26* 38 (365) 26.6 (255) 35.3 (339) Note. The mean was calculated from a 5-point Likert style scale where one (1) equals “strongly disagree” and five (5) equals “strongly agree”. *The means are presented as flipped scores. Abbreviations. A/SA, agree/strongly agree; NOP, no opinion; D/SD, disagree/strongly disagree; SD, standard deviation; n, number of participants in the survey sample.

Table 3

Perceptions of Vegetarianism of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Item Diet Mean ±SD % A/SA (n) % NOP (n) % D/SD (n)

“Organic Foods” are better for your Non-vegetarian 3.28± 1.13 50.3 (490) 20.3 (198) 29.4 (286) health because they contain more Vegetarian 3.32± 1.17 54.4 (118) 14.3 (31) 31.3 (68) vitamins, minerals and other important nutrients.

Today foods have so many vitamins Non-vegetarian 4.17±0.79* 3.6 (35) 10.9 (106) 85.5 (833) added that people don’t have to Vegetarian 4.27±0.78* 4.6 (10) 3.7 (8) 91.6 (198) worry about their nutrition.

It is healthy to eat a handful of nuts Non-vegetarian 3.93± 0.78 79.4 (772) 15 (146) 5.6 (55) daily. Vegetarian 4.13± 0.77 84.3 (183) 12.4 (27) 3.3 (7)

Vegan lifestyle is extreme. Non-vegetarian 2.62± 1.20 52.1 (508) 19.9 (194) 28 (272) Vegetarian 3.99±1.16* 15.6 (34) 7.4 (16) 76.9 (167)

The main reason to choose a Non-vegetarian 2.62±1.10* 25.8 (251) 20.6 (200) 53.7 (522) vegetarian lifestyle is that it is wrong Vegetarian 3.22± 1.25 51.2 (111) 12.4 (27) 36.4 (79) to kill animals.

“Health foods” give people more Non-vegetarian 3.52± 1.05 61 (594) 17.4 (169) 21.7 (211) energy than “regular foods”. Vegetarian 3.74± 1.07 68.5 (148) 16.2 (35) 15.3 (33)

Being vegetarian is too complicated Non-vegetarian 3.70±1.08* 17.2 (167) 15.7 (153) 67.1 (653) in today’s society. Vegetarian 4.62±0.79* 4.6 (10) 0.9 (2) 94.5 (205)

All fat is bad and we should Non-vegetarian 4.35±0.79* 4 (39) 4.4 (43) 91.6 (891) consume as little fat as possible. Vegetarian 4.44±0.71* 2.8 (6) 3.2 (7) 94.1 (204)

One effective way to lose weight is Non-vegetarian 3.08±1.21* 40.8 (397) 16.6 (162) 42.6 (414) to eat a lot of protein and eliminate Vegetarian 3.46±1.15* 26.3 (57) 20.3 (44) 53.6 (16) carbohydrates such as pasta and bread.

Vegetarian lifestyle is the healthiest Non-vegetarian 2.21±0.93* 10.6 (104) 18.3 (178) 71 (692) option we have. Vegetarian 3.09±1.07 40.6 (88) 24 (52) 35.5 (77)

The main reason to choose a Non-vegetarian 2.35±0.97* 12.4 (120) 27.5 (268) 60.2 (586) vegetarian lifestyle is the fact that Vegetarian 3.08± 1.08 40.5 (88) 24.9 (54) 34.6 (75) vegetarians live longer and are less sick.

Flax seeds and fish are good sources Non-vegetarian 4.13± 0.70 85.2 (829) 13.5 (131) 1.2 (12) of omega-3 fatty acids. Vegetarian 3.94± 0.93 77 (167) 15.7 (34) 7.4 (16)

Table 3 (continued)

Perceptions of Vegetarianism of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Item Diet Mean ±SD % A/SA (n) % NOP (n) % D/SD (n)

Vitamin B-12 is only found in foods Non-vegetarian 3.29± 0.86 12.5 (121) 49 (476) 38.5 (374) of animal origin. Vegetarian 3.61±1.18* 20.7 (45) 17.5 (38) 61.7 (134)

Milk consumption is the cause of Non-vegetarian 3.49±1.00* 16.4 (159) 29.1 (283) 54.6 (531) many serious diseases. Vegetarian 2.61± 1.22 50.2 (109) 22.1 (48) 27.7 (60)

The main reason to choose a Non-vegetarian 2.90±1.06* 31.6 (307) 30.1 (293) 38.5 (373) vegetarian lifestyle is that it is much Vegetarian 3.92± 1.03 72.8 (158) 15.7 (34) 11.5 (25) more protective against the environment.

Manufactured vitamins are Non-vegetarian 2.96± 1.00 30.4 (296) 36.7 (357) 32.8 (319) nutritionally inferior to natural Vegetarian 3.10± 1.06 35.1 (76) 33.2 (72) 31.7 (69) vitamins.

When I shop I read the food labels Non-vegetarian 3.54± 1.21 64.1 (623) 9.5 (92) 26.5 (257) and search for healthful foods. Vegetarian 4.27± 0.86 89.4 (194) 3.7 (8) 6.9 (15)

As long as appropriate weight is Non-vegetarian 4.18±0.84* 5.6 (55) 5.8 (56) 88.6 (862) maintained a person doesn’t have to Vegetarian 4.48±0.67* 2.3 (5) 1.4 (3) 96.3 (209) worry about nutrition.

Being vegetarian is cool. Non-vegetarian 3.02± 0.99 27.5 (268) 49.8 (485) 22.6 (221) Vegetarian 4.10± 1.01 71.4 (155) 22.6 (49) 5.9 (13)

There are water-soluble and fat- Non-vegetarian 3.91± 0.79 68 (661) 30.8 (300) 1.2 (12) soluble vitamins. Vegetarian 3.88± 0.81 63.9 (138) 35.2 (76) 1 (2)

Soy milk is good for your health. Non-vegetarian 3.21± 0.88 38.8 (378) 44 (428) 17.1 (167) Vegetarian 3.53± 0.94 56.2 (122) 30.9 (67) 12.9 (28)

To be vegetarian you must have a Non-vegetarian 3.92±0.92* 7.9 (77) 19.8 (192) 72.3 (702) strong personality. Vegetarian 4.07±1.00* 9.6 (21) 12 (26) 78.4 (170)

Vegetable proteins are incomplete Non-vegetarian 3.17± 1.01 37.9 (369) 38.6 (376) 23.5 (228) sources of essential amino acids; Vegetarian 2.71±1.24* 32.3 (70) 18 (39) 49.8 (108) thus vegetarians must be very careful in combining proteins from many sources.

Table 3 (continued)

Perceptions of Vegetarianism of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191) Item Diet Mean ±SD % A/SA (n) % NOP (n) % D/SD (n)

In magazines I usually read the Non-vegetarian 2.77±1.17* 33.6 (328) 19.7 (192) 46.6 (454) articles about nutrition. Vegetarian 2.92±1.23* 36.4 (79) 19.8 (43) 43.8 (95)

The movie “Supersize Me” clearly Non-vegetarian 3.44± 1.08 54.8 (534) 24.2 (236) 20.9 (204) identified the reason for American Vegetarian 3.39± 1.02 48.1 (104) 32.4 (70) 19.4 (42) epidemic of obesity- fast food.

Nutrition is important and a person Non-vegetarian 4.51± 0.71 94.7 (920) 3.3 (32) 1.9 (19) shouldn’t be careless about it. Vegetarian 4.66± 0.57 98.2 (213) 0.9 (2) 1 (2)

Parents should not raise their Non-vegetarian 3.14±1.06* 27.6 (269) 32.8 (319) 39.6 (386) children as vegetarians because of Vegetarian 4.28±0.96* 8.7 (19) 6.9 (15) 84.3 (183) nutritional problems with vegetarian diets.

Most food additives are safe when Non-vegetarian 3.47±0.98* 18.7 (182) 28.4 (276) 52.9 (515) used according to government Vegetarian 3.87±0.97* 10.1 (22) 21.2 (46) 68.6 (149) regulations.

Vegans need to take a vitamin B-12 Non-vegetarian 3.48± 0.77 45.8 (446) 48.5 (472) 5.6 (55) supplement or use fortified food like Vegetarian 3.79± 1.01 67.6 (147) 22.1 (48) 10.2 (22) soy milk.

The main reason to choose a Non-vegetarian 2.37±0.85 2.9 (28) 50.9 (496) 46.2 (450) vegetarian lifestyle is because it is Vegetarian 2.12±0.88* 3.2 (7) 35.9 (78) 60.9 (132) part Adventist beliefs and was recommended by E.G. White.

Excessive meat consumption is Non-vegetarian 2.73±1.21* 28.5 (277) 27.3 (265) 44.2 (429) causing global warming. Vegetarian 4.07± 1.10 75.6 (164) 12.9 (28) 11.5 (25) Note. The mean was calculated from a 5-point Likert style scale where one equals “strongly disagree” and five equals “strongly agree”. *The means are presented as flipped scores. Abbreviations. A/SA, agree/strongly agree; NOP, no opinion; D/SD, disagree/strongly disagree; SD, standard deviation; n, number of participants in the survey sample.

With a focus on gender, the results showed that participants most strongly agreed with the following statement: “Nutrition is important and a person shouldn’t be careless about it.” Moreover, males and females alike most strongly disagreed with the statement

“All fat is bad and we should consume as little as possible.” Additionally, females agreed more strongly with health foods giving people more energy than regular foods than males. Lastly, males and females alike seemed conflicted on the answers to vegetarian

lifestyle being the healthiest option and whether manufactured vitamins are inferior to natural vitamins.

Focusing on diet, results showed that participants most strongly agreed with the following statement: “It is healthy to eat a handful of nuts daily.” Both vegetarians and non-vegetarians strongly disagreed with the following statement: “All fat is bad and we should consume as little fat as possible.” Additionally 75% of vegetarians agreed with the statement “Excessive meat consumption is causing global warming.” while 28.5% of non-vegetarians agreed. Furthermore, more vegetarians agreed with reading food labels when shopping. Lastly, vegetarians strongly disagreed (94.5%) that “being vegetarian is too complicated in today’s society” while 67.1% of non-vegetarians disagreed.

Mean vegetarianism perception scores according to gender (male and female), are provided in Table 4. The Factorial ANOVA showed a statistically significant difference in perception scores between males and females, (p= 0.001). Females were found to have a significantly higher perception than males, indicating a more positive perception of vegetarianism.

Table 4 Perception Score of Vegetarianism of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191) Gender Mean ±SD N F p-value Male 3.38± 0.34a 230 10.613 0.001* Female 3.55± 0.30a 961 Total 3.5143 Note. Mean scores were calculated from a 5-point Likert style scale where one (1) equals “strongly disagree” and five (5) equals “strongly agree”. a = statistically significant difference between males and females, (p= 0.001) *Show ANOVA statistical significance, statistical significance was set at p< 0.05. Abbreviations. SD, standard deviation; n, number of participants in the survey sample.

Mean vegetarianism perception scores according to diet (vegetarian and non- vegetarian), are highlighted in Table 5. The Factorial ANOVA showed a statistically significant difference in perception scores between vegetarians and non-vegetarians, (p<

0.001). Vegetarians were found to have a significantly higher perception of vegetarianism than non-vegetarians, indicating a more positive perception toward vegetarianism than their counterpart. There was no interaction effect found for either variable: gender or diet p>0.05.

Table 5

Perception Scores of Vegetarianism of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Diet Mean ±SD N F p-value

Vegetarian 3.75± 0.29a 217 99.463 < 0.001* Non-vegetarian 3.45± 0.28a 974

Total 3.5143

Note. Mean scores were calculated from a 5-point Likert style scale where one (1) equals “strongly disagree” and five (5) equals “strongly agree”. a = statistically significant difference between vegetarians and non-vegetarians, (p< 0.001) *Show ANOVA statistical significance, statistical significance was set at p< 0.05. Abbreviations. SD, standard deviation; n, number of participants in the survey sample.

General Nutrition Knowledge

In this section, general nutrition knowledge of undergraduate college students was assessed using a 31-point scale to score responses. The results of this general nutrition knowledge assessment are displayed in Table 6, Table 7, Table 8 and Table 9 with a focus on gender and diet, in addition to the fill-in-the-blank question that does not follow a three-option scale. On a three-option scale containing “agree”, “disagree” and “I don’t know” and one question with a fill-in-the-blank option, there were no significant effects

found (p< 0.05) for knowledge and gender or knowledge and diet. This nutrition knowledge assessment showed there were not any knowledge differences in vegetarians when compared to non-vegetarians or females compared to males.

Table 6

General Nutrition Knowledge of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Item Gender Mean ±SD % C (n) % IC (n) % IDK (n)

Carbohydrates and fats are the main energy Male 1.43± 0.77 73.9 (170) 8.7 (20) 17.4 (40) sources for people. Female 1.52± 0.78 65.3 (628) 16.9 (162) 17.8 (171)

People should not eat sweets prior to Male 1.71± 0.81 50.9 (117) 27 (62) 22.2 (51) exercise. Female 1.73± 0.87 54.9 (528) 17.3 (166) 27.8 (267)

Eating carbohydrates makes you fat. Male 1.97± 0.57 17.8 (41) 67.4 (155) 14.8 (34) Female 1.93± 0.48 15 (144) 76.9 (739) 8.1 (78)

Protein is the main energy source for the Male 1.45± 0.67 65.2 (150) 24.8 (57) 10 (23) muscle. Female 1.35± 0.66 74.6 (717) 15.4 (148) 10 (96)

Protein supplements are necessary for a Male 1.93± 0.55 18.7 (43) 69.1 (159) 12.2 (28) healthy diet. Female 1.98± 0.58 17.7 (170) 66.3 (637) 16 (154)

A person should replace fluids before, Male 1.12± 0.46 93.5 (215) 1.3 (3) 5.2 (12) during and after a session of exercise. Female 1.13± 0.47 91.9 (883) 2.9 (28) 5.2 (50)

People should rely on thirst to ensure fluid Male 1.96± 0.44 11.7 (27) 80.4 (185) 7.8 (18) replacement. Female 1.97± 0.44 11.2 (108) 80.7 (776) 8 (77)

Urine color can indicate dehydration. Male 1.07± 0.32 94.8 (218) 3.5 (8) 1.7 (4) Female 1.05± 0.28 96.8 (930) 1.7 (16) 1.6 (15)

Vitamin and mineral supplements increase Male 1.77± 0.83 48.7 (112) 25.7 (59) 25.7 (59) energy levels Female 1.75± 0.88 54 (519) 16.9 (162) 29.1 (280)

A multivitamin and mineral supplement is Male 1.93± 0.65 24.3 (56) 57.8 (133) 17.8 (41) necessary for optimal health. Female 1.95± 0.72 28.4 (273) 48.1 (462) 23.5 (226)

Carbohydrates are not as easily and rapidly Male 2.07± 0.77 26.5 (61) 40.4 (93) 33 (76) digested as protein and fat. Female 2.00± 0.82 33.6 (323) 33.2 (319) 33.2 (319)

Eggs and legumes are examples of protein Male 1.16± 0.53 91.3 (210) 1.3 (3) 7.4 (17) sources other than meat. Female 1.12± 0.45 93.1 (895) 1.9 (18) 5 (48)

Table 6 (continued)

General Nutrition Knowledge of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Item Gender Mean ±SD % C (n) % IC(n) % IDK (n)

No more than 15% of calories in the diet Male 2.07± 0.89 36.1 (83) 21.3 (49) 42.6 (98) should be provided by fat. Female 2.05± 0.92 39.4 (379) 16.1 (155) 44.4 (427)

One 8-ounce glass of milk is enough to Male 2.20± 0.82 25.7 (59) 28.3 (65) 46.1 (106) fulfill the recommended amount of Female 2.17± 0.82 26.4 (254) 29.8 (286) 43.8 (421) calcium.

Those with a meatless diet are at higher Male 1.56± 0.84 67.4 (155) 9.6 (22) 23 (53) risk for iron deficiency. Female 1.49± 0.76 67.1 (645) 16.9 (162) 16 (154)

Due to menstruation, females need more Male 1.95± 0.98 50 (115) 4.8 (11) 45.2 (104) iron in their diets than men. Female 1.41± 0.77 76.6 (736) 5.9 (57) 17.5 (168)

Bananas and avocados are good sources of Male 1.11± 0.43 93.5 (215) 2.2 (5) 4.3 (10) potassium. Female 1.08± 0.38 95.3 (916) 1.4 (13) 3.3 (32)

Excess vitamin supplementation may be Male 1.41± 0.76 75.7 (147) 7.8 (18) 16.5 (38) harmful. Female 1.30± 0.67 81.6 (784) 6.5 (62) 12 (115)

The body can synthesize vitamin D upon Male 1.33± 0.72 81.3 (187) 3.9 (9) 14.8 (34) exposure to the sun. Female 1.33± 0.73 82.3 (791) 2.5 (24) 15.2 (146)

Potatoes, strawberries, and cantaloupe are Male 1.88± 0.94 50.4 (116) 11.3 (26) 38.3 (88) good sources of vitamin C. Female 1.86± 0.92 50.4 (484) 13.7 (132) 35.9 (345)

Salt is an essential part of a healthy diet. Male 1.47± 0.75 68.3 (157) 16.1 (37) 15.7 (36) Female 1.68± 0.80 53 (509) 26.2 (252) 20.8 (200)

Bread and cereals are the only food groups Male 2.01± 0.47 10.4 (24) 77.8 (179) 11.7 (27) that are a good source of fiber. Female 2.08± 0.37 3.1 (30) 85.8 (825) 11 (106)

During exercise, it is better to drink a large Male 2.07± 0.38 3.9 (9) 84.8 (195) 11.3 (26) amount of fluid all at once rather than Female 2.07± 0.35 2.7 (26) 87.3 (839) 10 (96) small amounts over time.

Sports drinks are the best way to replace Male 2.01± 0.47 10.4 (24) 77.8 (179) 11.7 (27) body fluids lost during exercise. Female 1.99± 0.47 11.6 (111) 78 (750) 10.4 (100)

Drinking beer is a good way to re-hydrate Male 2.00± 0.29 3.9 (9) 91.7 (211) 4.3 (10) after exercise. Female 2.02± 0.23 1.5 (14) 94.9 (912) 3.6 (35)

Drinking alcohol will add calories to your Male 1.20± 0.55 86.5 (199) 6.5 (15) 7 (16) diet. Female 1.13± 0.48 91.5 (879) 4.2 (40) 4.4 (42)

Caffeine has been shown to improve Male 2.06± 0.82 30.4 (70) 33 (76) 36.5 (84) endurance performance. Female 2.18± 0.76 21.5 (207) 39 (375) 39.4 (379)

Table 6 (continued)

General Nutrition Knowledge of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Item Gender Mean ±SD % C (n) % IC(n) % IDK (n)

A sound nutritional practice is to eat a Male 1.42± 0.75 74.3 (171) 9.6 (22) 16.1 (37) wide variety of different food types from Female 1.41± 0.76 75.8 (728) 7.5 (72) 16.8 (161) day to day.

What a person eats is only important if that Male 1.97± 0.37 8.3 (19) 86.1 (198) 5.7 (13) person is trying to gain or lose weight. Female 1.98± 0.28 4.8 (46) 92.4 (888) 2.8 (27)

Learning about nutrition is not important Male 1.94± 0.40 11.3 (26) 83.5 (192) 5.2 (12) because if you eat enough food you will Female 1.96± 0.32 7.2 (69) 89.8 (863) 3 (29) always get the nutrients your body needs.

I lose weight regularly to meet weight Male 1.89± 0.44 16.1 (37) 79.1 (182) 4.8 (11) requirements. Female 1.93± 0.38 10.7 (103) 85.1 (818) 4.2 (40)

I have experienced bone brakes and/or Male 1.68± 0.53 35.4 (81) 61.6 (141) 3.1 (7) fractures. Female 1.70± 0.50 31.9 (306) 66.3 (636) 1.9 (18)

During school days, I find I am too busy to Male 1.53± 0.55 49.1 (113) 48.3 (111) 2.6 (6) eat breakfast. Female 1.50± 0.53 52.1 (501) 46.1 (443) 1.8 (17)

I limit my fat consumption. Male 1.74± 0.58 32.6 (75) 60.4 (139) 7 (16) Female 1.72± 0.58 35.1 (336) 58 (556) 6.9 (66)

I carefully control my calorie intake. Male 1.76± 0.53 28.7 (66) 66.5 (153) 4.8 (11) Female 1.76± 0.51 27.5 (264) 68.8 (660) 3.8 (36)

I have skipped meals to prepare for social Male 1.74± 0.52 30 (69) 66.1 (152) 3.9 (9) events, like vacations or weddings. Female 1.60± 0.51 40.8 (391) 58 (556) 1.3 (12)

I have fasted for 24 or more hours for Male 1.89± 0.39 13.5 (31) 83.8 (192) 2.6 (6) social events. Female 1.86± 0.41 16.6 (159) 81.3 (780) 2.1 (20)

To lose weight, I have reduced my Male 1.71± 0.57 34.8 (80) 59.1 (136) 6.1 (14) carbohydrate intake. Female 1.58± 0.56 46 (441) 50.4 (483) 3.5 (34)

To lose weight, I have reduced my milk Male 1.81± 0.491 23.1 (53) 72.5 (166) 4.4 (10) and dairy intake. Female 1.69± 0.54 35.1 (337) 60.8 (584) 4.1 (39)

Abbreviations. C, correct; IC, incorrect; IDK, I don’t know; SD, standard deviation; n, number of participants in the survey sample.

Table 7

General Nutrition Knowledge of Male and Female Undergraduate College Students Surveyed Using Fill-in-the-Blank Question at a Midwestern University(N=1,191)

Item Gender Total n % CHO (n) % PRO (n) % FAT (n)

A person should consume a high Male 230 55.2 (127) 41.3 (95) 3.5 (8) carbohydrate meal 2-3 hours before Female 961 49.1 (472) 48.5 (466) 2.4 (23) exercise.

Abbreviations. CHO, carbohydrates; PRO, protein; SD, standard deviation; n, number of participants in the survey sample.

Table 8

General Nutrition Knowledge of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191) Item Diet Mean ±SD % C (n) % IC (n) % IDK (n)

Carbohydrates and fats are the Non-vegetarian 1.52± 0.79 66.5 (648) 15.1 (147) 18.4 (179) main energy sources for people. Vegetarian 1.46± 0.74 69.1 (150) 16.1 (35) 14.7 (32)

People should not eat sweets Non-vegetarian 1.71± 0.85 54.8 (534) 19.2 (187) 26 (253) prior to exercise. Vegetarian 1.79± 0.88 51.2 (111) 18.9 (41) 30 (65)

Eating carbohydrates makes you Non-vegetarian 1.92± 0.52 17.5 (170) 72.8 (709) 9.8 (95) fat. Vegetarian 2.01± 0.39 6.9 (15) 85.3 (185) 7.8 (17)

Protein is the main energy source Non-vegetarian 1.35± 0.65 74 (721) 16.5 (161) 9.4 (92) for the muscle. Vegetarian 1.45± 0.71 67.3 (146) 20.3 (44) 12.4 (27)

Protein supplements are Non-vegetarian 1.97± 0.58 18.3 (178) 66.2 (645) 15.5 (151) necessary for a healthy diet. Vegetarian 1.98± 0.55 16.1 (35) 69.6 (151) 14.3 (31)

A person should replace fluids Non-vegetarian 1.13± 0.47 92 (896) 2.7 (26) 5.3 (52) before, during and after a session Vegetarian 1.12± 0.44 93.1 (202) 2.3 (5) 4.6 (10) of exercise.

People should rely on thirst to Non-vegetarian 1.96± 0.45 12 (117) 80 (779) 8 (78) ensure fluid replacement. Vegetarian 2.00± 0.40 8.3 (18) 83.9 (182) 7.8 (17)

Urine color can indicate Non-vegetarian 1.06± 0.30 95.9 (934) 2.4 (23) 1.7 (17) dehydration. Vegetarian 1.02± 0.20 98.6 (214) 0.5 (1) 0.9 (2)

Vitamin and mineral Non-vegetarian 1.75± 0.87 53.2 (518) 18.4 (179) 28.4 (277) supplements increase energy Vegetarian 1.76± 0.87 52.1 (113) 19.4 (42) 28.6 (62) levels

A multivitamin and mineral Non-vegetarian 1.95± 0.70 27.3 (266) 50.5 (492) 22.2 (216) supplement is necessary for Vegetarian 1.94± 0.72 29 (63) 47.5 (103) 23.5 (51) optimal health.

Table 8 (continued)

General Nutrition Knowledge of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191) Item Diet Mean ±SD % C (n) % IC (n) % IDK (n)

Carbohydrates are not as easily Non-vegetarian 1.99± 0.82 34.1 (332) 33 (321) 33 (321) and rapidly digested as protein Vegetarian 2.10± 0.76 24 (52) 41.9 (91) 34.1 (74) and fat.

Eggs and legumes are examples Non-vegetarian 1.14± 0.49 92.2 (898) 2 (19) 5.9 (57) of protein sources other than Vegetarian 1.08± 0.39 95.4 (207) 0.9 (2) 3.7 (8) meat.

No more than 15% of calories in Non-vegetarian 2.04± 0.91 39.4 (384) 17.4 (169) 43.2 (421) the diet should be provided by Vegetarian 2.12± 0.91 35.9 (78) 16.1 (35) 47.9 (104) fat.

One 8-ounce glass of milk is Non-vegetarian 2.16± 0.83 27.8 (271) 28.1 (274) 44 (429) enough to fulfill the Vegetarian 2.26± 0.76 19.4 (42) 35.5 (77) 45.2 (98) recommended amount of calcium.

Those with a meatless diet are at Non-vegetarian 1.49± 0.80 69.8 (680) 11 (107) 19.2 (187) higher risk for iron deficiency. Vegetarian 1.54± 0.66 55.3 (120) 35.5 (77) 9.2 (20)

Due to menstruation, females Non-vegetarian 1.52± 0.84 71.4 (695) 5.5 (54) 23.1 (225) need more iron in their diets than Vegetarian 1.50± 0.83 71.9 (156) 6.5 (14) 21.7 (47) men.

Bananas and avocados are good Non-vegetarian 1.10± 0.41 94.4 (919) 1.5 (15) 4.1 (40) sources of potassium. Vegetarian 1.03± 0.22 97.7 (212) 1.4 (3) 0.9 (2)

Excess vitamin supplementation Non-vegetarian 1.34± 0.70 79.7 (776) 7 (68) 13.3 (130) may be harmful. Vegetarian 1.27± 0.64 83.9 (182) 5.5 (12) 10.6 (23)

The body can synthesize vitamin Non-vegetarian 1.34± 0.73 81.4 (793) 3 (29) 15.6 (152) D upon exposure to the sun. Vegetarian 1.28± 0.68 85.3 (185) 1.8 (4) 12.9 (28)

Potatoes, strawberries, and Non-vegetarian 1.90± 0.92 48.4 (471) 13.7 (133) 38 (370) cantaloupe are good sources of Vegetarian 1.70± 0.89 59.4 (129) 11.5 (25) 29 (63) vitamin C.

Salt is an essential part of a Non-vegetarian 1.64± 0.79 55.9 (544) 24.5 (239) 19.6 (191) healthy diet. Vegetarian 1.65± 0.80 56.2 (122) 23 (50) 20.7 (45)

Bread and cereals are the only Non-vegetarian 2.08± 0.41 4.6 (45) 83.1 (809) 12.3 (120) food groups that are a good Vegetarian 2.02± 0.32 4.1 (9) 89.9 (195) 6 (13) source of fiber.

During exercise, it is better to Non-vegetarian 2.07± 0.36 3.1 (30) 86.3 (841) 10.6 (103) drink a large amount of fluid all Vegetarian 2.06± 0.33 2.3 (5) 88.9 (193) 8.8 (19) at once rather than small amounts over time.

Table 8 (continued) General Nutrition Knowledge of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University (N=1,191) Item Diet Mean ±SD % C (n) % IC (n) % IDK (n)

Sports drinks are the best way to Non-vegetarian 1.99± 0.48 11.9 (116) 76.8 (748) 11.3 (110) replace body fluids lost during Vegetarian 1.99± 0.41 8.8 (19) 83.4 (181) 7.8 (17) exercise. Drinking beer is a good way to Non-vegetarian 2.02± 0.25 2.2 (21) 93.7 (913) 4.1 (40) re-hydrate after exercise. Vegetarian 2.01± 0.18 0.9 (2) 96.8 (210) 2.3 (5) Drinking alcohol will add Non-vegetarian 1.16± 0.49 89.7 (874) 4.9 (48) 5.3 (52) calories to your diet. Vegetarian 1.09± 0.37 84 (204) 3.2 (7) 2.8 (6)

Caffeine has been shown to Non-vegetarian 2.16± 0.77 22.8 (222) 38.7 (377) 38.5 (375) improve endurance performance. Vegetarian 2.15± 0.80 25.3 (55) 34.1 (74) 40.6 (88)

A sound nutritional practice is to Non-vegetarian 1.43± 0.77 74.7 (728) 7.8 (76) 17.5 (170) eat a wide variety of different Vegetarian 1.34± 0.70 78.8 (171) 8.3 (18) 12.9 (28) food types from day to day. What a person eats is only Non-vegetarian 1.98± 0.31 5.7 (56) 90.3 (880) 3.9 (38) important if that person is trying Vegetarian 1.97± 0.22 4.1 (9) 94.9 (206) 0.9 (2) to gain or lose weight.

Learning about nutrition is not Non-vegetarian 1.95± 0.34 8.3 (81) 88.1 (858) 3.6 (35) important because if you eat Vegetarian 1.96± 0.30 6.5 (14) 90.8 (197) 2.8 (6) enough food you will always get the nutrients your body needs. I lose weight regularly to meet Non-vegetarian 1.93± 0.40 12.1 (118) 83.2 (810) 4.7 (46) weight requirements. Vegetarian 1.92± 0.35 10.1 (22) 87.6 (190) 2.3 (5)

I have experienced bone brakes Non-vegetarian 1.68± 0.51 34 (330) 63.7 (619) 2.4 (23) and/or fractures. Vegetarian 1.75± 0.46 26.3 (57) 72.8 (158) 0.9 (2)

During school days, I find I am Non-vegetarian 1.49± 0.54 52.9 (515) 45.1 (439) 2.1 (20) too busy to eat breakfast. Vegetarian 1.56± 0.53 45.6 (99) 53 (115) 1.4 (3)

I limit my fat consumption. Non-vegetarian 1.73± 0.59 34.3 (333) 58 (563) 7.7 (75) Vegetarian 1.67± 0.54 35.9 (78) 60.8 (132) 3.2 (7)

I carefully control my calorie Non-vegetarian 1.77± 0.52 27.3 (266) 68.3 (665) 4.4 (43) intake. Vegetarian 1.72± 0.49 29.6 (64) 68.5 (148) 1.9 (4)

I have skipped meals to prepare Non-vegetarian 1.63± 0.52 38.6 (376) 59.3 (577) 2.1 (20) for social events, like vacations Vegetarian 1.62± 0.50 38.9 (84) 60.6 (131) 0.5 (1) or weddings.

I have fasted for 24 or more Non-vegetarian 1.87± 0.40 15.4 (150) 82.1 (797) 2.5 (24) hours for social events. Vegetarian 1.82± 0.41 18.4 (40) 80.6 (175) 0.9 (2)

To lose weight, I have reduced Non-vegetarian 1.59± 0.58 45.7 (444) 49.8 (484) 4.5 (44) my carbohydrate intake. Vegetarian 1.66± 0.51 35.6 (77) 62.5 (135) 1.9 (4)

To lose weight, I have reduced Non-vegetarian 1.74± 0.53 30.8 (300) 64.7 (630) 4.4 (43) my milk and dairy intake. Vegetarian 1.61± 0.54 41.7 (90) 55.6 (120) 2.8 (6)

Abbreviations. C, correct; IC, incorrect; IDK, I don’t know; SD, standard deviation; n, number of participants in the survey sample.

Table 9

General Nutrition Knowledge of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed Using Fill-in-the-Blank Question at a Midwestern University (N=1,191) Item Diet Total n % CHO (n) % PRO (n) % FAT (n)

A person should consume a high Non-vegetarian 974 49.2 (479) 47.9 (467) 2.9 (28) carbohydrate meal 2-3 hours Vegetarian 217 55.3 (120) 43.3 (94) 1.4 (3) before exercise.

Abbreviations. CHO, carbohydrates; PRO, protein; SD, standard deviation; n, number of participants in the survey sample.

When looking at the responses according to gender, participants most agreed with the statement: “Urine color can indicate dehydration.” Participants most disagreed with the statement: “Drinking beer is a good way to re-hydrate after exercise.” Most individuals didn’t know the answer to “No more than 15% of calories in the diet should be provided by fat”. Also, over 40% of participants didn’t know if an 8-ounce glass of milk was enough to fulfill the recommended amount of calcium per day. Additionally,

45% of males were unsure about iron needs for females, but over 70% of females agreed that females need more iron than men.

The responses according to diet show that participants most agreed with “Urine color can indicate dehydration.” Participants most disagreed with “Drinking beer is a good way to re-hydrate after exercise.” When prompted with a statement about carbohydrates causing a person to have a higher body fat, more than 85% of vegetarians disagreed, while 72% of their counterparts disagreed. The majority of both groups did not know how many calories from fat should be consumed or if a glass of milk can be enough to provide the recommended amount of calcium for the day. Lastly, more

vegetarians disagreed with carbohydrates not being as easily digested as protein and fat when compared to non-vegetarians.

Mean nutrition knowledge scores according to gender (male and female), are provided within Table 10. The Factorial ANOVA showed that there was not a statistical significant difference in knowledge scores between males and females, (p= 0.435). It was found that there was no main effect for gender and knowledge. No one gender was found to have higher nutrition knowledge than the other.

Table 10

Comparing General Nutrition Knowledge of Male and Female Undergraduate College Students Surveyed at a Midwestern University (N=1,191)

Gender Mean ±SD n F p-value

Male 17.90± 4.59 230

Female 17.76± 3.81 961 0.610 0.435

Total 17.79± 3.97 1191

Note. Mean scores were calculated using a 31-point scale; with one point being rewarded to each correct response. *Show ANOVA statistical significance, statistical significance was set at p< 0.05. Abbreviations. SD, standard deviation; n, number of participants in the survey sample.

Mean nutrition knowledge scores according to diet (vegetarian and non- vegetarian) are shown in Table 11. The Factorial ANOVA showed that there was not a statistical significant difference in nutrition knowledge scores between vegetarians and non-vegetarians, (p< 0.611). It was found that there was no main effect for diet and knowledge. Vegetarians and non-vegetarians were found to have no difference in their knowledge of nutrition. There was also no interaction effect found p= 0.611 (p>0.05).

Table 11

Comparing General Nutrition Knowledge of Vegetarian and Non-Vegetarian Undergraduate College Students Surveyed at a Midwestern University(N=1,191)

Diet Mean ±SD n F p-value

Vegetarian 18.46± 3.43 217

Non-vegetarian 17.64± 4.07 974 0.259 0.611

Total 17.79± 3.97 1191

Discussion

The purpose of this study was to determine the nutrition knowledge and perception of vegetarian diets between male and female vegetarian and non-vegetarian undergraduate college students at a Midwestern University. The results of the study indicated: 1) there was not a significant difference in nutrition knowledge between male and female college students. Meaning Hypothesis 1 was rejected. The results also indicated: 2) there was a significant difference in perception of vegetarian diets between males and females. Meaning, Hypothesis 2 was accepted. Additionally, the results showed: 3) there was not a significant difference in nutrition knowledge among vegetarians and non-vegetarians, indicating Hypothesis 3 was rejected. Lastly the results indicated: 4) there was a significant difference in perceptions of vegetarianism between vegetarian and non-vegetarian college students, meaning Hypothesis 4 was accepted.

Characteristics of Study Population

The demographic data collected from this study is consistent with the data collected from the university the participants of this study attended. The data collected

from the university report had revealed that: 1) the majority of students are between 20 and 22 years of age, 2) most of the undergraduate students are either freshman (29.3%) or seniors (23.0%) and 3) the majority of undergraduates students identify as being

Caucasian (77.8%) (Institutional Research, 2018; Institutional Research 2016).

Data collected from the present study indicated that 71% of the survey participants have had formal, college-level nutrition education. Most indicated the education was acquired through at least one college nutrition course that they either were currently taking or had already completed. These results are similar to that of previous research, in which 37% of individuals have had formal nutrition education in the form of something other than information from the media, news or radio (Barzegari, Ebrahimi,

Azizi and Ranjabar, 2011). The current study also showed that 18.2% of the undergraduates were vegetarian, making the majority of the participant’s non- vegetarians. These results also seem to be congruent with other research. Previous studies that provide information regarding college students’ opinions of vegetarianism show that many college students are not practicing a vegetarian diet (Brunt, Rhee and Zhong, 2008;

Ligia María, José Andrés and Marianela, 2013; McEvoy, Temple and Woodside, 2012;

Piazza et al., 2015). This coincides with the current study since the majority of participants were classified as non-vegetarians (81.8%).

Perceptions of Vegetarianism

This present study reveals college students have a supportive attitude toward vegetarianism, which is not in accordance with past research in this area. Overall,

regardless of the data being analyzed by gender or diet, participants showed a positive perception toward vegetarianism and agreed strongly with positive statements while disagreeing with negative statements offered in the survey. Some studies prior to this current research have explored college students support for vegetarianism (Cousineau,

Franko, Ciccazzo, Goldstein and Rosenthal, 2006; Smith, Burke and Wing, 2000; Haddad and Tanzan, 2003) but have not investigated beyond their acceptance of the vegetarian diet. Rather, research has focused on whether college students have been practicing this diet type during their college years. Therefore, this current study was designed to evaluate college students’ opinions and attitudes toward the vegetarian diet.

In this study, college students most strongly agreed with the statement “Nutrition is important and a person shouldn’t be careless about it.” They felt strongly about people having the opportunity to learn about nutrition and the ways to practice it well. Overall, participants were most inclined to agree with statements regarding eating healthy options, being mindful of consuming macronutrients and having a balance of nutrients, such as omega-3 fatty acids, calcium and vitamin B-12, each day. Participants also showed they do not have strong feelings concerning vegetarianism and were mostly apathetic about a person’s choice of that diet. Participants admitted that a strong personality is not necessary to be a vegetarian. There was dissent among participants regarding statements about nutrition being unimportant and not requiring much thought. Participants also disagreed when prompted with a statement about the vegetarian diet being too complicated. Other research has indicated that college students are unaccepting of the vegetarian diet and lack concern for overall nutrition (Brunt, Rhee and Zhong, 2008;

Ligia María, José Andrés and Marianela, 2013; McEvoy, Temple and Woodside, 2012).

This present study implies that college students may be more open to vegetarianism as time progresses. Therefore, college students might experiment with this diet and be more supportive of those who chose to practice it.

Abnormal or unnatural diet practices, low protein consumption, maintenance difficulties, general weakness and abundant nutrient deficiencies were all barriers to trying the vegetarian diet or supporting someone trying the vegetarian diet as indicated by previous research (Brunt, Rhee and Zhong, 2008; Huang, Harris, Lee, Nazir, Born and

Kaur, 2003; Ligia María, José Andrés and Marianela, 2013), but results of the current study indicate that college students have different ideas. As a matter of fact, the majority of participants strongly disagreed with vegetarianism being too complicated in today’s society. Participants also agreed that nutrients like vitamin B-12 are accessible in foods other than those of animal origin, meaning vegetarians can access them from other food sources. Additionally, participants demonstrated a limited agreement that parents should avoid raising their child as a vegetarian due to nutritional problems with the diet, signifying that college students have a positive attitude toward vegetarians. These results may demonstrate a previously unexplored open-mindedness to vegetarianism, making college students prospective supporters of the vegetarian diet.

In the current study, there was a significantly higher, more positive perception when looking at females compared to males. This was also found to be true for previous studies, many of which found females to be more open to health-related issues. Overall,

females seem to be more exposed to various considerations of a healthy lifestyle and are genuinely interested in nutrition (Sillman, Rodas-Fortier and Neyman, 2004; Poobalan,

Aucott, Clarke and Smith, 2014; Deshpande, Basil and Basil, 2009; Ruby, 2012). The relationship between gender and perception of vegetarianism, as well as a female’s well- established acceptance of health concepts, might be an area to explore when it comes to assisting males and females alike with becoming more mindful of vegetarian diets.

Knowledge of General Nutrition

Knowledge of and perception toward health-related topics are understood to be the foundation for helping people make behavior and lifestyle modifications (Plotnikoff et al., 2015). The current study looked at college students’ knowledge of general nutrition to assist in bettering college students’ attitudes and education. While investigating the nutrition knowledge level in students, there was no significant difference in females and males, nor in vegetarians versus non-vegetarians. Various other studies had found a general lack of nutrition knowledge in college students, males and females alike

(Barzegari, Ebrahimi, Azizi and Ranjbar, 2011; Deshpande, Basil and Basil, 2009;

Poobalan, Aucott, Clarke and Smith, 2014). In this current study, college students answered an average of 57% of nutrition knowledge questions correctly, indicating a lack of general nutrition knowledge among the college students in this study. Other survey research has been conducted on college student’s lack of formal nutrition education and it was found that students are forced to look elsewhere for knowledge and are finding disreputable information (Poobalan, Aucott, Clarke and Smith, 2014). It has also been

found that college students have a disinterest in nutrition due to cost being their main motivator when choosing the foods they eat (Deshpande, Basil and Basil, 2009).

Additionally, college students that are aware of the nutritional value of foods have a higher level of nutrition knowledge in general (Hwang and Cranage, 2015), which is why nutrition education is important. These findings support the findings of the current study, in that knowledge is low in the college population and they could benefit from general nutrition education no matter what diet they are practicing or gender they identify with.

Within the current study, it was found that college students seem to have a strong foundation of information regarding fluid needs and properly hydrating. They also realize that nutrition is important even if a healthy weight is maintained. However, they seem to be confused on daily needs of various macronutrients and micronutrients and are generally unaware of current nutrition recommendations. For example, there were uncertainties pertaining to carbohydrate, fat and various micronutrients, such as iron, vitamin C, calcium and sodium, needs. Yet, participants were aware of sources of protein, potassium sources and fiber-containing foods. Similar results were seen in other studies regarding college students current eating habits, in which they did not know all their nutritional needs but were aware of a few particulars (Brunt, Rhee and Zhong, 2008;

Huang, Harris, Lee, Nazir, Born and Kaur, 2003).

Overall, findings from the current study indicate a low level of nutrition knowledge among college students. This lack of knowledge could be affecting a person’s perception of vegetarianism since both knowledge and perception are the main

predecessors for behavior change. Poor nutrition knowledge could also cause college students not to have enough information on diet alternatives, such as the vegetarian diet.

The information from this study may explain the lack of support and openness toward the vegetarian diet and people who practice the vegetarian diet. This study may help facilitate formal nutrition knowledge and affirm the value of nutrition education for college students.

Within the current study, a lack of nutrition knowledge was seen in accordance with an overall positive perception toward vegetarianism. The lack of nutrition knowledge appears to stem from a shortage of formal nutrition education paired with an absence of reputable information. The surprisingly positive perceptions toward vegetarianism from all demographics in this study could be due to an increase in popularity of the vegetarian diet. This diet has more exposure now than it did ten years ago and continues to grow in popularity as a diet option due to increased levels of health conciseness and environmental awareness. Since vegetarianism is on the rise, people could only benefit from a stronger nutrition education and open-mindedness toward diet alternatives.

Limitations

As with any research design, there were limitations that existed within the context of this study. The first limitation was the validity and reliability of the questionnaire, which utilized some questions that were developed by the researcher and therefore not evaluated for validity and reliability. The second limitation includes self-reported data.

Survey responses were self-reported and therefore the validity of the data cannot be guaranteed. Another limitation includes the voluntary participation of the study. Since participation was voluntary, respondents who participated could have a higher interest or knowledge in this area rather than if the group of participants was made up of a class or a specific sample of people. The use of a convenience sample for the purpose of this study also presents itself as a limitation. Utilizing a convenience sample creates the possibility of biases being present in the current data due to the unique, specific viewpoint that can come with any particular group, such as a group of students from a Midwestern college campus, as opposed to a more comprehensive viewpoint when a wider population is being used. Lastly, there were no questions directly asking about vegetarianism and the types of vegetarianism the participant practiced. Instead there was only a question on the foods that are excluded from or avoided in their diet.

Applications

The current study showed that people who practice the vegetarian diet have a more positive perception than those who do not practice the diet. Over 25% of non- vegetarians feel that parents should not practice a vegetarian diet with their child because there are nutrition problems with the diet and the child would be at risk. Additionally, the majority of non-vegetarians feel anyone practicing a vegetarian diet needs to be cautious to be able to consume adequate protein in their diet. Many non-vegetarians feel veganism is an extreme diet choice, which stresses the importance of expanding awareness of this diet.

This current study showed a knowledge gap in matters regarding general nutrition. Students answered an average of 57% of the knowledge questions correctly, showing a limited knowledge of general nutrition. Of the students tested, 29% of them were currently in a nutrition class or had completed one at the collegiate level. Past research had shown that individuals in college with a lack of nutrition education make poorer food choices and are less healthy overall (Barzegari, Ebrahimi, Azizi and Ranjbar,

2011; Poobalan, Aucott, Clarke and Smith, 2014). By expanding nutrition knowledge in this population, as well as creating more positive perceptions of healthy diet options such as the vegetarian diet, students’ food choices should improve. They will also benefit by carrying their knowledge of healthy behaviors with them into adulthood.

Efforts should be made by higher education institutions to inform all students of nutrition and equip them with the baseline nutrition knowledge they need to make adequate food choices for themselves. With this knowledge and education should come an awareness of different diets, such as the vegetarian diet, the benefits it can bring someone and how to properly practice diets such as this one. Colleges should be working toward making nutrition education more feasible for students by implementing mandatory formal nutrition education and giving student’s easy access to reputable sources of nutrition information. It is important for students to be able to think about nutrition and vegetarianism in a more positive matter so they can keep an open mind and be able to make sound decisions regarding their diet using accurate nutrition information.

From a healthcare professional prospective, this information can be used in the education of individuals. By understanding the population’s current level of knowledge and their attitude toward vegetarianism, healthcare professionals, especially dietitians on college campuses, can better frame their advice and instructions. Dietitians can use this information to teach to people’s needs. The current study affords the profession a better understanding of what college students need in regard to knowledge, can help shed light on a diet that some do not understand and help healthcare professionals expand upon the public’s level of familiarity. Accumulating information regarding someone’s awareness of diets and health can help professionals meet individualized needs and dietary recommendations for nutrients students were unaware of needing, such as the appropriate fat intake and recommendations of micronutrients such as calcium and iron.

Conclusion

The findings from this study show that females had a more positive perception than their male counterparts and vegetarians had a more positive perception than individuals not currently practicing the vegetarian diet. However, knowledge of nutrition was not different among either group. Exploring these findings could help healthcare professionals educate patients more efficiently when discussing the nutritional implications of lifestyle choices, such as the vegetarian diet.

Overall, the current study shed light on college students’ perceptions of the vegetarian diet and their level of nutrition knowledge. Undergraduate students lacked knowledge of nutrition whether they were vegetarians or not. However, most students

had positive perceptions of vegetarianism. While exploring the current level of knowledge undergraduate students have and their attitudes toward the vegetarian diet, the current study created information healthcare providers can use to better educate this population. Additional research needs to be collected to get a clearer understanding of college students’ perceptions of vegetarianism and their baseline of general knowledge.

Future research might explore age as a factor affecting perceptions of this diet and if age has a positive impact on knowledge levels. Moreover, research in the future might want to look at more specific nutrition knowledge tests for vegetarianism to get a more comprehensive picture of what college students know about the diet.

APPENDICES

APPENDIX A

NUTRITION KNOWLEDGE AND PERCEPTION SURVEY

Appendix A

Nutrition Knowledge and Perception Survey

Start of Block: Consent Form

Nutrition Knowledge and Perception of Vegetarian Diets in Vegetarian and Non-Vegetarian, Male and Female College Students

You are being asked to take part in a research study on how college students perceive vegetarian diets and the basic level of knowledge a college student has regarding nutrition. Please read this form carefully and e-mail or call us with any questions you may have before agreeing to take part in the study.

The purpose of this study is to understand college student’s opinions of vegetarianism and the knowledge they have regarding nutrition, in general. You have to be an undergraduate student to take part in this study, but do not need to be a vegetarian to participate in this study.

If you agree to participate in this study, you will complete an online survey that will take you approximately 15-20 minutes to complete. The survey will include questions regarding demographics, nutrition knowledge and perception questions about vegetarian diets. The survey is completely anonymous.

I do not anticipate any risks to you participating in this study other than those encountered in day-to-day life. There are also no benefits to you. As a Kent State University student, I am looking to further understand college student’s knowledge about nutrition and the attitudes they have toward the vegetarian diet.

In a situation where this material may be reported publicly, any information that will make it possible to identify you will not be included in the report.

Taking part in this study is completely voluntary. You may skip any questions that you do not want to answer and can stop participation of the study at any point.

If you have any questions, please contact me at [email protected] or contact the director of my thesis, Dr. Natalie Caine-Bish, at [email protected]. If you have any questions regarding your rights as a participant or any other questions or concerns, please contact the Kent State University Institutional Review Board at 330-672-2704.

101 102

If you are 18 years of age or older and understand the statements above, who freely consents to participate in the study, please, click on “Yes” below to start the survey.

o Yes (1)

o No (2)

Skip To: End of Survey If The Nutrition Knowledge and Perception of Vegetarian Diets in Vegetarian and Non-Vegetarian, Male... = No End of Block: Consent Form

Start of Block: Part I: Demographics

Q2 Are you currently an undergraduate student or a graduate student?

o Undergraduate Student (1)

o Graduate Student (2)

Skip To: End of Survey If Are you currently an undergraduate student or a graduate student? = Graduate Student

Q3 What gender do you identify with?

o Male (1)

o Female (2)

o Other (3)

Q4 How old are you?

______

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Q5 What is your Race/Ethnicity?

o African American (1)

o American Indian/Native American (2)

o Asian/Pacific Islander (3)

o Hispanic (4)

o White/Caucasian (5)

o Other, please specify (6) ______

o I would rather not answer. (7)

Q6 What is your current living situation?

o Living on-campus (1)

o Living off-campus, alone (2)

o Living off-campus, with roommate(s) (3)

o Living off-campus, with parents or guardian (4)

o Living off-campus, with spouse (5)

Q7 What year are you in your undergraduate degree?

o Freshman (1)

o Sophomore (2)

o Junior (3)

o Senior (4)

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Q8 Have you completed a nutrition course or are currently in a nutrition course at the college level?

o Yes (5)

o No (6)

Q9 Are you currently a nutrition major?

o Yes (1)

o No (2)

Q10 Which of the following foods do you restrict or avoid in your diet?

▢ Poultry (chicken, turkey, etc.) (1) ▢ Red Meat (beef, pork, lamb etc.) (2) ▢ Seafood (salmon, tuna, lobster etc.) (3) ▢ Dairy Products (milk, cheese, yogurt etc.) (4) ▢ Eggs (5) ▢ Honey (6)

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Q11 How long have you been following this diet?

o 1 month or less (1)

o 2-6 months (2)

o 7-11 months (3)

o 1 year- 2 years (4)

o 3-5 years (5)

o Longer than 5 years (6)

End of Block: Part I: Demographics

Start of Block: Part II: Perceptions toward Vegetarianism

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Q12 Please indicate the extent to which you agree or disagree with each statement by selecting an answer for each statement listed. Strongly agree Strongly Agree (2) No opinion (3) Disagree (4) (1) disagree (5) “Organic foods” are better for your health because they contain more vitamins, o o o o o minerals, and other important nutrients. (1) Today foods have so many vitamins added that people don’t have to o o o o o worry about their nutrition. (2) It is healthy to eat a handful of nuts daily. o o o o o (3)

Vegan lifestyle is extreme. (4) o o o o o The main reason to choose a vegetarian lifestyle is that o o o o o it is wrong to kill animals. (5) “Health foods” give people more energy than “regular o o o o o foods”. (6) Being vegetarian is too complicated in o o o o o today’s society. (7)

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All fat is bad and we should consume as little fat as o o o o o possible. (8) One effective way to lose weight is to eat a lot of protein and eliminate o o o o o carbohydrates such as pasta and bread. (9) Vegetarian lifestyle is the healthiest option we o o o o o have. (10) The main reason to choose a vegetarian lifestyle is the fact that o o o o o vegetarians live longer and are less sick. (11) Flax seeds and fish are good sources of omega-3 fatty o o o o o acids. (12) Vitamin B-12 is only found in foods of animal o o o o o origin. (13) Milk consumption is the cause of many serious o o o o o diseases. (14)

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The main reason to choose a vegetarian lifestyle is that it is much more o o o o o protective against the environment. (15) Manufactured vitamins are nutritionally inferior to o o o o o natural vitamins. (16) When I shop I read the food labels and search for o o o o o healthful foods. (17) As long as appropriate weight is maintained a person doesn’t o o o o o have to worry about nutrition. (18) Being vegetarian is cool. (19) o o o o o There are water-soluble and fat-soluble o o o o o vitamins. (20) Soy milk is good for your health. (21) o o o o o To be vegetarian you must have a strong o o o o o personality. (22)

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Vegetable proteins are incomplete sources of essential amino acids; thus vegetarians o o o o o must be very careful in combining proteins from many sources. (23) In magazines I usually read the articles about nutrition. o o o o o (24) The movie “Supersize Me” clearly identified the reason for American o o o o o epidemic of obesity – fast food. (25) Nutrition is important and a person shouldn’t be o o o o o careless about it. (26) Parents should not raise their children as vegetarians because of nutritional o o o o o problems with vegetarian diets. (27) Most food additives are safe when used according to government o o o o o regulations. (28)

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Vegans need to take a vitamin B-12 supplement or use fortified o o o o o food like soy milk. (29) The main reason to choose a vegetarian lifestyle is because it is part Adventist o o o o o beliefs and was recommended by E.G White. (30) Excessive meat consumption is causing global o o o o o warming. (31)

End of Block: Part II: Perceptions toward Vegetarianism

Start of Block: Part III: General Nutrition Knowledge

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Q13 Please choose the option that best answers the question. Agree (1) Disagree (2) I don't know (3) Carbohydrates and fats are the main energy sources for people. (1) o o o People should not eat sweets prior to exercise. (2) o o o

Eating carbohydrates makes you fat. (3) o o o Protein is the main energy source for the muscle. (5) o o o Protein supplements are necessary for a healthy diet. (6) o o o A person should replace fluids before, during, and after a session of o o o exercise. (7) People should rely on thirst to ensure fluid replacement. (8) o o o

Urine color can indicate dehydration. (9) o o o Vitamin and mineral supplements increase energy levels. (10) o o o A multivitamin and mineral supplement is necessary for optimal o o o health. (11) Carbohydrates are not as easily and rapidly digested as protein and o o o fat. (13) Eggs and legumes are examples of protein sources other than o o o meat. (14)

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No more than 15% of calories in the diet should be provided by o o o fat. (16) One 8-ounce glass of milk is enough to fulfill the recommended amount of calcium per o o o day. (17) Those with a meatless diet are at a higher risk for iron deficiency. (18) o o o Due to menstruation, females need more iron in their diets than men. o o o (19) Bananas and avocados are good sources of potassium. (20) o o o Excess vitamin supplementation may be harmful. (21) o o o The body can synthesize vitamin D upon exposure to the o o o sun. (22) Potatoes, strawberries, and cantaloupe are good sources of vitamin o o o C. (23)

Salt is an essential part of a healthy diet. (24) o o o Bread and cereals are the only food groups that are a good source o o o of fiber. (25) During exercise, it is better to drink a large amount of fluid all at once rather than small o o o amounts over time. (26)

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Sports drinks are the best way to replace body fluids lost during o o o exercise. (27) Drinking beer is a good way to re-hydrate after exercise. (28) o o o Drinking alcohol will add calories to your diet. (29) o o o Caffeine has been shown to improve endurance o o o performance. (30) A sound nutritional practice is to eat a wide variety of different food types from day to day. o o o (33) What a person eats is only important if that person is trying to gain o o o or lose weight. (34) Learning about nutrition is not important because if you eat enough food you will o o o always get the nutrients your body needs. (31) I lose weight regularly to meet weight requirements. (32) o o o I have experienced bone brakes and/or fractures. (35) o o o During school days , I find I am too busy to eat breakfast. (36) o o o

I limit my fat consumption. (37) o o o I carefully control my calorie intake. (38) o o o

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I have skipped meals to prepare for social events, like vacations or o o o weddings. (39) I have fasted for 24 or more hours for social events. (40) o o o To lose weight, I have reduced my carbohydrate intake. o o o (41) To lose weight, I have reduced my milk and dairy intake. (42) o o o

Q14 Please choose the option that best answers the question. Carbohydrate (1) Protein (2) Fat (3) A person should consume a high-_____ meal 2-3 hours before o o o exercise. (1)

End of Block: Part III: General Nutrition Knowledge

APPENDIX B

RECRUITMENT E-MAIL

Appendix B

Recruitment E-Mail

Dear Perspective Survey Participant,

My name is Brielle Gay and I am a dietetic intern and master’s student in the Nutrition and Dietetics department, here, at Kent State University. I am conducting research on the perception of vegetarianism and the current nutrition knowledge in college students.

I am hoping for your help by participating in a web-based survey that can be found in this e-mail, below.

The survey will take about 15-20 minutes to complete. Your participation in the survey is strictly anonymous. The survey will start with questions regarding demographics and then questions regarding nutrition knowledge and perception of vegetarian diets.

The survey can be found at this link: https://kent.qualtrics.com/jfe/form/SV_cUgyH6Xaw8TliPX

Your participation is very helpful and greatly valued.

Please, contact me with any questions or concerns at [email protected].

Thank you for your time,

Brielle Gay Dietetic Intern and Master’s Student Kent State University

116

APPENDIX C

STUDY CONSENT FORM

Appendix C

Study Consent Form

Nutrition Knowledge and Perception of Vegetarian Diets in Vegetarian and Non-Vegetarian, Male and Female College Students

In a situation where this material may be reported publicly, any information that will make it possible to identify you will not be included in the report.

Taking part in this study is completely voluntary. You may skip any questions that you do not want to answer and can stop participation of the study at any point.

If you are 18 years of age or older and understand the statements above, who freely consents to participate in the study, please, click on “Yes” below to start the survey.

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APPENDIX D

SURVEY BY PETER PRIBIS

Appendix D

Survey by Peter Pribis Lifestyle practices survey

This survey will ask you questions about your lifestyle. The information you provide will help us better understand different beliefs and attitudes toward healthy lifestyles across generations. Thank you for completing this survey!

For each of the following questions, please mark an in the one box or circle the number  which best describes your answer.

Part 1: Census questions

What is your gender:  Male  Female

What year were you born: ______What is your ethnicity:  White, non-Hispanic  Black (African American)  Hispanic  Oriental  American Indian  Other  Mixed racial background

What is your marital status:  Never married  First time married  Separated  Divorced  Widowed

What is your education:  Some high school  High school diploma  Some college  Associate degree  Bachelor’s degree  Master degree  Doctoral degree

What is your occupation:  Andrews University Student  Other How many hours on average do you ______(hours) sleep every night? How many days a week do you ______(number of days) engage in physical activity at least 30 minutes or longer?

120 121

Are you a Seventh-day Adventist?  Yes  No

What is your height: ______(ft) ______(in)

What is your weight: ______(lb)

Part 2: Food Frequency Questionnaire

Never 1-3 1 2-4 5-6 1 2+ Food or per per per per per per rarely month week week week day day Beef (hamburger, ground beef, meatballs, casserole, etc.) Chicken or turkey (roasted, stewed, broiled, fried, in casserole, etc.) Pork (bacon, sausage, ham, chops, ribs) Lamb (steak, roast, stew, sausage, salami, etc.) Fish (tuna, salmon, herring, trout, mackerel et.) Milk (whole, 2%, skim) Cheese (American, cheddar, mozzarella etc.) Yogurt (regular, low fat) Sour cream (whole or low fat) Egg (fried, boiled, scrambled, egg salad etc.) Fresh fruit (apples, bananas, pears, grapes, oranges, etc.) Canned fruits (peaches, pineapple, pears, etc.) Dried fruits (dates, figs, raisins) Salads (iceberg, romaine) Raw vegetables (tomatoes, carrots, onions, etc.) Cooked vegetables (broccoli, cauliflower, peas, yams, etc.) Legumes (lentils, beans, soybeans) Whole grain bread or pasta Whole grain cereals (granola, shredded wheat, etc.) Nuts (walnuts, almonds, peanuts, peanut butter, cashews etc.) Drinking water (including sparkling) Soft drinks and coffee (Coke, Pepsi, Mountain Dew etc.) Caffeine free beverages (decaf soft drinks, decaf coffee, etc.) Juices (orange, grape, apple etc.) Tofu (scrambled, silken, etc.) Meat substitutes (Vegi-Franks, Fri-Chick, Veja Links, etc.) Soy or rice drinks (Silk, Rice dream or homemade) Pizza (Pizza Hut, Dominos, etc.) Fast food (hamburgers, burritos, fried chicken)

Part 3: Use of herbs and supplements

How often do you use vitamin/mineral  Daily  3-5 per week  1 per week  1-3 per month  Rarely or never supplements? What type of vitamin/mineral supplement do you use?  B complex  Protein supplement Check all that apply.  Multivitamin  Calcium  Vitamin C  Iron  Vitamin D  Omega-3

122

 Other: ………………………………………………………..... How often do you use herbal  Daily  3-5 per week  1 per week  1-3 per month  Rarely or never supplements? Where do you normally get information about herbal  Friends  Family  Internet  Magazines  TV supplements? Check all that apply.  Other: …………………………………………………………………………………………………………………………

State the health reason the supplement is used Did the supplement give

the desired

Which herbal effect?

supplement do you use? Check all that apply.

Write in other energy extra ide Yes No

supplements.

Improve overall health overall Improve colds/flu Prevent depression Treat symptoms PMS Treat throats flu/sore Treat immunity Enhance memory Improve Sleepdisorders Prov …………………… Other:

Garlic             Echinacea             Golden seal             Ambrotose             Cayenne             Evening             primrose oil St. John’s wort             Ginkgo                                                

How often is

the herbal month

supplement

5 per week per 5 per 3 -

taken? -

Daily 3 per 1 week 1 never Rarelyor

Garlic      Echinacea      Golden seal      Ambrotose      Cayenne      Evening      primrose oil St. John’s wort      Ginkgo               

123

    

Part 4: Nutritional and Lifestyle Habits

What lifestyle are you following:  Non-vegetarian (eat meat, dairy products, eggs, fish, vegetables, fruits, legumes, grains)  Pesco-vegetarian (eat fish, vegetables, fruits, legumes, grains)  Lacto-ovo-vegetarian (eat dairy products, eggs, vegetables, fruits, legumes, grains)  Vegan (eat vegetables, fruits, legumes, grains)

How long are following this lifestyle? …………………….. (years)

For the following questions please indicate the extent of your agreement or disagreement by circling the appropriate number.

Strongly disagree Strongly Disagree opinion No Agree agree Strongly 1. “Organic foods” are better for your health because they contain more 1 2 3 4 5 vitamins, minerals, and other important nutrients. 2. Today foods have so many vitamins added that people don’t have to worry 1 2 3 4 5 about their nutrition. 3. It is healthy to eat handful of nuts daily. 1 2 3 4 5 4. Vegan lifestyle is extreme. 1 2 3 4 5 5. The main reason to choose a vegetarian lifestyle is that it is wrong to kill 1 2 3 4 5 animals. 6. “Health foods” give people more energy than “regular foods”. 1 2 3 4 5 7. Being vegetarian is too complicated in today’s society. 1 2 3 4 5 8. All fat is bad and we should consume as little fat as possible. 1 2 3 4 5 9. One effective way to lose weight is to eat a lot of protein and eliminate 1 2 3 4 5 carbohydrates such as pasta and bread. 10. Vegetarian lifestyle is the healthiest option we have. 1 2 3 4 5 11. The main reason to choose a vegetarian lifestyle is the fact that vegetarians 1 2 3 4 5 live longer and are less sick. 12. Flaxseeds and fish are good sources of omega-3 fatty acids. 1 2 3 4 5

13. Vitamin B12 is only found in foods of animal origin. 1 2 3 4 5 14. Milk consumption is the cause of many serious diseases. 1 2 3 4 5 15. The main reason to choose a vegetarian lifestyle is that it is much more 1 2 3 4 5 protective against the environment. 16. Manufactured vitamins are nutritionally inferior to natural vitamins. 1 2 3 4 5 17. When I shop I read the food labels and search for healthful foods. 1 2 3 4 5 18. As long as appropriate weight is maintained a person doesn’t have to worry 1 2 3 4 5 about nutrition. 19. Being vegetarian is cool. 1 2 3 4 5 20. There are water-soluble and fat-soluble vitamins. 1 2 3 4 5 21. Soy milk is good for your health. 1 2 3 4 5 22. To be vegetarian you must have a strong personality. 1 2 3 4 5

124

23. Vegetable proteins are incomplete sources of essential amino acids; thus 1 2 3 4 5 vegetarians must be very careful in combining proteins from many sources. 24. In magazines I usually read the articles about nutrition. 1 2 3 4 5 25. The movie “Supersize Me” clearly identified the reason for American 1 2 3 4 5 epidemic of obesity – fast food. 26. Nutrition is important and a person shouldn’t be careless about it. 1 2 3 4 5 27. Parents should not raise their children as vegetarians because of nutritional 1 2 3 4 5 problems with vegetarian diets. 28. Most food additives are safe when used according to government 1 2 3 4 5 regulations. 29. Vegans need to take vitamin B supplement or use fortified food like 12 1 2 3 4 5 soymilk. 30. The main reason to choose a vegetarian lifestyle is because it is part 1 2 3 4 5 Adventist beliefs and was recommended by E.G White. 31. Excessive meat consumption is causing global warming. 1 2 3 4 5

Thank you for participating in this survey

APPENDIX E

SURVEY BY DR. AMY MIRACLE

Appendix E

Survey by Dr. Amy Miracle

Please circle the answer that best answers the question. 1 Carbohydrate and fat are the main energy Agree Disagree Don’t know sources for athletes. 2 Athletes should not eat sweets prior to an Agree Disagree Don’t know event. 3 Eating carbohydrates makes you fat. Agree Disagree Don’t know

4 An athlete should consume a high-_____ Carbohydrate Protein Fat meal 2-3 hours before an event. 5 Protein is the main energy source for the Agree Disagree Don’t know muscle. 6 Protein supplements are necessary for Agree Disagree Don’t know athletes. 7 An athlete should replace fluids before, Agree Disagree Don’t know during, and after an event. 8 Athletes should rely on thirst to ensure Agree Disagree Don’t know fluid replacement. 9 Urine color can indicate dehydration. Agree Disagree Don’t know

10 Vitamin and mineral supplements Agree Disagree Don’t know increase energy levels. 11 A multivitamin and mineral supplement is Agree Disagree Don’t know necessary for optimal sport performance. 12 Carbohydrates are not as easily and Agree Disagree Don’t know rapidly digested as protein and fat. 13 Eggs and legumes are examples of protein Agree Disagree Don’t know sources other than meat. 14 No more than 15% of calories in the diet Agree Disagree Don’t know should be provided by fat. 15 One 8-ounce glasses of milk is enough to Agree Disagree Don’t know fulfill the recommended amount of calcium per day 16 Those with a meatless diet are at a higher Agree Disagree Don’t know risk for iron deficiency 17 Due to menstruation, females need more Agree Disagree Don’t know iron in their diets than men.

18 Bananas and avocadoes are good sources Agree Disagree Don’t know of potassium.

126 127

19 Excess vitamin supplementation may be Agree Disagree Don’t know harmful. 20 The body can synthesize vitamin D upon Agree Disagree Don’t know exposure to the sun. 21 Potatoes, strawberries, and cantaloupe are Agree Disagree Don’t know good sources of vitamin C. 22 Salt is an essential part of a healthy diet. Agree Disagree Don’t know

23 Bread and cereals are the only food Agree Disagree Don’t know groups that are a good source of fiber. 24 During exercise, it is better to drink a Agree Disagree Don’t know large amount of fluid all at once rather than small amounts over time. 25 Sports drinks are the best way to replace Agree Disagree Don’t know body fluids lost during exercise. 26 Drinking beer is a good way to rehydrate Agree Disagree Don’t know after exercise. 27 Drinking alcohol will add calories to your Agree Disagree Don’t know diet. 28 Caffeine has been shown to improve Agree Disagree Don’t know endurance performance. 29 A sound nutritional practice for athletes is Agree Disagree Don’t know to eat a wide variety of different food types from day to day. 30 What the athlete eats is only important if Agree Disagree Don’t know the athlete is trying to gain or lose weight. 31 Learning about nutrition is not important Agree Disagree Don’t know for athletes because they eat so much food they always get the nutrients their bodies need. 32 I lose weight regularly to meet weight Agree Disagree Don’t know requirements for my sport. 33 I have experienced bone stress fractures. Agree Disagree Don’t know

34 During my season , I find I am too busy to Agree Disagree Don’t know eat breakfast. 35 I limit my fat consumption During season Off season Never

36 I carefully control my calorie intake During season Off season Never

37 I have skipped meals to prepare for Agree Disagree Don’t know competition 38 I have fasted for 24 or more hours for Agree Disagree Don’t know competition or training 39 To lose weight, I have reduced my Agree Disagree Don’t know carbohydrate intake.

128

40 To lose weight, I have reduced my Agree Disagree Don’t know milk and dairy intake.

Key:

129

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