EFFECT OF YOGA AND MEDITATION WITH AND WITHOUT NUTRITION EDUCATION ON SNACK NUTRIENT INTAKES IN SEVENTH AND EIGHTH GRADE STUDENTS
A thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Science
By
Natalie Mendez
August 2018
Thesis written by
Natalie Mendez
B.S., California State University, Chico, 2015
M.S., Kent State University, 2018
Approved by
______, Director, Master’s Thesis Committee Natalie Caine-Bish
______, Member, Master’s Thesis Committee David Sharp
______, Member, Master’s Thesis Committee Karen Gordon
Accepted by
______, Interim Director, School of Health Sciences Ellen Glickman
______, Dean, College of Education, Health and Human Services James Hannon
ii MENDEZ, NATALIE, M.S., AUGUST 2018 Nutrition
EFFECT OF YOGA AND MEDITATION WITH AND WITHOUT NUTRITION EDUCATION ON SNACK NUTRIENT INTAKES IN SEVENTH AND EIGHTH GRADE STUDENTS (139 pp.)
Director of Thesis: Natalie Caine-Bish, Ph.D., R.D., L.D.
The purpose of the study was to evaluate the effects of mind-body therapies (yoga and meditation) and nutrition education on snack intakes in seventh and eighth grade students. This was a non-randomized repeated measures design. The study was conducted at two different middle schools, one California public school (CPS, n = 29) and one Ohio private school (OPS, n = 19). The schools differed by time, frequency, and intervention. The interval times (IT) difference was 35-minutes for CPS and 45-minutes for OPS. The frequency of IT differed by the school; CPS accomplished conducting all
IT within one week versus OPS who completed IT once a week for three consecutive weeks. Interventions differed by the school as well, CPS studied the effects of MBT alone whereas OPS incorporated using MBT alone than with the nutrition education.
Thus, IT were compared individually for each school. The same snack items were provided and measured via digital photography during all IT. MBT was practiced at CPS to evaluate if it would inadvertently change snack nutrient intakes but did not display significant changes. Conversely, the study conducted at OPS was intended to determine the effects of including nutrition education along with the MBT practice. OPS was shown to have significantly influenced snack nutrient intakes through a significant increase for polyunsaturated fat (p < 0.009) and monounsaturated fat (p < 0.001), and a
significant decrease in sodium (p < 0.038) and iron (p < 0.012). Since the combination of
MBT with nutrition education was the only intervention to produce significant changes in nutrient intake, more research is needed on adolescents snacking behaviors to justify incorporating MBT with nutrition education into school curriculums.
ACKNOWLEDGMENTS
I am incredibly grateful for all those involved in making this research project
possible. Thank you to the participating schools that volunteered to be a part of this
study, this research could not have been accomplished without your willingness to
accommodate your busy school schedules with this project. Special thanks to all the school staff members and participants for the positive and courteous encounters through
this project. I would also like to thank my thesis committee members who guided and
worked with me throughout this project.
Most importantly, I would like to thank my family who encouraged and assisted me both financially and throughout this project. I could not have done it without my mother, brother, and sister’s support. Overall, I would like to dedicate this project to
Bryan Sickling. Words could not explain my gratitude for this gentleman, during the ups and downs of this project, he was the one person I could always rely on, count on, kept me motivated, and inspired me to accomplish this project successfully.
iii TABLE OF CONTENTS
Page ACKNOWLEDGMENT ...... iii
LIST OF FIGURES ...... vi
LIST OF TABLES ...... vii
CHAPTERS
I. INTRODUCTION ...... 1 Problem Statement ...... 3 Purpose Statement ...... 5 Hypothesis ...... 5 Operational Definitions ...... 6
II. LITERATURE REVIEW ...... 8 Nutritional Recommendations for Adolescents ...... 8 Grain, Protein, Dairy and Fat Dietary Guidelines ...... 12 Fruit and Vegetable Dietary Guidelines ...... 15 Smart Snacks Standards ...... 16 Adolescents Current Dietary Intake and Eating Behaviors ...... 18 Fruit and Vegetable Consumption ...... 21 Reasons for Adolescents Dietary Intake ...... 23 Environmental Influence ...... 23 Sociocultural Influence ...... 27 Behavior Factor ...... 30 Benefits of Healthy Eating ...... 31 Consequences of Poor Dietary Intake ...... 35 Mind and Body Therapy ...... 39 Meditation ...... 41 Yoga ...... 42 Recommendations for Mind-Body Therapy Practices ...... 43 The Practice of Mind-Body Therapy ...... 44 Benefits of Mind-Body Therapies ...... 46 Relationship Between Mind-Body Therapy and Eating Behaviors ...... 50
III. METHODOLOGY ...... 58 Design ...... 58 Setting ...... 59 Sample ...... 59 Measurement Instruments ...... 59 Materials ...... 59
iv Digital Photography Documentation ...... 61 Mind-body Therapy Intervention ...... 63 Procedures ...... 64 Data Analysis ...... 69
IV. JOURNAL ARTICLE ...... 71 Introduction ...... 71 Methods ...... 72 Participants ...... 72 Measures ...... 73 Materials ...... 73 Digital Photography ...... 75 Mind-Body Therapy ...... 76 Procedures ...... 77 Data Analysis ...... 80 Results ...... 81 California Public School ...... 83 Ohio Private School ...... 84 Discussion ...... 87 California Public School ...... 87 Ohio Private School ...... 89 Strengths and Limitations ...... 94 Application ...... 96 Recommendations for Future Research ...... 99 Conclusion ...... 99
APPENDICES ...... 100 APPENDIX A. PARENTAL CONSENT FORM ...... 101 APPENDIX B. INFORMED CONSENT TO PARTICIPATE IN A RESEARCH ___STUDY ...... 104
REFERENCES ...... 107
v LIST OF FIGURES
Figure Page
1. The ChooseMyPlate Logo ...... 10
2. Picture Examples of Snack Labels and Placement for the Three Interval Times ...... 61
3. Picture Examples of Research Digital Photography Documentation ...... 62
4. Sun Salutation Yoga Posture Sequence ...... 63
5. California Public School Participants Procedures During Each Interval Time ...... 66
6. Ohio Private School Participants Procedures During Each Interval Time ...... 67
7. Seventh and Eighth Grade Ohio Private School Participants’ Mean Polyunsaturated
___Fat Intake (grams) from the Three Interval Times (IT) ...... 85
8. Seventh and Eighth Grade Ohio Private School Participants’ Mean Monounsaturated
___Fat Intake (grams) from the Three Interval Times (IT) ...... 85
9. Seventh and Eighth Grade Ohio Private School Participants’ Mean Sodium Intake
___ (milligrams) from the Three Interval Times (IT) ...... 86
10. Seventh and Eighth Grade Ohio Private School Participants’ Mean Sodium Intake
___ (milligrams) from the Three Interval Times (IT) ...... 86
vi LIST OF TABLES
Table Page
1. USDA Fruit and Vegetable Recommended Amounts by Gender and Age ...... 16
2. The Perceived Benefits of Mind-Body Therapies Reported by Youths and
___Adolescents ...... 54
3. List of Snack Items Provided During Each Interval Times ...... 60
4. Difference Between School Procedures Based on Days, Weeks, Length of Time, and
___Interval Time Schedule ...... 65
5. Participating Schools’ Demographics on School Type, Residential State, Grade
___Levels, Percent Qualified for Free- and Reduced- Price Meals, Gender, and
___Race ...... 81
6. Demographics by School, Grade, Age, and Gender for Yoga and Meditation
___Intervention Participants ...... 82
7. Snack Mean ± SD and p Values for Nutrient Intake During the Three Interval Times
___for Seventh and Eighth Grade Yoga and Meditation Participants in the California
___Public School (n = 29) ...... 83
8. Snack Mean ± SD and p Values for Nutrient Intake During the Three Interval Times
___for Seventh and Eighth Grade Yoga, Meditation, and Small Nutrition Education
___Participants in the Ohio Private School (n =19) ...... 84
vii
CHAPTER I
INTRODUCTION
Adolescence (people between the ages of 9 to 18 years old) is the phase of life that is coupled with puberty, a biologically driven mechanism that causes psychological, emotional, and physical changes that affect health and wellness (Patton & Viner, 2007;
Sawyer et al., 2012). These changes during puberty have been found to be directly affected by adolescent’s dietary intakes (O’Neil et al., 2014; Patton & Viner, 2007;
Sawyer et al., 2012). Based on scientific evidence, the Dietary Guidelines for Americans
(DGA) 2015-2020 recommends that a healthy intake includes nutrient-dense foods such as whole grains, fruits, and vegetables; as well as limiting the consumption of calorie- dense (high calorie-low nutrient) processed foods made with refined starches, added sugar, sodium, trans fat, and saturated fats (The United States Department of Health and
Human Services [HHS] and United States Department of Agriculture [USDA], 2015).
Snacking should be considered a beneficial time for adolescents to incorporate healthy snack intakes as it could provide an opportunity to contribute to their daily DGA recommendations. On average, 75 percent of adolescents have been reported to consume two or more snacks a day (Larson, Story, Eisenberg, & Neumark-Sztainer, 2016b).
Research has shown that eating at more frequent intervals is associated with better cognitive performance and mood than eating larger quantities across longer intervals
(Hewlett, Smith, & Lucas, 2009; Smith, & Rogers, 2014). Nutrition practices are essential during the adolescence phase as poor eating habits during this time have been
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shown to produce immediate and long-term health implications, including nutrient deficiencies and chronic diseases (Ensaff et al., 2015a; Fitzgerald et al., 2010; HHS &
USDA, 2015; World Health Organization [WHO], 2018). With adolescents’ prevalence of snacking and with its potential to provide essential nutrients needed for their personal growth and wellbeing, developing healthy eating and snacking habits can help shape the foundation for their future health and behavioral outcomes (Ensaff et al., 2015a;
Fitzgerald et al., 2010; WHO, 2018).
Mind-body therapies (MBT) are holistic practices (e.g., yoga and meditation) used to facilitate the mind's capacity to affect and support overall well-being and foster healthy behavior choices, like less disordered eating (e.g., dieting and eating disorders) and improved metabolic functions (Astin, Shapiro, Eisenberg, & Forys, 2003; Godsey,
2013; National Health Institute [NIH], 2017). The practice of MBT aims to achieve a sense of calm and connection to one's mental and physical state, this can be accomplished through a variety of techniques like meditation, yoga, biofeedback, and hypnosis (Hart,
2015; Kemper, Vohra, & Walls, 2008; McClafferty et al., 2016). Yoga and meditation being the two most prevalent MBT practices among adolescents is the reason these two practices were chosen for this study. Clinically, MBT has been used in conjunction with western medicine to treat psychological (e.g., stress and eating disorders) and physical
(e.g., pain) issues due to its self‐care based activities being cost-effective (Ross, 2015).
The growing research on MBT has exhibited positive health-related outcomes, including aiding to lower healthcare costs, psychological issues, certain diseases, and to support mindful awareness (Barnes, Bloom, & Nahin, 2008; Herman et al., 2014; McClafferty,
3
2011; Mullin, Cheskin, & Matarese 2014; NIH, 2018). In 2012, data showed only four percent of adolescents practiced MBT at least once in the twelve months prior to being surveyed (McClafferty et al., 2016). Additionally, only three percent of adolescents practiced yoga, and two percent practiced meditation (Black, 2015). Thus, despite the reported benefits of MBT these techniques are not generally being utilized in the adolescent age group.
Problem Statement
The overall wellbeing of adolescents can be affected by their diet and lifestyle behaviors (Fitzgerald et al., 2010; Lytle, 2002; HHS & USDA, 2015). Despite research supporting how nutrient-dense snacks could contribute to a healthy diet, adolescents current snacking trends have been found to displace nutrient-dense snacks and full meals
(e.g., breakfast, lunch, and dinner) with an inconsistent consumption of high calorie- dense snacks often containing little to no essential nutrients (Bellisle, 2014; Evans et al.,
2015; Hess et al., 2016; Larson et al., 2016a; Popkin & Duffey, 2010). These dietary trends are the reason adolescents are the least likely age group to meet the DGA (HHS &
USDA, 2015). Studies have reported that adolescent’s current dietary intake of total fat, saturated fat, fruits, vegetables, dietary fiber, sodium, calcium-containing foods, and soft drinks are putting them at risk for diet-related chronic diseases such as certain cancers, cardiovascular diseases, and osteoporosis (Dong, Bilger, van Dam, & Finkelstein, 2015;
Lytle, 2002; HHS & USDA, 2015).
Schools have been given the responsibility to support the health of their students, for example, they provide health screenings and meal programs that support their
4
students' health (Crawford, Gosliner, & Kayman, 2011). The implementation of Smart
Snacks was intended to provide school students with a healthier food environment to ensure competitive foods were consistent with the DGA (USDA, 2016a; USDA, 2016b).
Unfortunately, adolescents snacking trends have not changed despite the inclusion of these standards, mainly being due to the snacks provided during special school events
(e.g., birthdays and celebrations) and those personally brought in by the students (Mann et al., 2017; Murray et al., 2015).
Several diseases in adulthood or even premature death have shown to stem from adolescent’s actions, for example, poor eating behaviors (WHO, 2018). Since adolescents are still maturing, their physical, emotional, and psychological health can be affected by their dietary intakes (O’Neil et al., 2014; Patton & Viner, 2007; Sawyer et al.,
2012). Disordered eating (e.g., dieting and eating disorders) has been found to begin during early adolescence, with the mean onset age of 12-14 (Neumark-Sztainer et al.,
2011; Patton & Viner, 2007). These issues present the time frame where intervention is needed as adolescents are in their most pivotal transition period where their adopted habits can impact their overall wellbeing (Ensaff et al., 2015a; Fitzgerald et al., 2010;
WHO, 2018).
MBT has been reported as a method for developing intrinsic (internal) or autonomous (internal and external) motivation (Deci & Ryan, 2008); these types of motivations are most strongly associated with long-term behavior changes (Teixeira et al., 2010). Thus, MBT could be applied to lead towards healthier lifestyle behaviors. In relation to eating, mindful and intuitive eating are the two forms of MBT that have
5
directly shown to influence positive eating behaviors (e.g., better diet quality and eating relationships), this is accomplished through the mindful awareness of internal physical symptoms associated with appetite and hunger (Barnes et al., 2016; Brown & Ryan,
2003; Oswald et al., 2017; Stites et al., 2015; Warren et al., 2017). MBT research has primarily been performed on overweight, obese, or eating disordered individuals (Barnes et al., 2016; Katterman et al., 2014; Neumark-Sztainer, 2014). There is a lack of research as to whether snacking intakes of adolescents could be affected by MBT, independent of and in conjunction with nutrition education.
Purpose Statement
The purpose of the study was to evaluate the different effects of mind-body therapies (yoga and meditation) with or without nutrition education on seventh and eighth grade students’ nutrient snack intake at different interval times (IT).
Hypotheses
California Public School (CPS):
1. There will be a difference in nutrient intake between baseline (IT-1) and CPS-IT-
2 and CPS-IT-3 (i.e., intervention; the practice of MBT yoga and meditation) in
seventh and eighth grade participants.
Ohio Private School (OPS):
1. There will be a difference in nutrient intake between baseline (IT-1) and OPS-IT-
2 (i.e., intervention; the practice of MBT yoga and meditation) in seventh and
eighth grade participants.
6
2. There will be a difference after the inclusion of nutrition education with MBT
(OPS-IT-3) compared to IT that did not include the nutrition education (IT-1 and
OPS-IT2) in seventh and eighth grade participants.
Operational Definitions
Interval Times (IT):
o IT-1: Baseline for both CPS and OPS: Regular physical education class plus
snack intake.
o CPS-IT-2: CPS Intervention #1: MBT (yoga and meditation) practice for 20
minutes plus snack intake.
o CPS-IT-3: CPS Intervention #2: MBT (yoga and meditation) practice for 20
minutes plus snack intake.
o OPS-IT-2: OPS Intervention #1: MBT (yoga and meditation) practice for 30
minutes plus snack intake.
o OPS-IT-3: OPS Intervention #2: MBT (yoga and meditation) practice for 25
minutes and a five-minute nutrition education lesson plus snack intake.
Mind-Body Therapies (MBT): Are therapeutic practices that use the body and mind synergistically to positively influence the spirit, mental psychology, and the physical body (Hart, 2015; Gurgevich & Nicolai, 2014). This study used Meditation and Yoga practices. Therefore, when MBT is referenced, it refers to yoga and meditation practices.
o Meditation- Are practices that can result in a state of greater physical relaxation,
mental calmness, and psychological balance (Black et al., 2015). Guided
mindfulness meditation for teens was used for interventions.
7
o Yoga- Are practices that uses multiple techniques, including physical
postures/exercises, breathing techniques, deep relaxation states, and
meditation/mindfulness practices to calm the nervous system and balance the
body, mind, and spirit. Sun Salutation Yoga was used for interventions.
Nutrition Education: A five-minutes nutrition lesson involving open discussion in response to nutrition questions posed to the participants about essential snack nutrients required for their diet. Questions asked involved “which foods do you believe are good for your body?”, “why are fruits, vegetables, and whole grains important?”, “how do you feel after you eat foods like fruits and vegetables?”. The researcher guided the conversation and reinforced suitable nutrition information, such as how fruits, vegetables, and whole grains have the essential nutrients needed for their body to grow.
Nutrient Intake: Individual nutrient consumption of snacks: total calories, fats in grams
(including total, saturated, mono- and poly- unsaturated fatty acids), carbohydrates in grams (including dietary fiber and sugar), proteins in grams, sodium in milligrams, and
Vitamin D, calcium, iron, and potassium.
Seventh and eighth grade students: Students academically enrolled in their seventh or eighth school year, between the ages of 12 to 15 years.
CHAPTER II
LITERATURE REVIEW
Nutritional Recommendations for Adolescents
Nutrition recommendations are standards the government sets for the general population to meet as they are essential nutrients necessary for proper health and wellbeing. The DGA are science-based recommendations that promote a diverse and healthy eating pattern to prevent diet-related chronic diseases including cardiovascular disease, type 2 diabetes, bone health, and some cancers (HHS & USDA, 2015). For adolescents, it is encouraged for them to maintain a healthy and balanced diet to support healthy growth and development without exceeding excess weight gain (HHS & USDA,
2015). Although the focus of this study is on adolescents, most references classify the age range of children and adolescents differently or combine them both. For example, the USDA (2018) classifies adolescents as ages 9-18 whereas the WHO (2018) classifies it as ages 10-19 years. Since the paper was mostly based on USDA information, children are classified as people between the ages of 2-8 years, adolescents as ages 9-18 years, and youths referring to both age groups as ages 2-18 years. If the sources age range differs from these groupings, the specific age range the paper is referencing to would be in parenthesis, for example, youths (ages 4-18 years) or adolescents (ages 12-15 years).
To promote a healthy eating pattern, the American Heart Association (AHA)
(2016) and the HHS and USDA (2015) both established similar dietary recommendations, which are to:
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• Follow healthy eating patterns across the lifespan that supports an appropriate
calorie and nutrient level for all age ranges.
• Focus on a variety of foods, nutrient densities, and serving sizes to get sufficient
carbohydrates, proteins, and other nutrients.
• Consume a variety of protein foods involving seafood, lean meats and poultry,
eggs, legumes (beans and peas), nuts, seeds, and soy products.
• Consume a variety of vegetables and fruits daily while limiting juice intake.
• Eat whole-grain rather than refined-grain products, making at least half of the
daily grain consumption come from whole grain products.
• Choose fat-free or low-fat dairy products (including milk, yogurt, cheese, and
fortified soy beverages).
• Limit or reduce calorie intake from added sugars, saturated fats, trans fat,
cholesterol, and sodium.
• Balance dietary calories with physical activity to maintain or reach desired growth
and body weight. Daily activity recommendations are to perform at least 60
minutes of moderate to vigorous play or physical activity.
Included in these recommendations are nutrient-dense foods, which are foods and beverages that provide vitamins, minerals, and other naturally occurring components that contribute to adequate nutrient intakes. Also, nutrient-dense items are made with little or no solid fats, added sugars, refined starches, and sodium. Items classified as nutrient- dense include vegetables, fruits, whole grains, legumes, fat-free and low-fat dairy products (HHS & USDA, 2015).
10
The HHS and USDA (2015) DGA and USDA (2018) MyPlate are federal government entities that provide science-based dietary recommendations for the general
U.S. population. For simplification and generalization, the HHS and USDA (2015) developed the federal symbol of MyPlate (Figure 1) to visually represent what a healthy diet should consists of. This symbol demonstrates the five major food groups, reminding individuals to adapt healthy eating behaviors across the food groups in order to make healthy food choices. The five food groups include: grains, proteins, dairy, fruits, and vegetables (HHS and USDA, 2015).
The difference between MyPlate and DGA are that the MyPlate focuses on the five major food groups, whereas the DGA provides more specific dietary recommendations, such as the individual nutrient contents. The daily recommendations
(and minimum daily amount) of the MyPlate food groups are typically provided in cups
(c.) or ounce equivalents (oz-eq). The Institute of Medicine established the DGA, which are estimated daily recommendations for healthy individual nutrient intakes, organized by age and sex. Nutrient requirements are categorized by nutrient type and source.
Figure 1- The ChooseMyPlate Logo Illustrates the Five USDA Recommended Food Groups. (USDA, 2018).
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Carbohydrate, protein, and fat recommendations are provided in the Acceptable
Macronutrient Distribution Range (AMDR), and the other essential nutrients are provided in Recommended Dietary Allowances (RDA) or Adequate Intakes (AI). These ranges were established to provide sufficient energy and nutrient recommendations and to reduce malnutrition and diet-related diseases. The daily caloric needs for moderately active adolescents ranges from 1,600- 2,000 calories for females and 1,800- 2,800 calories for males (HHS & USDA, 2015). Those who are more physically active may be able to consume more calories as long as it remains within the individuals' calorie needs
(USDA, 2018).
Nutrients are elements in food that are used by the body for growth, maintenance, and energy. More specifically, nutrients are categorized into two major subgroups, macronutrients and micronutrients. Macronutrients are required in higher amounts because they are the primary dietary components that provide the body with energy; they are comprised of fats, proteins, and carbohydrates, also cholesterol, fiber, and water
(HHS & USDA, 2015; Youdim, 2016). Micronutrients are vitamins and minerals that are needed in smaller amounts. Examples of micronutrients consist of calcium, iron, zinc, iodine, selenium, and vitamins A, B, C and D. They are essential nutrients that need to be consumed from food and drinks because the body is unable to naturally synthesized them (Youdim, 2016), and they are required for proper bodily functioning, metabolism, disease prevention, growth and repair (Van Duyn & Pivonka, 2000; Youdim, 2016).
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Grain, Protein, Dairy and Fat Dietary Guidelines
Grains are predominantly carbohydrate-containing foods made from wheat, rice, barley, cornmeal, or other grains (e.g., bread, pasta, tortillas, and breakfast cereals).
Carbohydrates are one of the three macronutrients that provide the body with energy.
The common forms are sugar, fiber, and starch. Grains are classified into two subgroups: whole grains and refined grains. To be considered a whole grain, all key components
(endosperm, germ, and bran) of the grain must be present in the same relative proportions as it exists in the intact kernel state, which is the pre-processed state after inedible parts like the hull and husk have been removed (Healthgrain Forum, 2017; Slavin, Tucker,
Harriman, & Jonnalagadda, 2013). The Healthgrain Forum (2017), recently recommended items labeled “whole grain” must contain 30 percent or more than of whole-grain ingredients in the overall product. Whole grains are more bioavailable sources of nutrients (such as dietary fiber, iron, zinc, folate, magnesium, copper, and B vitamins); this differs from refined grains in that refined grains have been processed to remove the bran and germ, which also removes some vital bioavailable nutrients in favor of consumer preferences (e.g., softer textures and increased shelf life) (HHS and USDA,
2015; USDA, 2018). Most refined grains are refortified, which means certain nutrients
(e.g., iron, thiamin, riboflavin, niacin, and folic acid) are returned after being processed, although some nutrients like fiber do not get added back (USDA, 2018). The finer texture of refined grains is generally used to make desserts and sweets, often requiring more sugar, fat, and sodium (Ferruzzi et al., 2014). The essential macro- and micro- nutrients, along with the phytonutrients present in whole grain foods are what
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synergistically provide the positive health benefits of whole grains (Slavin et al., 2016;
Wu et al., 2015). This is important as the body is able to digest and absorb natural and complementary nutrients more efficiently from whole foods than fortified nutrient foods, as in the refined grains (Bondonno, Bondonno, Ward, Hodgson, & Croft, 2017). For these reasons, whole grains are encouraged over refined grains. The daily grain recommendations for adolescent females is 5-6 oz-eq (3 oz-eq minimum), and 6-8 oz-eq
(3-4 oz-eq minimum) for males (USDA, 2018). Carbohydrates provide four calories per gram. For both male and female adolescents, carbohydrate recommendations per AMDR are 45-65 percent of total calories and per the RDA it is 130 grams per day. The general recommendation for dietary fiber is 14 grams per 1,000 kcal intake, therefore the recommendation for adolescent females is between 22.4-25.2 grams and 25.2-30.8 grams for males (HHS & USDA, 2015).
Proteins (composed of amino acids) are also a macronutrient, they are involved in human growth, repair, and maintenance of tissues and organs (HHS & USDA, 2015;
Rishikof, 2017). Protein foods include seeds, nuts, legumes, processed soy products, eggs, and meats. Proteins are also four calories per gram. The protein group daily recommendations are 10-30 percent of daily calories according to AMDR for both adolescent genders. The RDA recommendations per day are five oz-eq (34-46 grams) for females and 5-6.5 oz-eq (34-52 grams) for males (HHS and USDA, 2015; USDA, 2018).
The dairy food group consists of milk drinks (including soy milk) and milk containing products (e.g., cheese and yogurt). The dairy group is important because it provides essential nutrients like calcium, vitamin D, and potassium that synergistically
14
work together to support bone health, which is particularly crucial during the rapid skeletal growth of adolescents (Huth, DiRienzo, & Miller, 2006). These nutrients are considered “nutrients of public health concern” as low intakes have been associated with bone density, osteoporosis, type 2 diabetes, hypertension, and cardiovascular disease
(Huth et al., 2006; HHS & USDA, 2015). Other nutrients of public health concern for adolescents are dietary fiber and iron (HHS & USDA, 2015; USDA, 2013). Many of these nutrients are reported to be incorporated and fulfilled when consuming a healthy eating pattern such as the DGA recommendations (HHS & USDA, 2015). Plant-based kinds of milk, such as almond, rice, and coconut milk do not fall under the dairy food group because their nutrient content is not similar to dairy or fortified soy milk. Low-fat and fat-free dairy products are encouraged as they provide fewer calories. The dairy group recommendations for both adolescent genders are to consume three cups a day.
Adolescent’s RDA for both genders is 1,300 milligrams (mg) of calcium, 600 IU
(International Units) for vitamin D, 8-11 mg for iron, and 4,500-4,700 mg AI for potassium (USDA, 2018).
Fats are not included in the MyPlate but are still recommended as part of a healthy eating pattern. They are one of the three important macronutrients that provide essential nutrients, such as vitamin E. Oils are fats that are liquid at room temperature and are either extracted from plants (e.g., canola, corn, peanut, soybean, and sunflower) or naturally occurring in foods (e.g., nuts, seeds, avocados, olives, and some fish). Plant- based oils do not have cholesterol, but most oils contain high percentages of MUFA and
PUFA ratios. Although most plant oils are typically low in saturated fat, a few (e.g.,
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coconut oil and palm oil) are high in saturated fat and should be consumed less. Despite the increased risk for cardiovascular diseases, saturated fat consumption is not encouraged due to the abundance in the American diet and because the body no longer needs to consume it from external sources after the age of two (HHS & USDA, 2015;
Siri-Tarino, Sun, Hu, & Krauss, 2010). Saturated fat is solid at room temperature and typically come from animal sources, examples include butter, milk fat, and margarine.
Fats provide more calories than protein and carbohydrates at nine calories per gram; thus they are needed in lesser amounts. The daily AMDR for total fat is 25 to 35 percent of calories for both genders. The daily allowance for oils is five teaspoons for females and
5-6 teaspoons for males (HHS & USDA, 2015; USDA, 2018). A healthy eating pattern should limit saturated fats and trans fats by < 10 percent and < 1 percent of calories per day, respectively. Similar to saturated fat, sodium is limited to < 2,300 milligrams per day due to the high amounts of sodium in American diets and the associated risks of hypertension, cardiovascular disease, renal disease, osteoporosis and gastric cancer (HHS and USDA, 2015; Hoy, Goldman, Murayi, Rhodes, & Moshfegh, 2011).
Fruit and Vegetable Dietary Guidelines
The USDA (2018) MyPlate counts servings of fruits and vegetables in many forms whether it be whole, cut, or pureed; fresh, dried, frozen, or canned; raw or fresh; or in 100% juice. Daily recommendations for fruits and vegetables by age and gender are shown in Table 1. Vegetables are distinguished by their nutrient content into the following five subgroups: (a) dark green, (b) red and orange, (c) legumes (beans and peas), (d) starchy vegetables, and (e) others. The USDA weekly recommendations for
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these subgroups are illustrated in Table 1. Although 100% fruit or vegetable juice could classify as a fruit or vegetable serving, when compared to unprocessed foods, they are lower in essentials nutrients, like fiber, and higher in sugars and calories, which can contribute to dental cavities and weight gain (Heyman & Abrams, 2017). Therefore, the
American Academy of Pediatrics set juice recommendations of eight ounces or less a day for youths (ages 7–18 years) (Heyman & Abrams, 2017).
Table 1. USDA Fruit and Vegetable Recommended Amounts by Gender and Age Females w Males w Food Groups 9 to 13 14 to 18 9 to 13 14 to 18
Vegetables (cups/day) 2 2.5 2.5 3 Dark Greens 1.5 1.5 1.5 2 (cups/week) Red & Orange 5.5 5.5 4 6 (cups/week) Legumes 1 1.5 1.5 2 (cups/week) Starchy Vegetables 4 5 5 6 (cups/week) Other Vegetables 3.5 4 4 5 (cups/week) Fruits (cups/day) 1.5 1.5 1.5 2 Data Source: HHS & USDA, 2015; USDA, 2018.
Smart Snacks Standards
Snacks are meant to support proper daily nutrient intakes through proper snacking choices (Larson et al., 2016a; Sebastian, Goldman, & Wilkinson Enns, 2010). Smart
Snack standards are currently the only established snack guideline. The implementation of Smart Snacks (a federal requirement) was initially created to assure school students
(including adolescents) were provided with quality snacks that would produce positive snack intakes at schools (USDA, 2016a; USDA, 2016b). These standards were
17
implemented into school systems as a means to provide a healthier food environment, mainly to ensure that competitive foods sold at schools were consistent with the most recent DGA (Mann et al., 2017; Murray et al., 2015; USDA, 2016b). Smart Snacks standards require calories, fat, sodium, and sugar nutrient values to be addressed (USDA,
2016a; USDA, 2016b). According to the USDA (2016), to classify as a Smart Snack, a snack must meet the following nutrition standards:
• Be a grain product that contains 50 percent or more whole grains by weight (have
whole grain as the first ingredient); or
• Have as the first ingredient a fruit, a vegetable, a dairy product, or a protein food;
or
• Be a combination food that contains at least 1⁄4 cup of either a fruit or vegetable
or both; and
• The food must meet the nutrient standards for calories (200 calories or less),
sodium (200 mg or less), sugar (35 percent by weight or less), and fats (total fat
35 percent of calories or less, saturated fat less than 10 percent of calories, and 0
trans-fat) (p. 50134-50136).
The classification of food groups and nutrients are the same for MyPlate and DGA as they are all under the USDA. Although many items can fall under the smart snack standards, it is emphasized for adolescents to consume snacks that would contribute to their overall nutrient and food group recommendations, particularly “fruits, vegetables, and water with no added ingredients” (USDA, 2016a, p. 5).
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Adolescents Current Dietary Intake and Eating Behaviors
Currently, the average American diet does not align with the DGA. Compared to the recommendations, there is an under-consumption and over-consumption of certain nutrients and food groups (HHS & USDA, 2015). The 2007-2010 National Health and
Nutrition Examination Survey (NHANES) on dietary intake reported roughly three- fourths or more of Americans eating patterns fell below the recommended goal for positive foods like fruits (75 percent), vegetables (87 percent), whole grains (98.9 percent), dairy (86 percent), plant-based protein (71 percent), and healthy oils (72 percent). On the contrary, most Americans exceeded the recommended limit for unfavorable nutrients including refined grains (75 percent), added sugars (70 percent), saturated fats (71 percent), and sodium (89 percent) (HHS & USDA, 2015; National
Cancer Institute [NCI], 2015).
Although these are generalizations of the collective U.S. population, these results are representative of the cultural eating norms that shape the habits of adolescents (Berge et al., 2014; Granner et al., 2004; Neumark-Sztainer et al., 2003). This is demonstrated through the same 2007-2010 NHANES report on adolescent’s nutrient intakes. The report found adolescents’ average food intake was also below recommendations for fruits
(81 percent), vegetables (94 percent), total grains (27 percent below), whole grains (99.4 percent), dairy (78 percent), proteins (56 percent), plant-based proteins (75 percent), and healthy oils (67 percent). Similar to the average American consumption, adolescents exceeded recommended limit intakes for refined grains (85 percent), sodium (72 percent), solid fats and added sugars (both, 86 percent) (HHS & USDA, 2015; “NCI,” 2015). The
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intake patterns from the general population and adolescents demonstrate nutrients and food groups that are not in-line with the DGA.
Reedy and Krebs-Smith’s (2010) cross-sectional study identified youths average daily calorie contribution from their five highest calorie intake sources: (a) grain desserts
(e.g., cakes, cookies, donuts, pies, and granola bars) provided 138 calories a day, (b) pizza provided 136 calories a day, (c) sugar-sweetened beverages (e.g., soda and fruit drinks) provided 173 calories a day, and (d) milk (e.g., reduced and whole) provided 146 calories a day. These food sources contributed to 433 calories from saturated fat and 365 calories coming from added sugar. These types of calorie dense foods accounted for approximately 40 percent of their total daily calorie intakes (Reedy & Krebs-Smith,
2010).
In the past two decades, snacking has been integrated into U.S. adolescents’ diets.
The prevalence of snacking among U.S. youths had increased from 74% to 98% from
1998 to 2006 (Piernas & Popkin, 2010). Larson et al. (2016a) research study found adolescents typically consume an average of four snacks a day, two or more of those snacks showed to be calorie-dense sources, which was associated with higher BMI z- scores. This type of snacking behavior showed to be associated with a poor diet consisting of higher total calorie intakes, lower fruit and vegetable consumptions, higher sugar-sweetened beverage intakes, and frequent consumption of convenient foods. If their snacking patterns had consisted of smaller nutrient-dense snack portions, these snacking occasions could beneficially contribute to adolescent’s nutrient requirements and government recommendations (Larson et al., 2016a).
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The physical changes that occur during puberty tend to put adolescents at higher risks than other age groups for developing unhealthy eating behaviors such as skipping meals, dieting, and eating disorders centered around perceived body ideals (Brown, Kola-
Palmer, & Dhingra, 2015). A national U.S. survey on eight to tenth grade students found that 32 percent skipped meals, 22 percent fasted, seven percent used diet pills, five percent induced vomiting after meals, and three percent used laxatives to lose weight
(Young, 1997). More recently, Eaton et al. (2012) found 46 percent of U.S. adolescents tried losing weight, a greater prevalence of 61.2 percent was seen in females. The same report showed that of the adolescents attempting to lose weight 12.2 percent fasted for at least a 24-hour period, 5.1 percent took diet pills, powders, or liquids without medical advice, and 4.3 percent purged or took laxatives (Eaton et al., 2012).
Skipping meals is common amongst adolescents as only half consume all three meals a day (HHS & USDA, 2015). Zapata et al. (2008) study demonstrated breakfast being the least likely meal to be consumed by more than half of the 4,452 students in grades sixth to eighth. Nationwide, 13 percent of adolescents skipped breakfast and only
38 percent ate breakfast seven days out of the week (HHS & USDA, 2015). Skipping specific meal periods has been linked with other unfavorable eating patterns. As described by de Moraes, Adami, and Falcão (2012), there are three components to adolescents eating patterns based on certain meal times: (a) fried foods, sweets, and soft drinks were positively associated with not having breakfast for females and dinner for males; (b) consumption of fruit and vegetables were positively associated with having specifically breakfast in males and positively associated with an increased intake of daily
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meals in females; (c) beans, eggs, and meat were positively associated with having lunch for females and negatively associated with having lunch and dinner for males. The current dietary intakes and behaviors in adolescents are being shown as being inconsistent with healthy eating patterns and needs to be addressed. Low socioeconomic status is linked with skipping meals, which causes adolescents to consume more energy- dense snacks with low nutrient contents (Evans et al., 2015; Larson et al., 2016a; Larson,
Story, Eisenberg, & Neumark-Sztainer, 2016b; Zizza, Duffy, & Gerrior, 2008).
Fruit and Vegetable Consumption
Despite the health benefits of eating whole fruits and vegetables, most adolescents do not meet the dietary recommendations. A study assessing middle school students
(grades sixth to eighth) dietary behaviors and knowledge based on the 5-A-Day (five servings of fruits and vegetables a day) recommendations indicated less than one fifth
(17.8 percent) of student knew the daily serving size recommendations and less than one fourth (22.8 percent) of students met the recommendations (Zapata, Bryant, McDermott,
& Hefelfinger, 2008). Non-Hispanic white seventh to eighth grade students were even less likely to meet these minimum standards (Zapata et al., 2008). Rasmussen et al., 2006 study did not show a big difference in fruit and vegetable consumption pertaining to sex, yet between age groups, a meta-analysis showed females and younger children tend to have a higher or more consistent fruit and vegetable intake than males and older children
(Rasmussen et al., 2006). According to the HHS and USDA (2015), the two groups with the lowest vegetable intake in relation to the recommendations were males ages 9-13 years and females ages 14-18 years. Compared to children and adults, research indicated
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adolescents were four times more likely to under-consume fruits and nearly two and a half times more likely to under-consume vegetables (Lorson et al., 2009).
Another research study examining the effects of the 2012-2013 USDA Nutrition
Standards in the National School Lunch and Breakfast Program on students (grades third to eighth) found that when combined with an implemented standard of requiring students to choose a fruit or vegetable, fruit intake increased by 23 percent whereas vegetable intake did not change (Cohen, Richardson, Parker, Catalano, & Rimm, 2014). Micha et al. (2018) systematic review of the Smart Snack standards found there was a decreased consumption of unhealthy snacks (by 0.17 servings a day), yet was not associated with healthier snack consumption, particularly in terms of fruits, vegetables, whole grains, and low-fat dairy products. Illustrating policy implementation can help students make better food choices, yet there is still a need to continue researching tactics to increase adolescents’ fruits and vegetable consumption.
Not all fruit or vegetable intake is necessarily beneficial. When generalizing fruit and vegetable consumption, it is important to keep in mind the different subgroups of fruits and vegetables as they vary in nutrient and calorie contents. For instance, Lorson,
Melgar-Quinonez, and Taylor (2009) found adolescents leading sources of total fruit intake was 100% fruit juice and for total vegetable it was french fries. The most recent
What We Eat in America (WWEIA) data from 2013-2014 displays these eating patterns still exist, adolescents consumed less amounts of total fruits (55.2 percent) and vegetables
(58.86 percent) compared to their recommendations, and the primary subgrouping intakes for total fruit was from juice (33.3 percent) and for total vegetables was from potatoes (30
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percent) (USDA, ARS, 2016b). The type of fruit and vegetable is important to decipher.
Consuming a variety of notably dark-green leafy, cruciferous, and deep-yellow-orange vegetables and deep-yellow-orange citrus fruits have been shown to have the best health outcomes (e.g., prevention of future diseases) due to their nutrient properties like phytochemicals (Van Duyn & Pivonka, 2000). Phytochemicals are properties produced by plants to help prevent and delay some types of cell damage in humans (Slavin &
Lloyd, 2012; Van Duyn & Pivonka, 2000). These benefits are the particular reason a variety of fruits and vegetables are recommended.
Reasons for Adolescents Dietary Intake
This section describes some of the factors that influence adolescents' dietary behaviors. Factors associated with adolescents’ eating behavior can be categorized into three components: (a) environmental influence (e.g., American culture, eating away- from-home, school food environment, parental/family food practices, home food availability, and socioeconomic position); (b) social influence (e.g., peer influences, food advertisements, and social and cultural eating norms), and (c) behavior factor (e.g., eating patterns, individual influence and taste preference). It is valuable to know the influencing factors encouraging adolescent’s dietary consumption as a nutrient-rich diet is essential for the proper development of adolescents.
Environmental Influence
The American diet has inadvertently created an environment that has negatively affected adolescent eating behaviors. As indicated by Berge et al. (2014), there is an association between adolescents’ eating behaviors and their home (e.g., family meals,
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functioning, and modeling of health behaviors) and neighborhood (e.g., location, distance, and quantity of fast food restaurants, convenience stores, and supermarkets) environment. For example, families living in neighborhoods with nearby supermarkets and fewer or further fast food restaurants and convenience stores were associated with healthier home environments, with the adolescents consuming less fast food and increasing nutrient-dense intakes (Berge et al., 2014). In addition, the distance of fast- food restaurants to adolescents’ schools was shown to be another environmental influence affecting adolescents eating habits. Davis and Carpenter (2009) compared schools with fast-food restaurants located near them (within one half mile distance) to schools that did not; they found that adolescents in schools with fast food restaurants located nearby tended to (a) consume less serving of fruits, vegetables, and whole grains;
(b) increased serving intake of soda; and (c) were more likely to be overweight or obese.
The researchers made every attempt to control for external influences, but also addressed that the presence of fast-food restaurants may in fact be a proxy for an unobserved influence, such as the socio-economic location status or race (Davis & Carpenter, 2009).
Furthermore, adolescents who ate fast food (compared to the ones who did not) reportedly had a significantly lower intake in essential nutrients and nutrient-rich foods like certain vitamins, dietary fiber, fruits, vegetables, 100% juices, milk, legumes, healthy proteins, whole grain breads and cereals. They also significantly consumed more total calories (about 800-1,100 calories per visit) from calorie dense sources like fried potato
(french-fries and potato chips), chicken, meat mixture (mostly fatty meat dishes), and sugar carbonated drinks. This contributed to most of their calories coming from fat,
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sodium, and added sugar (Bowman, Gortmaker, Ebbeling, Pereira, & Ludwig, 2004;
Colapinto et al., 2007; Paeratakul at al., 2003). Youths who reported to consume fast food frequently tended to prefer more substantial food portions, usually ate while watching television, and came from low socioeconomic-disadvantaged families
(Colapinto et al., 2007).
Fast food restaurants are not the only source influencing adolescents’ high empty calorie intakes (calories from solid fat and added sugar). Poti, Slining, and Popkin (2014) found fast food restaurants, stores, and schools provided relatively similar individual contributions of empty calories to total calories from each location. Empty calories from fast food were slightly higher at 35 percent of intake, stores had 33 percent, and schools had 32 percent intake coming from empty calories (Poti et al., 2014). This study shows that despite the negative reputation held by fast food restaurants, store and school influences are equally responsible for adolescent’s empty calorie consumption. Each location provides empty calories from specific sources, schools specific contributions are from milk, pizza, and grain desserts, whereas fast foods contributions came from sugar- sweetened beverages, dairy desserts, french fries, and pizza (Poti et al., 2014).
Adolescent’s school environment can influence their eating behaviors and health through the following factors: (a) food and beverage items offered during and on school grounds (e.g., vending machines, school stores, fundraising sales); (b) education programs (factors like knowledge and attitudes); (c) school policies; (d) audio, visual, and physical cues; and (e) qualified staff and healthy administrative role modelling (De
Bourdeaudhuij et al., 2011). School programs, such as school gardens have shown to
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have a positive association to adolescent’s vegetable intake, recognition, attitude, preference, and willingness to taste (Ratcliffe, Merrigan, Rogers, & Goldberg, 2011).
Evidence on policy implemented programs like the Nation School Breakfast and Lunch programs have demonstrated positive eating behaviors like increased fruit intake (Cohen et al., 2014). School meal standards alone were not associated with adolescents’ body composition, knowledge, attitudes, and dietary behavior changes. However, positive changes were displayed when combined with direct nutrition education, especially when it involves physical activities like cooking demonstrations (De Bourdeaudhuij et al.,
2011; Micha et al., 2018; Salvy, De La Haye, Bowker, & Hermans, 2012; Van
Cauwenberghe et al., 2010).
Another factor strongly associated with adolescents eating patterns are parents/families. Granner et al. (2004) reported family influences on adolescents eating behaviors were equally as impactful as social influences from friends and peers.
Research has shown parents/families provide both the genetic predispositions and food home environments that are strongly correlated with youths’ physical disposition, health beliefs, behaviors, lifestyles, dietary intakes, and taste preferences (Berge et al., 2014;
Birch & Fisher, 1998; Salvy et al., 2012; Santiago-Torres et al., 2014; Van
Cauwenberghe et al., 2010). Adolescents had a positive diet associated with fruit and vegetable home availability and frequency of family meals (Berge et al., 2014; Granner et al., 2004; Santiago-Torres et al., 2014). Research on home environment factors on adolescents’ fruit and vegetable eating behaviors found that 45 percent of the influence was home availability (correlates were parental influence, social support for healthy
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eating, family meal patterns, family food security, and socioeconomic status) and 28 percent of the influence was taste preference (correlations included health/nutrition attitudes and home availability of foods) (Neumark-Sztainer et al., 2003).
Sociocultural Influence
The influence of body pressure ideals interrelates with adolescents’ puberty, a period of physical changes including weight, height, body composition, and secondary sex characteristics that tends to coincide with an increased attention and focus on physical appearance (Voelker, Reel, & Greenleaf, 2015). Adolescents’ beliefs regarding their weight, body image, and eating behaviors can be influenced by their friends and peers through means such as appearance-based bullying and criticism, modeling and discussing appearance concerns, making appearance comparisons, and social conflict or exclusion (Hutchinson & Rapee, 2007; Salvy et al., 2012; Voelker et al., 2015; Webb &
Zimmer-Gembeck, 2014). Studies have shown peers and friends were strongly associated with youths eating behaviors of energy-dense foods, fruits, vegetables, juices, breakfast, whole grains, and dairy consumption (Bruening et al. 2012; Cullen et al., 2001;
Salvy et al., 2012). Social norms have also found to shape food choice, portion size, and when to start or stop eating (Salvy et al., 2012). Giese et al. (2015) research showed students shaped classroom eating norms through positive peer reinforcement of unhealthy snack items, whereas healthy snack items were attenuated.
With the readily available access of the internet and mobile devices, technology has become a part of adolescents’ culture, with 51 percent reportedly having laptops, 73 percent having smartphone or tablet, and 92 percent reported going online daily (Lenhart,
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2015; Wartella, Rideout, Montague, Beaudoin-Ryan, & Lauricella, 2016). The increased use of the internet and social media has been connected to body image concerns (Voelker et al., 2015). Poor body image is connected to poor dieting strategies (e.g., binging, purging, and limiting intake) that impact food intakes and diet quality (Woodruff,
Hanning, Lambraki, Storey, & McCargar, 2008). Despite this, the easy access and privacy of the internet makes it accessible for adolescents to inquire about health information online too. It was reported that 84 percent of adolescents’ search for health information online, 36 percent reported using the internet for diet/nutrition information,
42 percent for fitness/exercise, and 31 percent for beauty trends (Lenhart, Purcell, Smith,
& Zickuhr, 2010; Voelker et al., 2015; Wartella et al., 2016). Unfortunately, there are pro-eating disorder websites as well that encourage and support anorexia and bulimia practices as part of a lifestyle with 91 percent of sites being available to anyone with internet access (Borzekowski, Schenk, Wilson, & Peebles, 2010).
Along with technology, there has subsequently been an increased spread of food- related marketing and advertising. Compared to the $333 million the USDA spent for nutrition education, evaluation, and demonstrations, it is estimated that more than a billion dollars is spent on food advertisements mainly marketing unhealthy items like candy and sugary drinks to youths with the goal of developing brand loyalty (Frazier &
Harris, 2016; Story & French, 2004). According to Frazier and Harris (2016), there has been an increase in healthy advertising (e.g., fruits, vegetables, dairy, and water) from
2007 to 2016, yet it only represented nine percent of food-related advertisements for youths with unhealthy advertisements remaining to be the most common food-related
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advertising, contributing to more than three quarters of ads. The top four unhealthy food advertisements viewed by adolescents are fast food restaurants (31 percent), candy (ten percent), other restaurants (ten percent), and cereals (8%) (Frazier & Harris, 2016).
Media and business marketing commonly aim to target and influence youths since their susceptibility to food ads makes them the perfect target population (Story & French,
2004). Children under the age of eight are unaware advertisements intend to sell products, but by the adolescent years, they have begun to understand the purpose of advertisements. Although they can still be persuaded by ads pertaining to their developmental concerns of appearance, sexuality, belonging, and self-identity (Story &
French, 2004). In 2016, it was reported that youths were exposed to 10-11 food related commercial advertisements a day on television alone (Kraak, Gootman, & McGinnis,
2006). Students have reported consuming foods they know are not good for them, especially branded items, to build social image and standing among their peers (Salvy et al., 2012).
Besides television advertisements, television has been associated with other adverse health influences like sedentary behavior and poor dietary intakes (Hobbs,
Pearson, Foster, & Biddle, 2014). According to Larson et al. (2016a), 69 percent of adolescents have been reported to consume a snack, usually tending to be high in calories, while watching television. These snacking intakes coupled with their sedentary behaviors and increased screen time (television, electronic games, and DVDs/videos) has been associated with a poor-quality diet, including lower fruit and vegetable consumption, and a higher intake of total calories, fast foods, energy-dense snacks, salty
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snacks, and sugar-sweetened beverages (Falbe et al., 2014; Kraak et al., 2006; Larson et al., 2016a; Pearson & Biddle, 2011). Consequently, these behaviors have shown to increase the prevalence of developing health-related diseases (Reedy & Krebs-Smith,
2010).
Behavior Factor
The external expectations and pressure to look a certain way (e.g., emphasis on being thin with an hourglass figure for females and muscular and tall for males) stem from advertisements, media, television, and the internet are reinforced through peers
(e.g., family, friends, and classmates) and cause many adolescents to adopt unhealthy body perceptions and eating practices, like low self-esteem, extreme dieting, and skipping meals (Brown, Kola-Palmer, & Dhingra, 2015; Voelker et al., 2015). Extreme dieting has been associated with poor mental health, substance abuse, and weight-related problems. Brown et al. (2015) found extreme weight-control behaviors (e.g., purging) were strongly associated with (a) being overweight, (b) psychosocial concerns including bullying (at school and electronically), depression, victimization experiences (physical abuse and rape), and suicide thoughts/attempts, and (c) substance use including daily smoking, marijuana use, and binge drinking. Hence, adolescents’ self-perception and dietary behaviors are strongly related to their past experiences, mental health, and socio- environmental pressures.
Adolescents are in the transitional stage where parental control starts to diminish and they begin to exercise their independence. Eating behaviors (e.g., eating out with friends, purchasing items, and preparing food) are one of the first things adolescents do to
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practice their autonomy. It is presumed less healthy items are chosen due to practices going against healthy food items enforced by adults (Fitzgerald et al., 2010; Giese et al.,
2015). Fitzgerald et al. (2010) study showed that adolescents were well aware of what a healthy and unhealthy food was, yet their food preferences seemed to override this knowledge when making decisions about food, particularly in relation to taste, texture, and appearance. Food literacy (dietary knowledge) has been reported to have a positive association with adolescents’ dietary intake, for example healthier dietary practices were associated with greater food knowledge and frequent food preparation behaviors
(Vaitkeviciute, Ball, & Harris, 2015).
Benefits of Healthy Eating
Adolescents rapid growth rate is one of the primary reason a healthy (nutrient- dense) diet is essential for this age group, it is also required for proper bodily functioning and physical health. According to the HHS and USDA (2015), a healthy diet is considered to follow the DGA which is comprised of a variety of fruits, vegetables, whole grains, fat-free and low-fat dairy products, proteins, and healthy oils with reduced intake of solid fats (mainly saturated- and trans- fats), added sugars, and sodium. A well- balanced diet is a balance of calorie-dense and nutrient-dense foods. The purpose of this is not to follow a strict diet (does not cut out certain foods) but to consume palatable foods that ensure the body is given the proper nutrients needed for energy, growth, and repair (Rohrlach, 2017).
Fruits and vegetables are universally considered healthy due to their low calorie dense and high nutrient-dense health-promoting properties (Newby, 2009; Slavin &
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Lloyd, 2012; Van Duyn & Pivonka, 2000). A higher consumption of fruits and vegetables is related to a lower intake of calorie-dense foods, such as salty snacks or baked goods (Newby, 2009). This type of eating pattern is strongly associated with better body weights and body mass index (BMI) z-scores in adolescents (Bertoia et al., 2015;
Field, Gillman, Rosner, Rockett, & Colditz, 2003; Newby, 2009). According to Bertoia et al. (2015), the type of fruit and vegetable can positively or negatively affect weight.
The article found weight loss was more associated with lower calorie fruits and vegetables like berries, apples/pears, tofu/soy, cauliflower, and cruciferous and green leafy vegetables; whereas weight did not change with intakes of starchy vegetables like potatoes, peas, and corn but was still encouraged since they still provided essential nutrients such as protein, fiber, iron, B vitamins, vitamin C, and potassium. Evidence has proven fruits and vegetables play a functional role in preventing diseases like cancer, heart disease and stroke, cataracts, diverticulosis, chronic obstructive pulmonary disease, and hypertension (Van Duyn & Pivonka, 2000). The benefits are due to their concentrations of vitamins, minerals, fiber, antioxidants, and phytochemicals (Slavin &
Lloyd, 2012; Van Duyn & Pivonka, 2000).
Similarly, whole grains have been reported to be equally as crucial as fruits and vegetables. Research on higher intakes of whole grains have been associated with various health benefits and a lower risk of total mortality from chronic diseases such as cardiovascular disease, diabetes/insulin sensitivity, lipid profile, respiratory disease, infectious, and certain cancers, as well as playing a role in body weight management and digestive health (Dong et al., 2015; Huang, Xu, Lee, Cho, & Qi, 2015; Slavin et al., 2016;
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Wu et al., 2015). The bioavailability of whole grains phytonutrients and essential macro- and micro- nutrients (e.g., carbohydrates, fiber, and iron) are what synergistically provide the health benefits (Slavin et al., 2016; Wu et al., 2015). The health promoting and disease prevention outcomes associated with whole grain foods are the reason they are encouraged and apart of the DGA recommendations (HHS and USDA, 2015; USDA,
2018; Wu et al., 2015).
These three food groups (fruits, vegetables, and whole grains) are all primary sources of dietary fiber. Dietary fiber is a carbohydrate composed of soluble and insoluble subgroups (Ötles & Ozgoz, 2014). Soluble fiber forms a gel-like material in the stomach that allows for slower absorption processes, allowing the digestive system more time to absorb nutrients. The slower absorption processes also help to lower the amount of cholesterol and glucose (simple sugars that provide energy at the cellular level) that is absorbed into the body. Insoluble fiber is not absorbable and thus promotes the movement of material through the digestive system and increases bowel movement, including stool bulk, which helps regulate bowel movements and avoid constipation.
These components of dietary fiber have been shown to play an essential role in improving the digestive system and overall health. Research has shown the recommended fiber intake has positive health-related effects like improved serum lipoprotein values, lower blood pressure, improved blood glucose control (including individuals with diabetes), improved bowel regularity, and aids in satiety and weight loss (“Dietary fiber,” 2015;
Ötles & Ozgoz, 2014). Compared to people who did not consume adequate amounts of fiber those who did exhibited lower risks of developing cardiovascular health diseases,
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hypertension, diabetes, obesity, and certain gastrointestinal diseases (Ötles & Ozgoz,
2014). These reasons highlight the importance of dietary fiber. Fiber sources mainly come from plant-based products such as whole grains, fruits, vegetables, legumes (like beans and peas), seeds, and nuts (“Dietary fiber,” 2015).
The plant-based diet is associated with many health benefits and a reduction of nutrition-related chronic diseases already mentioned. It consists of any food items deriving from plants like whole grains, fruits, vegetables, legumes, nuts, and healthy oils and has the best health benefits when combined with lower animal food intakes like meat and cheese (“Plant-based diets,” 2018). This type of diet is recommended for adolescents to increase their intakes of healthier foods in order to adequately support their rapid growth and development (Ensaff et al., 2015a; Neumark-Sztainer, Wall, Perry, & Story,
2003). Also, adolescents who consumed this type of diet displayed better health outcomes later in life. For example, intakes of dietary fiber, vegetable protein, vegetable fat, and nuts during adolescence was associated with a lower risk of breast cancer later in life (Liu, Colditz, Cotterchio, Boucher, & Kreiger, 2014). Ensaff et al.’s (2015b) study examined the possibility of successfully integrating plant-based diets into adolescents eating behaviors by building a healthier food environment that would encourage them to consume the healthier options. The study changed secondary schools dining environment to indirectly point students towards more plant-based food choices and found that students were two and a half times more likely to choose fruit, vegetable, or salad items
(Ensaff et al., 2015b). This study demonstrated how adolescents’ food environment could cause this susceptible age group with poor dietary intakes to increase their diet quality
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while continuing to practice autonomy. Some studies have reported the plant-based diet to increase the Estimated Average Requirement (EAR) of certain nutrients (e.g., calcium, protein, vitamin A, and vitamin D), yet the lower consumption of dairy and meat led some individuals to not meet other nutrient requirements (e.g., vitamin C, magnesium, vitamin E, folate, and iron). Therefore, it is advised for individuals to obtain professional medical advice before experimenting with diets, especially ones that exclude specific food groups (Cifelli, Houchins, Demmer, & Fulgoni, 2016).
The importance of a healthy dietary eating pattern is identified to enhance overall health and have been strongly associated with a decrease in negative health implications such as high blood pressure, diabetes, heart diseases, osteoporosis, iron deficiencies, dental cavities, and some cancers (HHS & USDA, 2015). Dietary behaviors do not only affect physical health but mental health as well. O’Neil et al. (2014) study found a healthy eating pattern is positively associated with bettering or even reversing some mental health issues like depression, low mood, low self-esteem, and anxiety in adolescents. Likewise, academic achievement was related to breakfast consumption, lower calorie-dense food and drinks, and overall better diet quality (Burrows, Goldman,
Pursey, & Lim, 2017). For adolescents to live healthy lives and avoid diet-related consequences, it is important that they make the healthy choice of consuming the proper nutrients needed for adequate energy and growth.
Consequences of Poor Dietary Intake
Nutrition is essential to provide the body with energy but also to support the body with the nutrients it requires to function correctly. Adolescents not meeting dietary
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recommendations can subsequently lead to nutrient deficiencies, energy intake imbalances (e.g., eating less or more calories than the body needs or requires), and becoming overweight or obese. All are considered harmful to youths developing bodies, as well as it increases their risk for emerging chronic diseases and illnesses (HHS &
USDA, 2015; Larson, Miller, Watts, Story, & Neumark-Sztainer, 2016; Taylor, Evers, &
McKenna, 2005). About half of all American adults (about 117 million people) have one or more preventable chronic diseases, many of which have been reported to be connected to a poor-quality diet and physical inactivity (HHS & USDA, 2015). Hence the importance of incorporating or maintaining healthy eating behaviors in adolescents.
Foods reported to be associated with weight gain include solid fats (e.g., butter or margarine), breaded or fried poultry, potatoes cooked in oil (e.g., french fries, roasted potatoes, and potato chips), breaded or fried fish, meats, fast food and full-service restaurants, refined grains and added sugar, milk, and sugar-sweetened beverages (Dong et al., 2015; HHS & USDA, 2015; Powell & Nguyen, 2013). Selhub (2015) reported a correlation between diets high in refined sugars and impaired brain functioning or mood disorders, such as depression.
In addition, an unhealthy lifestyle can pose a serious threat to the current and future health outcomes of adolescents; adversely affecting the physical, psychological and psychosocial well-being (Newby, 2009). Disordered eating and dieting have negative consequences such as poor dietary intake, weight gain, and eating disorders
(Neumark-Sztainer et al., 2011). O’Neil et al.’s (2014) study found there to be a relationship between unhealthy dietary patterns and severe mental health issues in
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adolescents. More than 500,000 U.S. adolescents suffer from an eating disorder with anorexia being the third most common chronic illness in adolescents (“Eating Disorder
Statistics,” n.d.). Anorexia also accounts for fifty percent of deaths from attempted suicide (Rosen, 2010). The mean onset age for all eating disorders is reported to be 12 years of age. It has been reported that only one in ten individuals with eating disorders receive treatment and 80 percent of those do not receive the proper treatment (Swanson,
Crow, Le Grange, Swendsen, & Merikangas, 2011). Eating disorders can cause numerous medical complications such as anemia, severe dehydration, electrolyte imbalance, endocrine dysfunction, congestive heart failure and other heart problems, bone loss, gastrointestinal problems, tooth decay and gum disease, substance abuse, and growth retardation (Rosen, 2010). Research on adolescents’ unhealthy dieting and disordered eating behaviors were shown to persist or increase into adulthood (Larson,
Neumark-Sztainer, & Story, 2009; Neumark-Sztainer et al., 2011). Since early intervention results in the best outcomes, early diagnosis and intervention during preadolescents years is advised (Nierengarten, 2015; Rosen, 2010). These undesirable health outcomes consequently lead to enormous medical and health expenses (Rosen,
2010).
Oncology healthcare finances were reported to be $157 billion in 2010 (Mariotto,
Yabroff, Shao, Feuer, & Brown, 2011). The American Diabetes Association (2013) estimated total healthcare costs of individuals with diabetes was $245 billion in 2012 from which $176 billion were from direct medical costs. According to Go et al. (2014), in 2010, the total costs of heart disease and stroke was estimated to be $315 billion.
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From this $193 billion was for direct medical costs. Eating disorder treatment is also expensive, ranging from $30,000 to $180,000 (about $500 -$2,000 per day) depending on treatment and duration (“Eating Disorder Statistics,” n.d.; Rosen, 2010).
Some adolescent lifestyle behaviors have also shown to increase the likelihood of adult morbidity and mortality (Dietz, 1998). Approximately half of all deaths each year are due to heart disease and cancers associated with poor health behaviors (Johnson et al.,
2014). Johnson et al. (2015) reported many of these deaths, as well as those from stroke, diabetes, and other chronic illnesses could have been prevented or delayed, and quality of life could have improved with health-promoting behaviors like eating a healthy diet, exercise, not smoking, and other types of behavioral risk reductions. In 2000, the number of deaths caused by poor dietary intake and lack of physical inactivity was approximated to be 65,000 people (Mokdad, Marks, Stroup, & Gerberding, 2005).
Overall, the result of adolescent’s poor dietary behaviors can include: depression, social stigmatization, low self-esteem, poor academic performance, quality-of-life issues, overweight or obesity, cardiovascular diseases, hypertension, dyslipidemia, type 2 diabetes, certain types of cancers (e.g., lung, esophageal, stomach, colorectal, and prostate), poor bone health, and premature death (“Childhood Nutrition,” 2017; HHS &
USDA, 2015; Reedy & Krebs-Smith, 2010; Sahoo et al., 2015). The consequences of poor dietary intakes highlight the importance of healthy eating in adolescents. Beyond the immediate effects of their diet, they are of the age where they are forming the habits that can affect their overall health well into the future.
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Mind and Body Therapy
Mind-body therapies (MBT) derived mainly from Eastern philosophies and traditions, in recent decades has been integrated more into western countries (Galantino,
Galbavy, & Quinn, 2008; Kemper, Vohra, & Walls, 2008). MBT’s are therapeutic practices that use the body and mind synergistically to positively influence the spirit, mental psychology, and physical body (West, 1975). It is often described as an interaction between the mind and the body with the intention to use the mind to influence physiological functions that can directly affect health (Hart, 2015; McClafferty et al.,
2016). In this context, the term “mind” indicates the mental states (thoughts, emotions, beliefs, attitudes, spirit, and images) versus the actual brain functions themselves (Hart,
2015). Medically, MBT has been shown to balance cortisol (hormone) production which aids to reduce or manage stress (Gurgevich et al., 2014). This is important as cortisol dysregulation in adolescents has been associated with metabolic health, disordered eating, and higher BMI or obesity (Radin et al., 2016).
There are a diverse number of ways in which MBT can be practiced. Common
MBT modalities include: visualization, breathing exercises, hypnosis, guided imagery, cognitive behavioral therapy, therapeutic journaling, affirmations, self-talk, concentration meditation, mindfulness techniques, therapeutic support group, and mindful exercises like yoga and martial arts (Hart, 2015; McClafferty et al., 2016; Gurgevich et al., 2014).
Individuals reported their use of MBT was to reduce or manage stress, relax, regulate emotions or feelings, gain self-knowledge, sharpen concentration or attention, decrease or prevent diseases, and improve overall health (NHIS, 2012; Greenberg & Harris, 2012).
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The mode of MBT practiced is based on individual preference, but all usually intend to connect the mind and body for positive mental and physical health (Greenberg & Harris,
2012).
Medically, mind-body therapy research refers to MBT as complementary and alternative medicine (CAM). The only difference between the two is that CAM may incorporate dietary supplements as part of the therapeutic practice. The National
Institutes of Health (NIH) (2017) defines CAM as health and wellness therapies that can be used with or in place of conventional medical treatments. The goal of achieving overall wellness is the same for MBT and CAM; both use remedies that focus on the overall health of the individual, including physical, mental, emotional, and spiritual well- being (Kemper, Vohra, & Walls, 2008; NIH, 2017).
Mindfulness could be used as a verb or synonym for MBT as it the intended state of mind during most MBT practices; which includes the balance, relaxation, control, and consciousness of internal and physical self to help to maintain or improve overall health
(Murphy et al., 2012; Sampaio et al., 2016). Findings on mindfulness are consistent with
Buddhist philosophies which view overall wellbeing from a holistic perspective involving spiritual, mental, emotional, physical, social, and environmental aspects. When one or more of these qualities is lacking, one might feel personally unfulfilled or distressed. The purpose of these practices is to be fully aware of the present moment through internal self-consciousness and to adopt an open and accepting stance toward experiences. MBT practices can be used as a way to help people achieve mindfulness, which is a balance, relaxation, control, and consciousness of internal and physical self to help to maintain or
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improve overall health (Murphy et al., 2012; Sampaio et al., 2016). Through continued practice, mindfulness is assumed to become routinized as a mindset to positively regulate behavior in relatively automatic ways (Greenberg & Harris, 2012).
Meditation
The word meditation derived from the word dhyana in the Sanskrit language, which means attention and contemplation (Sampaio et al., 2016). Meditation is a group of techniques, most originating from Eastern religious or spiritual traditions in which individuals learn to focus their attention and detach from thoughts normally occupying the mind (Black et al., 2015). According to Jain, Walsh, Eisendrath, Christensen, and
Cahn (2015), meditation is defined as; “a broad set of psychosomatic practices that involve training and regulating attention towards interoceptive or exteroceptive foci, or intentionally created mental images, while observing or redirecting attention from distracting thoughts” (p. 2). Interoceptive foci is the focus or attention of feelings or other physical aspects (e.g., breathing). Exteroceptive foci may involve visual imagery or verbal mantras (repetitive words or sets of syllables) or both (Jain et al., 2015).
Meditation practices involve muscular and mental relaxation with the goal of reasoning and harmonize thoughts and judgments within one’s self (Cardoso, Camano, & Leite,
2004; Green & Harris, 2012; Sampaio et al., 2016).
There are many forms of meditation, two common types used in research are mindfulness meditation (similar to interoceptive foci) and concentration meditation
(similar to exteroceptive foci). According to Wisner, Jones, and Gwin (2010), concentration meditation “involves repeatedly focusing on a particular word, phrase (for
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example, the mantra), or object in an attempt to quiet the mind” (p. 151). Common forms of concentration meditation are relaxation response and transcendental meditation
(Wisner et al., 2010; McClafferty et al., 2016). Mindfulness meditation, also known as mindfulness relaxation or mindfulness-based stress reduction, is based on the concept of being mindful or having increased awareness of the present moment, emotions, cognitive thoughts, and sensory experience (Black et al., 2015; McClafferty et al., 2016).
Mindfulness meditation practices use “breathing methods, guided imagery, and other practices to relax the body and mind and help reduce stress” (Black et al., 2015, p. 17).
Meditation is believed to result in a state of greater physical relaxation, mental calmness, and psychological balance. These practices have shown to positively help adolescents regulate their emotions and mental thoughts (Black et al., 2015). Meditation is commonly promoted as a way to reduce stress, bring about relaxation, and even manage mental health issues like depression (Awasthi, 2013).
Yoga
The word yoga is derived from the Sanskrit word “yuj” meaning “union”
(McClafferty et al., 2016). Therapeutic yoga is a holistic system of practices that use multiple techniques, including physical postures/exercises, breathing exercises, deep relaxation techniques, and meditation/mindfulness practices to calm the nervous system and balance the body, mind, and spirit (Black et al., 2015; Khalsa & Butzer, 2016;
McClafferty et al., 2016). The Merriam-Webster's Learner's Dictionary defines yoga as;
“a Hindu theistic philosophy teaching the suppression of all activity of body, mind, and will in order that the self may realize its distinction from them and attain liberation
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[peace]; a system of physical postures, breathing techniques, and meditation derived from yoga but often practiced independently especially in Western cultures to promote bodily or mental control and well-being” (“Yoga,” n.d.; para. 1)
Yoga is known as a form of physical activity that is usually practiced on a continuous basis with the intention of improving fitness performance, musculoskeletal, and mental health (Galantino, Galbavy, & Quinn, 2008). Although the mechanisms are not entirely understood, yoga has been associated with positive effects regarding heart rate and the parasympathetic nervous system (Khattab et al., 2007).
Recommendations for Mind-Body Therapy Practices
There is currently no set duration or frequency recommendation in order for individuals to receive the benefits of MBT due to the limited and inconsistent research regarding the type, time, and frequency of yoga practice to determine recommendations
(Büssing et al., 2012; Khalsa, & Butzer, 2016). However, Wisner et al. (2010), reported meditation benefits to be found in adolescents when practiced once for about 10-12 minutes a day or several times a week. This recommendation is half of adult’s recommendation due to adolescent’s attention span being less than adults (Wisner et al.,
2010).
Additionally, specific types of yoga can fulfill adolescents' physical activity requirements. Currently, children and adolescents’ physical activity guidelines are to perform 60 minutes or more of physical activity a day, most of this activity is recommended to be either moderate- or vigorous-intensity aerobic activity for at least three days a week (“Active,” 2008). Potiaumpai et al.’s (2017) research on the speed of
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yoga reported that it could meet the aerobic recommendations when it is performed at a faster speed (e.g., three seconds between poses versus twelve seconds or more).
Moreover, when yoga effects were compared to exercise, for both healthy and diseased participants, yoga indicated to be as effective or better than exercise at improving a variety of health-related outcomes (e.g., mental health, energy level, and flexibility)
(Ross & Thomas, 2010). Some health professionals incorporate MBT in conjunction with patient treatment. In practice, they are sometimes used to help with disease-related symptoms (e.g., pain) (Ross, 2015). However, since the type of practice of MBT tends to be based on individual preference, there are currently no set guidelines or recommendations, mainly because research varies greatly in practice, duration, and frequency.
The Practice of Mind-Body Therapy
MBT, like mindfulness, dates back to over 3000 years ago. It was not until the
1970s when Jon Kabat-Zinn introduced the Mindfulness-Based Stress Reduction
(MBSR) program to western health care, this was the first-time mindfulness meditation had gained international awareness. It was initially developed to manage stress but was tested in other areas of health and continued to demonstrate positive results, such as in anxiety, depression, psychological well-being, skin diseases, pain, immune disorders, hypertension and diabetes (Niazi & Niazi, 2011; Sampaio et al., 2016; Warren et al.,
2017).
The NHIS disclosed data regarding U.S. adults use of MBT from 2002, 2007, and
2012, respectively; 32 percent, 36 percent and 33 percent of adults 18 years and over
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reported to have used a form of MBT during the prior 12 months (Barnes et al., 2008;
Barnes, Powell-Griner, McFann, & Nahin, 2004; Clarke et al., 2015). The most commonly used MBT among adults were deep breathing exercises (12 percent, 13 percent, and 11 percent); yoga, tai chi, and qi gong (six percent, seven percent, and ten percent); and meditation (seven percent, nine percent, and eight percent) (Barnes et al.,
2008; Barnes, Powell-Griner, McFann, & Nahin, 2004; Clarke et al., 2015). The MBT trend from 2002 to 2007 showed an increase amongst all practices, yet all practices besides yoga regressed in 2012 (Barnes et al., 2008; Barnes, Powell-Griner, McFann, &
Nahin, 2004; Clarke et al., 2015). Demographically, there was a significant rise of MBT practice in Hispanic adults (particularly regarding yoga), non-Hispanic white adults displayed some increase yet was not substantial, and black adults practice had decreased
(Clarke et al., 2015).
Adults practicing MBT is relevant as it influences youths practice. According to
Barnes et al. (2008), youths whose parents used MBT displayed to be 24 percent (five times) more likely to practice MBT than parents who did not (five percent). The National
Health Interview Survey (NHIS) (2012) was the first to collect MBT data from youths
(ages 4-17) and adolescents (ages 12-17). The use of MBT reported by adolescents in the prior 12 months of being surveyed was seven percent and six percent, respectively from
2007 and 2012. In 2012, of the 94 percent who had not practiced MBT in the prior 12 months, nearly all of the adolescents (93.4 percent) reported to have never used MBT.
From the same year, four percent of adolescents reported to practice yoga and one percent reported to practice meditation. The following are the reasons provided by
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youths as to why they practiced MBT: (a) 62 percent- to practice natural forms of therapy; (b) 54 percent- to treats the cause and not just the symptoms of health; (c) 44 percent- to focuses on the whole person, mind, body, and spirit; (d) 44 percent- for specific health conditions; and (e) 39 percent- part of upbringing. Adolescents who practiced MBT in regard to expecting a particular outcome, reported it was for the following reasons: (a) 62 percent- for general wellness or disease prevention; (b) 31 percent- to improve energy; (c) 24 percent- to improve immune function; (d) 38 percent- to improve athletic or sports performance (30 percent and), and (e) 19 percent- to improve memory or concentration (Barnes et al., 2008; NHIS, 2012).
Benefits of Mind-Body Therapies
Generally, MBT research has shown positive biological, psychological, and social associations (Wisner, 2017). Yoga and meditation are amongst the two most commonly researched forms of MBT practice (NIH, 2017). Yoga has been found to have positive effects on musculoskeletal conditions and psychological functioning, particularly in youths with emotional, mental, and behavioral health problems (Barnes et al., 2008;
Birdee et al., 2008; McClafferty et al., 2016). A clinical evidence review of yoga indicated its practice had been proven to be the most successful with a wide range of psychosomatic and psychiatric disorders (Goyeche, 1979). The effectiveness of yoga can thus be partially understood through neurophysiological philosophy.
Adolescents who practiced yoga showed they could better handle mental challenges through improved mental ability, motor coordination, and social skills
(Galantino et al., 2008). Students also reported having improved mood and reduced
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negative effects after practicing yoga (Felver, Butzer, OlsonSmith, & Khalsa, 2015).
Khalsa, Hickey-Schultz, Cohen, Steiner, and Cope (2012) performed a yoga evaluation study on secondary schools, and their preliminary results suggested that yoga implementation is highly acceptable and affordable, but has the potential to play a protective or preventive role in maintaining mental health, particularly influencing anger control and fatigue. Due to the inconsistencies of yoga effects on adolescents, further research on the efficacy of yoga in regards to treating or preventing certain health conditions is needed (Birdee et al., 2008; Galantino et al., 2008).
Culbert and Olness (2010), suggests adolescent spiritual development may be as important to explore and follow as BMI charts since it may help positively shape adolescent's inner-self (e.g., ethical, social, and worldview beliefs). Meditation interventions (including mindfulness, imagery, and group support) may address various components of spiritual health, such as self-identity, self-awareness, self-esteem, and a deep connection and trust within oneself, others, and society (Hawks, Hull, Thalman, &
Richins, 1995; Wisner, 2017). Research on meditation describes the benefits to be correlated with a reduction of cognitive vulnerability to stress and emotional distress
(Bishop et al., 2004). Just like yoga, meditation seems to be an effective intervention to help treat physiological, psychosocial, and behavioral conditions, even amongst youths
(Black, Milam, & Sussman, 2009). McClafferty et al. (2016) systematic review on structured meditation programs showed benefits for improving mental health, coping, self-regulation, decreasing hypertension, and negative school behaviors. For example, mindfulness meditation showed positive emotions, self-regulation, self-concept, goal
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setting, optimism, and externalizing behaviors in fourth through seventh grade students
(Schonert-Reichl, & Lawlor, 2010).
Many studies have shown positive health changes may arise from incorporating
MBT practices; such as communication, diet activity, physical, and emotional health outcomes, such as heart disease, reversal of health problems, decreased cancer mortality, reduced anxiety, and improved mood states (Aaron, 2011; Hawks et al., 1995). MBT have also shown a reduction in inflammatory signaling affecting gene expression
(ultimately affecting mental and physical health), yet longitudinal research is still needed to confirm long-term effects (Bower & Irwin, 2016).
MBT research studies on youths found the following benefits: psychological
(depression, anxiety, stress; improve concentration, cognitive performance, mood / emotions, optimism, and self-esteem), physical benefits (increase cardiovascular health and decrease hypertension, coronary artery disease, headaches, insomnia, chronic low back pain, pain or control discomfort, and other diseases; aid in treatment-related symptoms of cancer and improving postsurgical outcomes), and social (better academic, social, and classroom interactions; and reducing disruptive behavior) (Aaron, 2011; Astin et al., 2003; McClafferty et al., 2016; Renshaw, Fischer, & Klingbeil, 2017; Wisner,
2017). Gurgevich and Nicolai (2014), summarize advantages of MBT as; “Simple, requiring little or no equipment; economical and relatively inexpensive; noninvasive; easy to learn and use; available to all ages; compatible with other therapies used simultaneously; appropriate for those with mobility limitations; and free from negative side effects” (p. 418).
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Due to the reported benefits of MBT, it has been suggested that health care providers should encourage and facilitate MBT conversations with youths and parents.
To discuss the use of MBT and help them to become familiar with their practices to encourage non-pharmacologic options when it comes to improving mood, behavior, and overall quality of life (McClafferty et al., 2016). Some individuals have reported to prefer treating their health issues with MBT techniques over the use of medications because some medications may have adverse side-effects (Jain et al., 2015).
Implementation of MBT in place of medications would require training in the theoretical and methodological foundations of interventions, and more research is needed to validate the impact of these interventions (Hawks et al., 1995). Regarding healthcare, Kinser,
Robins, and Masho (2016) found MBT could reduce health disparities through centering and empowering the patients to be actively engaged in their own health and encourage a self-management of symptoms system.
Although MBT has been related or associated to positive health outcomes and behaviors, research on MBT is still relatively new and has been conducted more on adults than adolescents (Greenberg & Harris, 2012; Wisner et al., 2010). As Greenberg and
Harris (2012) stated, mindfulness research review suggests meditation and yoga may be associated with beneficial outcomes like cultivating positive mind and body habits as well as to promote the health and well-being of adolescents. However, the limited quality of research interferes with these results. Therefore, more research is required to identify the specific, appropriate, and effective MBT practices to use on different age groups and their direct and future outcomes.
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Relationship Between Mind-Body Therapy and Eating Behaviors
During adolescents' transition time between childhood and adulthood, they are faced with many changes that ultimately impact their health and wellbeing. Those changes are physical (puberty causing maturation of secondary sexual reproductive organs and physical growth), cognitive (academic pressure, transition to high school, increase sense of independence and responsibility causing behavioral changes as they seek a stronger sense of self and identity), emotional (changes can impact hormones, create stress, and new emotions), and social (the need to develop new social relationships with people other than their parents) (“Adolescence,” 2015). Adolescent’s behaviors are likely to persist later in life and have been associated with causing many serious diseases, health problems, or premature death in adulthood (Ensaff et al., 2015a; WHO, 2018).
One major health problem in adolescents is their disordered eating, which shares many common risk factors associated with obesity and other unhealthy eating patterns. For example, media exposure, weight-related teasing, history of dieting, and body image dissatisfaction (Ross, 2015). Eating disorders can also cause nutritional deficiencies and protein-energy malnutrition, which can influence brain functioning (particularly affecting the mood and behavior related transmitters) and may explain many of the symptoms associated with eating disorders, for instance stress, anxiety, and depression may exacerbate disordered eating behaviors (Ross, 2015). As reported earlier, a healthy
(nutrient-dense) diet mostly aligns with the DGA (Ötles & Ozgoz, 2014). However, it has also been widely reported that adolescents are the least likely age group to meet those guidelines (HHS & USDA, 2015).
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One hypothesized way to guide adolescents to practice healthy lifestyles habits is through MBT practices. The changes and pressure adolescents go through have been associated with a lot of negative health behaviors that include an increase of stress and lower health and academic achievements (Yeager et al., 2014). In relationship to dietary effects, stress has shown to negatively influence people’s appetites and eating behaviors
(Gurgevich & Nicolai, 2014; Masih et al., 2017). The relationship between MBT and eating behaviors may best be explained through both biological and psychological mechanisms (Masih et al., 2017). The hypothalamic– pituitary–adrenal (HPA) axis and the sympathetic nervous system (SNS) are prompted as a response to physical or psychological demands (stressors) that cause various psychological, behavioral, and physiological effects which are mainly due to the release of cortisol and catecholamines
(epinephrine and norepinephrine). Cortisol is a hormone that is associated with stress and helps maintain a steady supply of blood glucose. The response to stress can lead to hypervigilance (state of the ‘‘fight or flight’’ response) when there are prolonged releases of HPA axis and SNS (constant release of cortisol) can lead to dysregulation of the physiological systems and adverse health effects. These high levels of stress and cortisol responses have been linked to suppressed thyroid function, imbalanced blood glucose levels, decreased bone and muscle mass, increased blood pressure, and impair cognitive performance; also increase chances for obesity, diabetes, autoimmune disorders, depression, substance abuse, and cardiovascular diseases (Bose, Oliván, & Laferrère,
2009; Gurgevich & Nicolai, 2014; Masih et al., 2017; Ross & Thomas, 2010; Qualter et al., 2013). These biological processes are important as cortisol dysregulation in
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adolescents had also been directly associated with metabolic health, disordered eating, behavioral problems, negative moods, mental health issues, and higher BMI z-scores
(Radin et al., 2016). Stressors and hypervigilance in adolescents is stated to stem from self-identity, self-esteem, academic pressure, decision-making, and social-emotional concerns (Güçray, 2005; Qualter et al., 2013).
The eating behaviors associated with increased stress/cortisol levels can subsequently lead to extreme appetite increase/decrease, cravings for high fat and high sugar foods, and reduction in nutritious meals and foods like vegetables (Gurgevich &
Nicolai, 2014; Masih et al., 2017). Gurgevich and Nicolai (2014) reported the physiological mechanism that cortisol regulates are “glucose metabolism, insulin release, and immune functions; regulates blood pressure, sugar cravings, appetite, thyroid function, sleep and the inflammatory response; and manages fat storage and energy- excess levels” (p.414). This is how stress and cortisol synergistically play a role in the human health, including nutrition-related mechanism.
A certain amount of stress is needed to motivate individuals, hence the term stress management, yet high stress levels can have detrimental effects towards health. MBT practices are natural and inexpensive forms of reducing stress and balancing cortisol production. Research evidence has supported the belief that yoga and meditation techniques can improve physical and mental health through achieving balance, self- control, relaxation or stress management (Gurgevich & Nicolai, 2014; Masih et al., 2017;
Sampaio et al., 2016). Stress reduction causes a down-regulation of the HPA axis and the
SNS, which may positively reduce the activation of the stress and other hormonal
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responses that cause an imbalance of cortisol levels (Dallman, 2010; Masih et al., 2017;
Ross & Thomas, 2010). These stress management techniques may allow individuals to make better decisions when not stress-eating or not eating (Gurgevich & Nicolai, 2014;
Masih et al., 2017).
Although Gurgevich and Nicolai’s (2014) report focused on the use of MBT in conjunction with weight management, they summarize how MBT can influence eating and other positive health behaviors by:
• Reinforcing intentions to make wise food choices.
• Palate and food preference changes.
• Creating more motivation to be more physically active.
• Uncovering suppressed emotional barriers for greater compliance to eating
behaviors and learned mental / emotional associations to food.
• Encouraging a commitment to health activities.
• Developing a “love affair” for healthy foods and eating patterns and portion sizes.
• Increasing self-esteem and self-confidence.
• Reinforcing self-compassion and self-love that will soothe, protect, and support
commitment to behavioral changes and emotional associations to food, eating,
and exercise.
• Ego-strengthening, which encourages greater respect of self and empowerment to
be confident to achieve goals and activities.
• Creating a stronger belief in specific expectations for achieving health outcomes,
compliance, and success.
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The positive health behaviors identified by Gurgevich and Nicolai (2014) are similar to the perceived benefits of MBT reported by youths and adolescents, listed in
Table 2. All besides the last two perceived benefits listed in Table 2 can be related to positive health behaviors.
Many studies associating MBT directly with eating behaviors have primarily involved mindfulness and intuitive eating. For example, yoga and meditation training have both shown promising results in increasing body awareness, internal state, and physical factors like appetite and hunger (Oswald, Chapman, & Wilson, 2017). Mindful eating generally consists of making conscious behaviors, based on self-awareness of psychological and physical hunger and fullness signs, eating healthy based on those signs; this involves being aware and paying attention to the physical and emotional impressions of the food and senses when one is eating (Warren, Smith, & Ashwell,
2017). Mindful eating is often used interchangeably with intuitive eating as they both concentrate on internally focusing eating; however, intuitive eating does not directly
Table 2. The Perceived Benefits of Mind-Body Therapies Reported by Youths and Adolescents Youths Adolescents Perceived Benefits (ages 4-17) (ages 13-17) Motivated to Eat Healthier 23 percent 26 percent Motivated to Eat More Organic Foods 16 percent 15 percent Motivated to Exercise More Regularly 25 percent 31 percent Had A Sense of Control Over Health 36 percent 42 percent Were More Relaxed or Had Reduced Stress Levels 47 percent 52 percent Slept Better 44 percent 44 percent Felt Better Emotionally 39 percent 41 percent Made It Easier to Cope with Health Problems 27 percent 29 percent Improved Overall Health and Made Feel Better 66 percent 68 percent Improved Relationships with Others 23 percent 22 percent Improved School Attendance 19 percent 17 percent Source: NHIS (2012).
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incorporate meditation (Mathieu, 2009; Warren et al., 2017). These practices are predominately used to with eating disorders (such as binge eating and emotional eating)
(Culbert & Olness, 2010; Katterman, 2014).
Studies suggest both mindfulness and intuitive eating display positive influence concerning the complex relationships of food and eating behaviors (Barnes et al., 2016;
Oswald et al., 2017; Stites et al., 2015; Warren et al., 2017). Barnes et al. (2016) study on adolescents looked at the difference between Mindfulness-Based Eating Awareness
Training (MB-EAT, which incorporates mindful meditation and yoga) and a control group (given general health education) on eating choices (at lunch) and exercise. The program was implemented for twelve weeks, once a week for 90 minutes. Results demonstrated the MB-EAT group increased moderate/intense exercise, the number of servings per week of low-calorie foods, foods with no saturated fats and low in saturated fats, and the number of foods with no fat and low in fat. The study concluded by recommending this technique as an easy, affordable, and enjoyable way to guide adolescents to eat better (Barnes et al., 2016). Stites et al.’s (2015) study on mindful food choice also showed trends in employees choosing healthier food options after the integration of a 4-week mindful eating training intervention (approximately 90 minutes per session). Oswald et al. (2017) describe individuals' bodily signals and internal awareness being necessary when it comes to relying on internal hunger and satiety cues, the individual’s response to these signals plays an essential role for intuitive eating. Prior research studies have illustrated MBT potential to enhance inner-awareness and self-care through personal respect and encouragement (Gurgevich & Nicolai, 2014; Masih et al.,
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2017). As reported by Mendelson et al. (2012), those who performed yoga and mindfulness in schools have found interventions to be compatible and feasible to implement in schools and is likely to be attractive to students, teachers, and administrators. It also showed promising results in reducing students stress-related problematic physiological and cognitive patterns. Incorporation of MBT into their lives can guide them to realize the importance of self-care through proper nutrition, sleep and exercise (McClafferty et al., 2016; Gurgevich et al., 2014). The beneficial outcomes of these therapies are enhanced school performance and healthy bodies physically, spiritually, socially, psychologically, and emotionally (McClafferty et al., 2016;
Mendelson et al., 2012).
Recent findings suggest that MBT may offer a promising approach to improving eating behaviors (Oswald et al., 2017). Benefits of MBT and healthy lifestyle behaviors are now encouraged by researchers to encompass their overall wellbeing, specifically for proper treatments and healthy lifestyle practices (Sampaio et al. 2016). However, according to Warren et al.’s (2017) literature review on mindful eating, five studies measured food after mindfulness intervention, three reported positive eating behaviors, and two studies reported mixed/neutral results. Thus, while MBT can improve health, the relationship to increasing healthy lifestyle behaviors, such as increasing healthy and mindful eating is still not fully understood.
Incorporating healthy lifestyle behaviors is essential to receive maximum health benefits (Jensen et al., 2014; Zeytinoglu, 2015). Although more research is needed to verify the relationship between MBT and eating behaviors, the proposed benefits of MBT
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resemble those provided through nutrient-dense eating behaviors. Evidence from the studies provided showed they both achieve similar ends to the means. Once enough research has been conducted to solidify these findings as meaningful, it should be seen that they have a direct relationship with one another and that MBT can affect adolescents’ eating behavior (Greenberg & Harris, 2012; Masih et al., 2017; Warren et al., 2017).
CHAPTER III
METHODOLOGY
Design
The purpose of the study was to evaluate the different effects of mind-body therapies (including yoga and meditation), with and without nutrition education, on seventh and eighth grade students’ nutrient snack intakes at different interval times (IT).
This study was a non-randomized repeated measures design. The dependent variables were snack nutrient intakes. The independent variables were the three different Interval
Times (IT) for each school. The two schools were the California Public School (CPS) and Ohio Private School (OPS). The length of intervention differed by the school; CPS had 35 minutes of IT and OPS had 45 minutes of IT. Snacks were provided at each IT, documentation was done via digital photography (DP). To evaluate the hypothesis, a repeated measures ANOVA was performed separately for each school. The participants nutrient intakes were compared over the three IT. The baseline for both schools was on
IT-1. CPS-IT-2 and OPS-IT-2 was the first yoga and meditation intervention day. CPS-
IT-3 was the second yoga and meditation intervention day. OPS-IT-3 involved yoga, meditation, and a small nutrition education lesson. Before research was conducted approval for the participation of human subjects was obtained through procedures set by the Institutional Review Board at Kent State University.
Setting
The study was conducted at two different middle schools. CPS was a public school located in Oxnard, California. OPS was a private school located in Cleveland,
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Ohio. These schools were selected based on a volunteer-recruitment basis which was accomplished via personal networking and recruitment emails. Schools submitted a
“Letter of Support” to the IRB as a signed agreement and commitment to participate in this research study. The physical location of the experiment was conducted in the school’s indoor gym during the participant’s physical education (PE) class period.
Sample
The sampling procedure used was a convenience sample. Therefore, the participants were restricted to the school sites and teachers that volunteered to participate in the study. The inclusion criteria were students enrolled in a seventh and eighth grade
PE class at one of the participating schools. The exclusion criterions were students with food and beverage allergies to any of the food and beverage items offered. Also, those that did not submit both their assent form and parent/guardian consent form could not partake in the study. The two identification markers obtained were the participant’s gender (male or female) and date of birth (month, date, and year).
Measurement Instruments
This study was performed on adolescent snacking intakes after the inclusion of
MBT, with and without nutrition education. Therefore, the materials measured mainly associated with snack items and DP equipment. Measurements were conducted pre- and post-MBT intervention.
Materials
To assess the snack nutrient intake, snack food and drink items provided for the participants to choose from (Table 3). All snack items were required to correspond with
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the Smart Snack Standards (USDA, 2016a; USDA, 2016b). As shown in Figure 2(a), everything was labeled to avoid confusion regarding the food and drink items. Figure
2(b) shows the placement of the snack food and drink.
Snack items were set on two long rectangular tables that were positioned on one side of the gym to provide ample space for participation of MBT and to create separation from where they had their snacks. Snack food and drink placements were arranged to limit potential bias (Kahn & Wansink, 2004). The layout placement of snack items was randomly distributed over the tables to mix healthier and less healthy snack items
Table 3. List of Snack Items Provided During Each Interval Times Food and Beverage Items Fruits • Raisins • Bananas • Apple Slices • 100% Apple Juice • 100% Orange Juice • Unsweetened Applesauce • Mandarin Oranges (Cuties) • Frozen Mixed Berries (Strawberries, Raspberries, Blueberries, and Blackberries)
Vegetables • Carrot Sticks • Celery Sticks • Broccoli Florets • Oven Baked Potato Chips
Dairy • Low Fat Milk • Vanilla Yogurt • Strawberry Yogurt • Chocolate Pudding • Low Fat Chocolate Milk
Grains/Sweets • Pita Chips • Whole Grain Granola • Chocolate Chunk Cookies • Whole Grain Goldfish Crackers
Dips • Classic Hummus • Light Ranch Dressing
Other • Water
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a) b)
Figure 2. Picture Examples of Snack Labels and Placement for the Three Interval Times. Picture a) is a top view of the labels in front of items offered, b) is a side view, demonstrating the food and beverage placement.
together, the same layout placement was used throughout all of the IT. This experiment was a self-serve buffet approach, allowing participants to control the amounts of food and drinks they served themselves. Drinks were self-poured into a see-through 8-ounce cup and plates were white 8.5" paper plates. These items were placed on food trays to allow for digital photography documentation.
Digital Photography Documentation
Participant’s food selections and plate waste were recorded on food trays using the digital photography (DP) method. DP has been reported to be an efficient manner to document food consumption (Thompson, Subar, Loria, Reedy, & Baranowski, 2010;
Williamson et al., 2003). According to Williamson et al. (2003), advantages include a rapid collection of data on eating environments, allows for thorough food assessments, and can be convenient for the participants and researchers. Weighed food assessments are considered time-consuming, disruptive, and costly. Evaluating portion sizes of food intake through DP is particularly well suited for cafeterias and social settings due to being
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less disruptive and costly when compared to the weighing method (Thompson et al.,
2010; Williamson et al., 2003). The camera used was a Sony HDR-CX190 High
Definition Handycam 5.3 MP Camcorder. The camera was placed in a well-lit area to allow for clear DP records. The only pictures documented were of the food trays; thus, no pictures of the participants or schools were obtained.
As shown in Figure 3, the researcher took an above and horizontal picture of each food tray to ensure maximum visibility of all items and guarantee more accurate measurements. Food trays were documented twice: (1) after food/drink selection and (2) after food/drink consumption. If the participants choose to consume more food, another before and after food photograph was taken and added to the participant’s total food intake. Participants identification flashcards were placed on the food trays to distinguish and identify each food tray (as shown in Figure 3).
a) b)
c) d)
Figure 3. Picture Examples of Research Digital Photography Documentation. These are before and after consumption picture examples from both angles: (a) before consumption, top view (b) before consumption, horizontal view (c) post consumption, top view (d) post consumption, horizontal view.
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After participants finished eating, food trays were left where the participants ate and were then gathered and documented by the researcher. Once the last DP was taken,
food and drinks were discarded, and participants identification flashcards were collected and shredded at the schools’ main office. Pictures were transferred to a protected computer and evaluated by the researcher. Photos were deleted from the camera post transfer.
Mind-Body Therapy Intervention
The two forms of MBT used were Sun Salutation Yoga and Mindfulness
Meditation. The participants performed the yoga and meditation in a circle using yoga mats and pads. The researcher obtained a youth yoga certification in order to ensure participants’ safety when directing the yoga poses. Figure 4 demonstrates the Sun
Salutations Yoga sequence. This sequence was performed twice, with four second transitional time increments in-between yoga poses in order for the participants to fulfill their anaerobic exercise to contribute to their PE requirements.
Figure 4. Sun Salutation Yoga Posture Sequence. (“Surya Namaskar,” 2016).
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The guided mindfulness meditation recordings were derived from the
Mindfulness for Teens website (“Guided Meditations,” n.d.). The four recorded guided meditation files derive from the Mindfulness for Teens website were: Eating a Raisin
Mindfully (five-minutes long), Body Scan (five-minutes for CPS and ten-minutes for
OPS), Mindful Breathing (five-minutes), and Mindfulness of Thinking (five-minutes)
(“Guided Meditations,” n.d.). They were played through a loudspeaker (UE Boom 2) and placed in the center of the circle to ensure each participant could hear and follow the recordings. Meditation music was used during the MBT portion to support a tranquil environment.
Procedures
The study was conducted over three days (IT) during the participant’s physical education (PE) class. All materials and equipment items were set up before the participants' intervention. The research assistant helped with set-up, maintained snack portion sizes relatively equally, and tear-down during each IT. CPS had an open indoor gym with thick exercise mats; this area was used for the MBT practices and for the participants to consume their snack food and drinks. OPS had an indoor gym with a basketball court. Yoga and meditation sessions were performed on the court using towels as yoga mats, and the courtside bleachers were used for the students to sit and consume their food and drink(s). The students excluded from the study could not participate in any of the research activities, thus were separated from the research participants to not interfere with the study.
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Although both school data collections were done over three IT, the data collection days and PE times differed between schools. Table 4 explains the different IT procedures for each school based on IT time, day, and weeks. Figure 5 describes the procedures of
CPS participants, including the times for each step; likewise, Figure 6 did the same for
OPS. CPS had PE for 35 minutes every day; therefore, the data collection was completed within one week (the specific days being Monday, Wednesday, and Thursday). OPS had
PE only once a week for 45 minutes; thus, the IT took place over the span of three weeks.
The first IT (IT-1) was the baseline for both schools. On this day, the participants had their typical PE class except for the last 20 minutes. During this time, the researcher explained the research instructions to the participants. First, the participants were provided with instructions on how to correctly fill out their identification flashcards, which involved circling their gender (male or female) and writing their date of birth
(month, day, and year). It was emphasized to visibly place and leave the identification card on their food tray for DP documentation, which the participants successfully followed.
Table 4. Difference Between School Procedures Based on Days, Weeks, Length of Time, and Interval Time Schedule California Public School (CPS) Ohio Private School (OPS) (n = 29) (n = 19) Procedure Days Three Days Three Days Weeks One Week Three Weeks Length of Time 35 Minutes per IT 45 Minutes per IT Interval Times (IT) IT-1 Monday- RPE + Snack Week 1- RPE + Snack CPS-IT-2 Wednesday- MBT + Snack -- OPS-IT-2 -- Week 2- MBT + Snack CPS-IT-3 Thursday- MBT + Snack -- OPS-IT-3 -- Week 3- MBT + NE + Snack “n” means the number of individuals; “RPE” stands for Regular Physical Education class; "MBT" stands for Mind-Body Therapy (this includes both yoga and meditation); “NE” stands for Nutrition Education.
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The participants were then instructed to line up at the tray end of the tables for the food and drink selection. During which, the participants chose their snack items as they went down the tables. Participants were allowed to select any item they wanted and had no portion or serving size limit. The only food request was not to throw anything away.
At the end of the tables was a space left for DP, the researcher took a DP documentation of the participants' food trays before they consumed their snacks to ensure all of the participants' food trays were recorded before they began to eat. Once the participants
Week 1 - Monday
IT-1 (Baseline) Regular physical education class: 15 minutes
Study instructions and snack intake: 20 minutes • Introduction to study: 5 minutes • Snack nutrient intake: 15 minutes
Week 1 - Wednesday
CPS-IT-2 (Intervention #1) MBT practice: 20 minutes • Sun Salutation Yoga: 10 minutes (20 second per pose) • Mindful Meditation: 10 minutes o Mindful Breathing: 5 minutes o Body Scan (short): 5 minutes
Snack nutrient intake: 15 minutes
Week 1 - Thursday
CPS-IT-3 (Intervention #2) MBT practice: 20 minutes • Sun Salutation Yoga: 10 minutes (20 second per pose) • Mindful Meditation: 10 minutes o Eating a Raisin Mindfully: 5 minutes o Mindfulness of Thinking: 5 minutes
Snack nutrient intake: 15 minutes
Figure 5. California Public School Participants Procedures During Each Interval Time. “IT” stands for Interval Time; “CPS” stands for California Public School.
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finished eating their snacks, they were asked to either leave their food trays where they were or had a designated area for the participants to leave their food trays. This was done to allow the researcher enough time to collect and document all the post food tray pictures adequately.
Lastly, the children were explained that the following two PE classes would be the intervention days. During which they would begin with 20 to 30 minutes of yoga and meditation, followed by the same food and beverage snack selection. The participants successfully followed all of the instructions.
Week 1
IT-1 (Baseline) Regular physical education class: 25 minutes
Study instructions and snack intake: 20 minutes • Introduction to study: 5 minutes • Snack nutrient intake: 15 minutes
Week 2
OPS-IT-2 (Intervention #1) MBT practice: 30 minutes • Sun Salutation Yoga: 15 minutes (30 second per pose) • Mindful Meditation: 15 minutes o Mindful Breathing: 5 minutes o Body Scan (long): 10 minutes
Snack nutrient intake: 15 minutes
Week 3
OPS-IT-3 (Intervention #2) MBT practice: 25 minutes • Sun Salutation Yoga: 15 minutes (30 second per pose) • Mindful Meditation: 10 minutes o Eating a Raisin Mindfully: 5 minutes o Mindfulness of Thinking: 5 minutes
Nutrition education: 5 minutes Snack nutrient intake: 15 minutes
Figure 6. Ohio Private School Participants Procedures During Each Interval Time. “IT” stands for Interval Time; “OPS” stands for Ohio Private School.
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The second IT (IT-2) was the first MBT intervention, which involved yoga and meditation practice plus a snack intake. The participants began this day with 10 (CPS) to 15
(OPS) minutes of Sun Salutation Yoga. CPS held each yoga poses for about 20 seconds and
OPS held poses for about 30 seconds. The classes were performed in a circle versus all the participants facing in one direction. After the yoga session, the participants followed
10 (CPS) to 15 (OPS) minutes of the guided mindfulness meditation recordings from the
Mindfulness for Teens website (“Guided Meditations,” n.d.). Both schools started with the “Mindful Breathing” (~5 minutes) meditation. The second meditation recording was
“Body Scan (short)” (~5 minutes) for CPS and “Body Scan (long)” (~10 minutes) for
OPS (“Guided Meditations,” n.d.). These recordings involved the participants focusing on internal or physical signals, like breathing and being present. The rest of the class time (about 15 minutes) was for snack intake. The participants filled out their identification cards, visibly placed them on their food trays, and had the researcher document them via DP. The trays were again collected, documented, and discarded in the same manner as IT-1.
CPS on the third IT (IT-3) had their second MBT intervention, which involved the same yoga, meditation, and snack intake routine as IT-2. The only difference was the two mindfulness recordings the participants practiced, included “Eating a Raisin
Mindfully” (~5 minutes) and “Mindfulness of Thinking” (~5 minutes) (“Guided
Meditations,” n.d.). Whereas OPS on the third IT (OPS-IT-3) had their second MBT intervention, which involved yoga, meditation, a small nutrition education, and snack intake. OPS had practiced the same guided mindfulness recordings, yet the nutrition
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education occupied a five-minute gap in between MBT practices and snack intake.
Engaging nutrition education questions were used to teach how fruits, vegetables, whole grains, dairy products, protein, and water are important for their growing bodies, for example, “which foods do you believe are good for your body?” and “why are fruits and vegetables important?”. The researcher reinforced nutrition information to show how fruits, vegetables, and whole grains have the essential nutrients needed for their bodies to provide energy for daily activities and proper growth. Overall, identification cards, snack intake, and DP documentation were all successfully incorporated throughout all IT.
Data Analysis
The researcher estimated the participant's snack selection, consumption, and portion sizes and documented via excel. The researcher reviewed the documents twice to ensure accurate DP assessments were computed. Snack items were pre-measured using measuring spoons and cups then placed on the same cups and plates used by the participants and were recorded using the same DP method. These pre-measured pictures were then used as a reference to compare to the participants DP. Participant’s consumptions were determined by comparing the first food tray picture (before consumption) to the second (post consumption) and then subtracting the difference via excel. Once computed into excel, each snack item was linked to its nutrition information.
The nutrition information was derived from the USDA Food Composition Databases
(USDA, Agricultural Research Service [ARS], 2016a). The nutrient intakes assessed were: total calories (kcals), fats in grams (including total, saturated, MUFA and PUFA),
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carbohydrates in grams (including dietary fiber and added sugar), proteins in grams, and sodium, Vitamin A, D, C, calcium, and iron in milligrams.
For statistical analysis, this information was then transferred into IBM SPSS
Statistics (2017) software version 25. Of the 78 participants, only 48 participants attended all three IT. The rest were not included in the data analysis. OPS had 19 participants and CPS had 29 participants in total. For each school, a repeated measures
ANOVA analyzed the difference between IT for the snack groupings and nutrient intakes. The Greenhouse-Geisser correction was used when Mauchly's test of sphericity was violated (p < 0.05). Significance was established at p < 0.05 value. When necessary, the Bonferroni post-hoc test was performed to assess further where the statistically significant changes between IT occurred.
CHAPTER IV
JOURNAL ARTICLE
Introduction
One of the most significant health concerns in adolescents is their eating behavior.
The socio-culture pressures of dieting have compounded unhealthy food behavior in adolescents (Ensaff et al., 2015a; Fitzgerald et al., 2010). According to the Dietary
Guidelines for Americans (DGA) 2015-2020, adolescents are reported as the least likely age group to meet the national nutrition guidelines (The United States Department of
Health and Human Services [HHS] and United States Department of Agriculture
[USDA], 2015). Eating behaviors have also been shown to affect the physical, emotional, and physiological health and growth of adolescents (O’Neil et al., 2014). Many diseases in adulthood or even premature death can stem from adolescents’ actions, for example high stress levels and poor eating behaviors (Gurgevich & Nicolai, 2014; Larson et al.,
2016a; Masih et al., 2017; Ross, 2015; Taylor, Evers, & McKenna, 2005; Yeager et al.,
2014). Therefore, healthy behaviors in adolescents should include proper eating behaviors and stress reduction techniques for direct and future health benefits (Fitzgerald et al., 2010; HHS & USDA, 2015).
Mind-body therapies (MBT) are a mix of therapeutic practices with the intention to achieve a positive mind (thoughts) and spirit (emotions) synergistically with the body to positively enhance health (Astin, Shapiro, Eisenberg, & Forys, 2003; McClafferty,
2011; McClafferty et al., 2016; Sampaio, Lima, & Ladeia, 2016; West, 1975). Examples of MBT involve breathing exercises, affirmations, concentration meditation, mindfulness
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techniques, and mindful exercises like yoga and martial arts (Hart, 2015; McClafferty et al., 2016; Gurgevich et al., 2014). MBT has been reported as a method for developing intrinsic (internal) or autonomous (internal and external) motivation (Deci & Ryan,
2008); these types of motivations are most strongly associated with long-term behavior changes (Teixeira et al., 2010). Thus, MBT could be applied to build healthier lifestyle behaviors, such as consuming nutrient-dense foods. However, research on MBT concerning healthier eating behaviors, such as choosing to consume more nutrient-dense foods (e.g., fruits and vegetables) versus processed foods (e.g., chips and cookies) is insufficient. In addition, an average of only 3.7 percent of youths (ages 4-17 years) practiced MBT despite its reported benefits (McClafferty et al., 2016). The relatively small percentage of adolescents who practice MBT makes it harder to research and assess
MBT effects on eating behavior in adolescents. The purpose of the study was to evaluate the effect of MBT (yoga and meditation), with and without a nutrition lesson, to evaluate the difference in snack group and nutrient intake in seventh and eighth grade students.
Methods
The study was a non-randomized repeated measures design. The independent variables were the three different Interval Times (IT) for each school. The two schools were the California Public School (CPS) and Ohio Private School (OPS). The dependent variables were snack nutrient intakes.
Participants
Approval from Kent State University’s Institutional Review Board was obtained for the study and the participation of human subjects. Participants were based on
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convenience sampling; thus, the inclusion criteria were seventh and eighth grade students from the volunteered schools and PE classes. The two middle schools that volunteered were from different locations. OPS was a private school in Cleveland, Ohio and CPS was a public school in Oxnard, California. The exclusion criteria were students with food and beverage allergies to the items offered (illustrated in Table 3) and students that did not submit both their assent form and parent or guardian consent form. The students excluded from the study could not participate in any of the research activities, thus were separated to not interfere with the research participants. The two identifications markers obtained were the participants' date of birth (month, date, and year) and gender (male or female).
Measures
The materials used for this study mostly pertained to the snack items provided and
DP measuring equipment. Measurements were conducted before and after the use of Sun
Salutation Yoga and Guided Mindfulness Meditation for Teens.
Materials
Snack items (listed in Table 3) were provided in a self-serve buffet approach for the participants to choose and self-serve themselves. All snack items were required to correspond with the Smart Snack Standards (USDA, 2016a; USDA, 2016b). Snack items and digital photography (DP) documentation were located on one side of the room using two long rectangular tables. As shown in Figure 2(a), everything was labeled to avoid confusion regarding the snack items. Figure 2(b) displays the placement of the snacks,
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which were done in a manner to avoid potential bias (mix nutrient-dense and energy- dense items) and maintain environmental consistency (same setting and placements
during IT) (Kahn & Wansink, 2004). Drinks were self-poured into a see through eight- ounce cup, and 8.5" white paper plates were provided for food items. These items were placed on food trays to allow for DP.
Table 3. List of Snack Items Provided During Each Interval Times Food and Beverage Items Fruits • Raisins • Bananas • Apple Slices • 100% Apple Juice • 100% Orange Juice • Unsweetened Applesauce • Mandarin Oranges (Cuties) • Frozen Mixed Berries (Strawberries, Raspberries, Blueberries, and Blackberries)
Vegetables • Carrot Sticks • Celery Sticks • Broccoli Florets • Oven Baked Potato Chips
Dairy • Low Fat Milk • Vanilla Yogurt • Strawberry Yogurt • Chocolate Pudding • Low Fat Chocolate Milk
Grains/Sweets • Pita Chips • Whole Grain Granola • Chocolate Chunk Cookies • Whole Grain Goldfish Crackers
Dips • Classic Hummus • Light Ranch Dressing
Other • Water
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a) b)
Figure 2. Picture Examples of Snack Labels and Placement for the Three Interval Times. Picture a) is a top view of the labels in front of items offered, b) is a side view, demonstrating the food and beverage placement.
Digital Photography
Participant’s snack consumption was documented utilizing the DP approach. DP has reportedly been found to have many advantages, such as rapid collection of data in eating environments that still allowed for thorough food assessments,
which is convenient for both the participants and researchers (Williamson et al., 2003, pp. 1140). Evaluating portion sizes of food intake through DP is particularly well suited for cafeterias and social settings due to being less disruptive and costly when compared to the weighing method (Thompson et al., 2010; Williamson et al., 2003). The camera used for DP was a Sony HDR-CX190 Handycam 5.3 MP Camcorder.
As shown in Figure 3, photographs were taken from above and horizontal angles to ensure maximum visibility of the snack items for more accurate measurements.
Participant’s trays were photographed twice: (1) after food/drink selection and (2) after food/drink consumption. If the participants choose to consume more food, a third set of
DP was taken and added to the participant’s total intake. To identify the pictures, the participants placed their identification flashcard on their food trays (as shown in Figure
3). The participants left post consumption trays where they were or in a specific area for
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the researcher to collect and complete DP documentation. These photographs were reviewed and analyzed after all three IT and incorporated into excel spreadsheets that detailed the intakes of adolescents.
a) b)
c) d)
Figure 3. Picture Examples of Research Digital Photography Documentation. These are before and after consumption picture examples from both angles: (a) before consumption, top view (b) before consumption, horizontal view (c) post consumption, top view (d) post consumption, horizontal view.
Mind-Body Therapy
The two MBT practices were Sun Salutation Yoga and Guided Mindfulness
Meditation. The researcher obtained a youth yoga certification in order to ensure participants’ safety when directing the yoga poses. The Sun Salutations Yoga session consisted of twelve yoga poses and were instructed with four-second transitional time increment in-between yoga poses to fulfill their anaerobic exercise to contribute to their
PE requirements. The four recorded guided meditation files derive from the Mindfulness
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for Teens website were: Eating a Raisin Mindfully (five-minutes long), Body Scan (five- minutes for CPS and ten-minutes for OPS), Mindful Breathing (five-minutes), and
Mindfulness of Thinking (five-minutes) (“Guided Meditations,” n.d.). The audio recordings were played through a speaker placed in the center of the room to ensure each participant could hear and follow the guided meditation recordings.
Procedures
The study was conducted during three physical education (PE) classes for each school. Although both school data collections were done in three days (IT), IT differed based on the schools PE schedule and time, which ranged from 35 or 45 minutes. The different IT times, days, and weeks between the two schools are explained in Table 4 and illustrated in Figure 5 and Figure 6.
The IT-1 (baseline) was a typical PE class for the participants with the last 20 minutes being allocated to provide research instructions. The instructions involved identification flashcards, DP, and the MBT interventions. Afterward, the participants chose and consumed their snack items. For this, participants lined up and served
Table 4. Difference Between School Procedures Based on Days, Weeks, Length of Time, and Interval Time Schedule California Public School (CPS) Ohio Private School (OPS) (n = 29) (n = 19) Procedure Days Three Days Three Days Weeks One Week Three Weeks Length of Time 35 Minutes per IT 45 Minutes per IT Interval Times (IT) IT-1 Monday- RPE + Snack Week 1- RPE + Snack CPS-IT-2 Wednesday- MBT + Snack -- OPS-IT-2 -- Week 2- MBT + Snack CPS-IT-3 Thursday- MBT + Snack -- OPS-IT-3 -- Week 3- MBT + NE + Snack “n” means the number of individuals; “RPE” stands for Regular Physical Education class; "MBT" stands for Mind-Body Therapy (this includes both yoga and meditation); “NE” stands for Nutrition Education.
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themselves as they went down the table where a camera was located for DP. Each participants food tray was only identified by the DP identification flashcards that included their gender (male or female) and their written date of birth (month, day, and year). Once participants finished eating their snacks and departed to their following class, their food trays were collected by the researcher and documented via DP.
For both schools, IT-2 and IT-3 incorporated MBT intervention. The participants began these IT with Sun Salutation Yoga. After the yoga session, the participants
Week 1 - Monday
IT-1 (Baseline) Regular physical education class: 15 minutes
Study instructions and snack intake: 20 minutes • Introduction to study: 5 minutes • Snack nutrient intake: 15 minutes
Week 1 - Wednesday
CPS-IT-2 (Intervention #1) MBT practice: 20 minutes • Sun Salutation Yoga: 10 minutes (20 second per pose) • Mindful Meditation: 10 minutes o Mindful Breathing: 5 minutes o Body Scan (short): 5 minutes
Snack nutrient intake: 15 minutes
Week 1 - Thursday
CPS-IT-3 (Intervention #2) MBT practice: 20 minutes • Sun Salutation Yoga: 10 minutes (20 second per pose) • Mindful Meditation: 10 minutes o Eating a Raisin Mindfully: 5 minutes o Mindfulness of Thinking: 5 minutes
Snack nutrient intake: 15 minutes
Figure 5. California Public School Participants Procedures During Each Interval Time. “IT” stands for Interval Time; “CPS” stands for California Public School.
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followed the guided mindfulness meditation recordings from the Mindfulness for Teens website (“Guided Meditations,” n.d.). Both schools started with the “Mindful Breathing” meditation, yet the second meditation recording for CPS was the shorter version of the
“Body Scan” recording whereas OPS participants practiced the longer version (“Guided
Meditations,” n.d.). The rest of the class time was allocated to the snack selection and
DP documentation. CPS-IT-3 was similar to CPS-IT-2, except the mindfulness meditation was “Eating a Raisin Mindfully” and “Mindfulness of Thinking.” OPS-IT-3
Week 1
IT-1 (Baseline) Regular physical education class: 25 minutes
Study instructions and snack intake: 20 minutes • Introduction to study: 5 minutes • Snack nutrient intake: 15 minutes
Week 2
OPS-IT-2 (Intervention #1) MBT practice: 30 minutes • Sun Salutation Yoga: 15 minutes (30 second per pose) • Mindful Meditation: 15 minutes o Mindful Breathing: 5 minutes o Body Scan (long): 10 minutes
Snack nutrient intake: 15 minutes
Week 3
OPS-IT-3 (Intervention #2) MBT practice: 25 minutes • Sun Salutation Yoga: 15 minutes (30 second per pose) • Mindful Meditation: 10 minutes o Eating a Raisin Mindfully: 5 minutes o Mindfulness of Thinking: 5 minutes
Nutrition education: 5 minutes Snack nutrient intake: 15 minutes
Figure 6. Ohio Private School Participants Procedures During Each Interval Time. “IT” stands for Interval Time; “OPS” stands for Ohio Private School.
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also performed the same yoga practice as OPS-IT-2 and the same mindfulness recordings as CPS-IT-3. OPS-IT-3 also included a five-minute nutrition education lesson. The lessons involved asking probing questions whose answers highlight healthier snack options (e.g., fruits, vegetables, whole grains, and water) that are important for their growing bodies. The probing questions asked included “which foods do you believe are good for your body?” and “why are fruits and vegetables important?”. The researcher guided the conversations to reinforce adequate nutrition information was provided. After the last IT, the photos were reviewed, reorganized, and computed into Excel tables.
Data Analysis
Snack nutrition information was derived from the USDA Food Composition
Database (USDA, ARS, 2016a). The nutrient intakes assessed were: total calories
(kcals), fats in grams (including total, saturated, MUFA and PUFA), carbohydrates in grams (including dietary fiber and added sugar), proteins in grams, and sodium, Vitamin
A, D, C, calcium, and iron in milligrams. Participant’s consumptions were determined by comparing the pre- and post- consumption of snack DP and subtracting the difference.
This information was transferred to the IBM SPSS Statistics (2017) software
(version 25) for statistical analysis. A repeated measures ANOVA was used to assess the nutrient intakes from the independent variables (IT) for each school. Significance was established at p < 0.05 value and Bonferroni post-hoc test were performed when necessary to assess statistical significance further.
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Results
The participating CPS and OPS demographic information is shown in Table 5.
Both schools had a total of forty-eight participants included in the study. From the participants that attended all three IT, 29 came from CPS and 19 were from OPS.
Students that were absent from school during one or two of the IT were excluded. CPS had 13 participants dropout due to school absence. OPS had 17 student’s dropouts mainly due to school holiday break and weather storms occurring during the time of the study. The rest of the participants had a 100% compliance rate, implying all participants that attended their regularly scheduled classes chose to partake in the study.
Table 5. Participating Schools’ Demographics on School Type, Residential State, Grade Levels, Percent Qualified for Free- and Reduced- Price Meals, Gender, and Race Demographic Variables Participating Schools School Type Public Private Residential State California Ohio Grades (Total # of Students) 6 – 8 (1,136) Prekindergarten - 8 (575) Students enrolled in seventh grade 385 67 Students enrolled in eighth grade 380 57 Free- and Reduced- Price Meals % 74.0% a 95.89% b Gender Male 557 331 c Female 579 258 c Race American Indian / Alaska Native 3 0 Asian 48 12 Black 57 128 Hispanic 933 172 White 79 144 Native Hawaiian / Pacific Islander 0 0 Two or More Races 16 77 Adapted from the National Center for Education Statistics (n.d.). a California Department of Education (2018). b Ohio Department of Education (2018). c USASchoolInfo (2010).
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The forty-eight research participants demographic information is illustrated in
Table 6. There were ten more participants in CPS than OPS and ten more female participants than males. The grade levels had a relatively similar number of participants with four more seventh graders than eighth graders. The overall mean age at the time of the study was 12 years old (standard deviation [SD] was seven). Since the two schools had different interventions times during IT, they are discussed separately to better understand nutrient snack intakes after the integration of yoga and meditation, including with and without a five-minute nutrition education.
Table 6. Demographics by School, Grade, Age, and Gender for Yoga and Meditation Intervention Participants
Demographic Variable n % Mean ± SD School CPS 29 60
OPS 19 40 Grade Seventh Grade 26 54
Eighth Grade 22 46 Age 12 15 31 13 18 38 12.0 ± 7.0 14 13 27 15 2 4 Gender Males 19 40
Females 29 60 CPS = California Public School; OPS = Ohio Private School; SD = Standard Deviation; % = Total Percentage; n = Number of Participants.
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California Public School
Table 7 describes CPS participants snack nutrient intakes for the three IT. The table shows CPS did not display any significant changes in nutrient intake between IT.
Table 7. Snack Mean ± SD and p Values for Nutrient Intake During the Three Interval Times for Seventh and Eighth Grade Yoga and Meditation Participants in the California Public School (n = 29)
CPS-IT-1 CPS-IT-2 CPS-IT-3 Nutrition Information p M ± SD M ± SD M ± SD
Total calories (kcals) 317.87 ± 91.67 309.08 ± 107.87 312.00 ± 100.15 0.915
Total Fat (g) 8.62 ± 4.23 9.22 ± 5.23 9.34 ± 4.53 0.657
Total Fat (% of kcals) 23.38 ± 7.20 25.41 ± 9.19 25.93 ± 8.88 0.152
Saturated Fat (g) 2.02 ± 1.27 2.16 ± 1.53 2.25 ± 1.36 0.607
Saturated Fat (% of 5.32 ± 2.55 5.78 ± 2.96 6.15 ± 3.03 0.177 kcals)
Polyunsaturated Fat (g) 0.83 ± .47 0.98 ± .52 1.03 ± .59 0.118
Monounsaturated Fat (g) 3.48 ± 2.23 3.59 ± 2.57 4.01 ± 2.62 0.446
Sodium (mg) 271.04 ± 118.59 283.18 ± 147.44 257.29 ± 137.87 0.536
Total Carbohydrate (g) 56.70 ± 13.57 51.55 ± 15.90 52.31 ± 15.62 0.293
Dietary Fiber (g) 4.10 ± 1.43 3.64 ± 1.22 3.42 ± 1.28 0.106
Sugars (g) 33.89 ± 8.57 28.84 ± 10.14 30.72 ± 9.95 0.062
Sugar (% by weight) 12.49 ± 2.12 13.67 ± 3.65 13.12 ± 4.47 0.355
Protein (g) 6.16 ± 3.43 6.55 ± 3.54 6.06 ± 3.43 0.736
Iron (mg) 1.67 ± 0.56 1.56 ± 0.65 1.6. ± 0.64 0.757
Calcium (mg) 134.91 ± 105.85 148.06 ± 106.40 129.03 ± 107.58 0.639
Vitamin D (IU) 22.20 ± 34.09 32.36 ± 34.21 26.71 ± 35.27 0.300
Potassium (mg) 498.73 ± 178.63 445.08 ± 142.28 439.145 ± 139.45 0.185
CPS-IT-1 = baseline; CPS-IT-2 = first yoga and meditation intervention; CPS-IT-3 = second yoga and meditation intervention. *p < 0.05.
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Ohio Private School
The OPS participants nutrient intake results are summarized in Table 8. The
Greenhouse-Geisser correction was used for total calories, polyunsaturated fatty acids
(PUFA), monounsaturated fatty acids (MUFA), total carbohydrates, sugar, iron, and calcium. Statistical significance was found for PUFA, MUFA, sodium, and iron.
Table 8. Snack Mean ± SD and p Values for Nutrient Intake During the Three Interval Times for Seventh and Eighth Grade Yoga, Meditation, and Small Nutrition Education Participants in the Ohio Private School (n =19)
OPS-IT-1 OPS-IT-2 -IT-3 Nutrition Information p M ± SD M ± SD M ± SD
Total calories (kcals) 321.10 ± 135.23 351.76 ± 197.56 299.29 ± 159.40 0.298
Total Fat (g) 7.26 ± 4.28 8.98 ± 7.12 7.83 ± 5.70 0.287
Total Fat (% of calories) 19.32 ± 7.31 20.37 ± 8.06 21.26 ± 9.73 0.429
Saturated Fat (g) 1.34 ± 1.03 1.78 ± 1.75 1.52 ± 1.55 0.285
Saturated Fat (% of kcals) 3.55 ± 2.35 3.88 ± 2.05 3.84 ± 2.54 0.779
Polyunsaturated Fat (g) 0.45 ± .44 0.47 ± .35 1.04 ± .89 0.009*
Monounsaturated Fat (g) 0.79 ± 1.11 0.95 ± 1.49 3.26 ± 2.77 0.001*
Sodium (mg) 316.40 ± 183.45 362.39 ± 250.12 260.12 ± 180.02 0.038*
Total Carbohydrate (g) 59.43 ± 24.07 61.77 ± 32.19 50.82 ± 25.01 0.155
Dietary Fiber (g) 3.47 ± 1.87 3.10 ± 1.57 3.59 ± 1.76 0.453
Sugars (g) 31.16 ± 14.59 31.32 ± 19.18 25.99 ± 14.69 0.097
Sugar (% by weight) 10.08 ± 5.35 10.95 ± 4.62 10.47 ± 7.09 0.702
Protein (g) 6.88 ± 4.04 7.28 ± 4.04 6.93 ± 4.18 0.845
Iron (mg) 2.14 ± .95 2.69 ± 2.07 1.47 ± .85 0.012*
Calcium (mg) 156.00 ± 127.73 155.64 ± 106.25 144.82 ± 107.31 0.715
Vitamin D (IU) 33.75 ± 40.67 28.86 ± 28.85 31.95 ± 35.04 0.660
Potassium (mg) 526.58 ± 245.96 454.53 ± 212.38 468.62 ± 241.56 0.333
IT-1 = control; OPS-IT-2 = first yoga and meditation intervention; OPS-IT-3 = second yoga and meditation intervention plus nutrition education *p < 0.05.
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Bonferroni post-hoc tests were therefore performed on these nutrients.
Bonferroni post-hoc results for both poly- and mono-unsaturated fatty acid intakes were similar in that OPS participants’ intakes had significantly increased between OPS-
IT-2 to OPS-IT-3 for PUFA (p < 0.028) and MUFA (p < 0.007). Figure 7 and Figure 8 visually demonstrate the mean difference of PUFA and MUFA, respectfully.
1.2
1 1.04 0.8 0.6
(grams) 0.4 0.47
0.2 0.45 Polyunsaturated Polyunsaturated Fat Mean IntakeMean Fat 0 IT-1 OPS-IT-2 OPS-IT-3 Interval Times
Figure 7. Seventh and Eighth Grade 6. Ohio Private School Participants’ Mean Polyunsaturated Fat Intake (grams) from the Three Interval Times (IT). IT-1 = control (regular physical education class); OPS-IT-2 = first intervention (yoga and meditation); OPS-IT-3 = second intervention (yoga, meditation, and small nutrition education). The significant difference was found between OPS-IT-2 and OPS-IT-3 (p < 0.028).
4
3 3.26 2
(grams) 1 0.79 0.95
Fat Mean IntakeMean Fat 0 Monounsaturated Monounsaturated IT-1 OPS-IT-2 OPS-IT-3 Interval Times
Figure 8. Seventh and Eighth Grade Ohio Private School Participants’ Mean Monounsaturated Fat Intake (grams) from the Three Interval Times (IT). IT-1 = control (regular physical education class); OPS-IT-2 = first intervention (yoga and meditation); OPS-IT-3 = second intervention (yoga, meditation, and small nutrition education). The significant difference was found between OPS-IT-2 and OPS-IT-3 (p < 0.007).
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Figure 9 illustrates the average sodium intake of participants from OPS. The figure and post-hoc results demonstrated the mean consumption had increased from IT-1 to IT-2, but significantly decreased from OPS-IT-2 to OPS-IT-3 (p < 0.024). Similarly, iron’s mean intake increased from IT-1 to OPS-IT-2 and then significantly decreased on
OPS-IT-3 (p < 0.013), shown in Figure 10.
400
350 362.39 300 316.40 250 260.12 Sodium Mean Mean Sodium 200
(milligrams) Intake IT-1 OPS-IT-2 OPS-IT-3 Interval Times
Figure 9. Seventh and Eighth Grade Ohio Private School Participants’ Mean Sodium Intake (milligrams) from the Three Interval Times (IT). IT-1 = control (regular physical education class); OPS-IT-2 = first intervention (yoga and meditation); OPS-IT-3 = second intervention (yoga, meditation, and small nutrition education). The significant difference was found between OPS-IT-2 and OPS-IT-3 (p < 0.024).
3
2.5 2.69 2 2.14 1.5
(milligrams) 1 1.47 IntakeMean Iron IT-1 OPS-IT-2 OPS-IT-3 Interval Times
Figure 10. Seventh and Eighth Grade Ohio Private School Participants’ Mean Iron Intake (milligrams) from the Three Interval Times (IT). IT-1 = control (regular physical education class); OPS-IT-2 = first intervention (yoga and meditation); OPS- IT-3 = second intervention (yoga, meditation, and small nutrition education). The significant difference was found between OPS-IT-2 and OPS-IT-3 (p < 0.013).
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Discussion
The results from CPS participant’s snack nutrient intakes did not display any significant changes with the integration of MBT (yoga and meditation) during IT, therefore the hypothesis was rejected for this school. The results from OPS participant’s snack nutrient intakes did not display significant changes between baseline (IT-1) and
OPS-IT-2 in seventh and eighth grade participants, therefore the first hypothesis for OPS was rejected. Conversely, the study did show significant differences in OPS seventh and eighth grade student’s snack nutrient intakes after the inclusion of nutrition education with MBT compared to IT that did not include the nutrition education; thus the second hypothesis for OPS was accepted. This suggests nutrient snack intakes can differ when
MBT is integrated with nutrition education and may be beneficial in helping seventh and eighth grade students consume healthier nutrients during snack occasions, such as a decrease in OPS sodium intake. The distinction between the two schools was the length and frequency of IT, as well as the addition of a five-minute nutrition education lesson during OPS-IT-3. These differences are the reason the results will further be discussed separately by the school.
California Public School
The nutrient snack intake results from CPS did not present any significant changes. CPS participant’s mean calorie and sodium intakes exceeded the Smart Snack standards on all three IT with an average intake of 313 calories and 270.5 mg of sodium.
The Smart Snack standards for both calories and sodium were set to not exceed 200 calories or 200 mg of sodium per snack occasion. Even with CPS-IT-3 displaying the
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lowest sodium consumption between the three IT, the mean intake was still 57 mg above the Smart Snack standard. The percent of fat intake for all three IT was less than recommendations with an average total fat intake of 25% and saturated fat intake of 6%
(USDA, 2016a; USDA, 2016b).
The average carbohydrate mean intakes, including dietary fiber and sugar, contributed to about 41% (54 grams) of the daily carbohydrate recommendations (USDA,
2016b). Of adolescent’s daily fiber recommendations, CPS participants average intake had accounted for about 15% (3.7 grams) of their daily needs (HHS & USDA, 2015).
The intake of dietary fiber can be linked with the consumption of fruits, vegetables, and whole grains since these food groups are the highest sources of dietary fiber (Concanno,
2011; HHS & USDA, 2015). In 2016, U.S. adolescents on average were reported to consume one-fifth of their daily fiber recommendations (USDA, ARS, 2016b). CPS participant’s dietary fiber consumption from this one snack occasion was just 5% below the average daily intake, demonstrating snacks potential to help adolescents fulfill their daily nutrient recommendations. The slightly higher fiber intake is positive as adolescents' dietary fiber has been reported to be under-consumed (Rishikof, 2017).
Moreover, sugar intake for CPS participants was on average 22 percent below the Smart
Snack standard of < 35 percent sugar by weight (USDA, 2016a; USDA, 2016b). These outcomes are good because sugar has been emphasized to be over-consumed by adolescents and is thus recommended that daily sugar intake be limited. Overall, seventh and eighth grade participants baseline (IT-1) results did not significantly differ in snack
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nutrient intakes after the practice of MBT (yoga and meditation) was implemented during
CPS-IT-2 and CPS-IT-3; thus, the hypothesis for CPS was rejected.
The research participants different snack nutrient intakes could have been impacted by external factors that were not tested during this pilot study. For example, peer influence could have affected eating behaviors (e.g., selection, preference, amount, and consumption) due to participants choosing their snack items in line with their peers and consuming their snacks in a social setting (Hutchinson & Rapee, 2007; Salvy et al.,
2012). The unhealthy preferences of adolescents are presumed to be due to the autonomy practice of going against food enforced by adult’s (Evans et al., 2015; Giese et al., 2015;
Neumark-Sztainer, Story, Perry, & Casey, 1999). Participants level of nutrition education was not measured and could have also influenced participants eating choices as CPS did not incorporate any nutrition information. Other factors that could have impacted the consumption of nutrient snack items is their home availability, socio-cultural influences, food attitudes, and inconsistent eating patterns (Granner et al., 2004; Neumark-Sztainer et al., 2003). Although these factors were not assessed, their potential influences should be considered in future research.
Ohio Private School
The snack nutrient intake results from OPS displayed differences between IT after incorporating MBT with nutrition education, compared to IT that did not include the nutrition education. The average nutrient intakes for OPS participants were compared with the Smart Snack standards and varied in calorie, sodium, fat, and sugar consumption. The mean calorie intake of all three IT was 324 calories, this exceeded the
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< 200 calorie Smart Snack standards for school snacks (USDA, 2016a; USDA, 2016b).
The snack occasions for this study provided on average 14 percent of the daily calorie recommendations for adolescents, which is 11 percent less than the average U.S. calorie snack consumption (USDA, ARS, 2016b).
OPS participant’s average intake for calories derived from total fat was roughly
20 percent. This intake was below U.S. adolescents average snack intake of 22 percent and did not exceed the 35 percent or less Smart Snack standard for total calories from fat
(USDA, 2016a; USDA, 2016b; USDA, ARS, 2016b). PUFA and MUFA intakes had shown a significant increase, particularly between OPS-IT-2 and OPS-IT-3. Of the 10-16 grams of PUFA and 1-1.6 grams of MUFA recommendations (HHS & USDA, 2015), the average OPS participants intake was five percent (0.65 grams) for PUFA and fulfilled for
MUFA (1.7 grams). Unsaturated fat intake for this study was mainly correlated with whole grain granola, mandarins, baked chips, pita chips, and banana intakes, as these items contained the highest sources of MUFA and PUFA ratios. Unsaturated fats are recommended as part of a healthy diet due to the good sources of essential fatty acids and antioxidants (e.g., vitamin E) that can help decrease the risk of cardiovascular diseases
(HHS & USDA, 2015; Nicklas, Weaver, Britten, & Stitzel, 2005). These fats are also encouraged in place of saturated fats, not only because of their nutrient contents but because the body produces enough saturated fat after two years of age that it is no longer required from outside sources (HHS & USDA, 2015). Primary sources of saturated fat include meats and high-fat dairy products, these items have been linked with unhealthy blood lipid levels (increase low-density lipoprotein and cholesterol) which have shown to
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cause an increased risk for developing cardiovascular diseases (Siri-Tarino, Sun, Hu, &
Krauss, 2010). Provided from highest to lowest, the greatest sources of saturated fat in this study were cookies, ranch, hummus, chocolate milk, and regular milk. OPS participants average mean intake for saturated fat was four percent of calories, this was better than the national U.S. average of twenty-three percent for adolescents and was below the ten percent Smart Snack standard (USDA, ARS, 2016b).
Although the mean sodium intake for OPS was 60 mg above the 200 mg Smart
Snack standard (USDA, 2016a; USDA, 2016b), sodium intake showed a significant decrease by 100 mg between OPS-IT-2 and OPS-IT-3. This is substantial as it demonstrates how the inclusion of a nutrition education lesson combined with the MBT can significantly decrease sodium intake versus the practice of MBT without nutrition education. The lower sodium consumption is beneficial as sodium is one of the major nutrients to be over-consumed by U.S. adolescents (HHS & USDA, 2015).
Similar to sodium, sugar had its lowest intake on OPS-IT-3 with a mean decrease of five grams (down to 26 grams). The sugar by weight percentage, averaged for all snack occasions, was 11 percent for OPS participants. This intake was 25 percent below the Smart Snack standard (USDA, 2016a; USDA, 2016b). The average total sugar consumption during a snack occasion for adolescents was 37 percent (USDA, ARS,
2016b), implying that sugar intakes for OPS participants were comparatively positive.
Both total carbohydrate and fiber intakes varied between IT. Compared with the daily intake recommendations, the average intake for all snacking occasions total carbohydrates was 44 percent (57.3 grams), and fiber was 13 percent (3.4 grams) (HHS
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& USDA, 2015). According to the WWEIA, adolescents consumed 28 percent of their daily carbohydrate recommendations and 21 percent of their daily fiber recommendations during the snack occasions (USDA, ARS, 2016b). These results demonstrated there was a higher intake of carbohydrates and a lower intake of fiber in OPS participants compared to the U.S. national average. This could have been due to a possible lower intake in fruits, vegetables, and whole grains since these sources were the highest containing fiber items.
From the nutrients of public health concern for adolescents, iron was the only nutrient to demonstrate significant changes during IT. The significant difference in iron intake was between OPS-IT-2 and OPS-IT-3 with a 1.2 mg consumption decrease, the opposite of positive findings. The average iron intake for the three IT contributed to 18 percent (2.1 mg) of the average iron recommendations for adolescents (HHS & USDA,
2015). OPS participant intake was just slightly higher than the 17.5 percent national U.S. snacking average for iron intake (USDA, ARS, 2016b). Iron is essential in adolescents for physiological growth and female menstruation as both require an increased amount of blood volume (HHS & USDA, 2015; Mesías, Seiquer, & Navarro, 2013). Iron from non- heme (plant based) sources, which were the types provided in this study (e.g., hummus, granola, and raisins), are best absorbed when coupled with vitamin C rich foods (Drake,
2012; HHS & USDA, 2015). Vitamin C rich foods provided in this study were broccoli, mandarin, and apple slices.
Protein intake is recommended during snack occasions to support growth and aid with satiety (HHS & USDA, 2015). U.S. adolescent’s national average protein
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consumption during snack occasions was 14 percent (USDA, ARS, 2016b), whereas the average OPS mean protein intake was 16 percent (HHS & USDA, 2015). OPS participants had an average protein intake of seven grams, the highest sources of protein came from hummus and dairy products (primarily low fat milk and chocolate milk).
Even though the participants' intakes did not have substantial differences between all IT, the average intake of protein from the snacking occasions for OPS showed to be good overall.
The results of the study confirmed that adolescent seventh and eighth grade participants performing MBT with the inclusion of a five-minute nutrition education lesson (OPS-IT-3) had significantly different nutrient snack intakes compared to IT that did not include the nutrition education (IT-1 and OPS-IT-2). Significant changes occurred for PUFA, MUFA, and sodium; thus, the hypothesis for OPS was accepted.
The addition of a nutrition education lesson with MBT demonstrated to have greater effects on nutrient intakes than MBT alone.
MBT was used in this study for its positive influences provided through synergistically using the mind and body together (Hart, 2015; Gurgevich & Nicolai,
2014). The practice of MBT interventions were introduced into adolescents snacking environment in order to see if the synergism achieved through MBT would encourage adolescent participants to incorporate and reinforce positive nutrition information; in ways that allow for proper dietary assessments based on internal signals (e.g., hunger and appetite signals, and how certain foods make the body feel) versus external influences
(e.g., peers) (Barnes et al., 2016; Brown & Ryan, 2003; Oswald et al., 2017; Stites et al.,
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2015; Warren et al., 2017). No other study on adolescents’ nutrient intakes had evaluated the effect of MBT alone and in combination with nutrition education, but the results produced from this short pilot study demonstrated snacking nutrient intakes differed significantly after incorporating both. Prior studies with programs similar to MBT successfully used intuitive or mindful eating (some including yoga and meditation) to emphasize proper eating behaviors, such as internal appetite cues and specific nutrient intakes, these were linked with a decreased consumption of calories, total fat, and saturated fat (Barnes et al., 2016; Katterman et al., 2014; Neumark-Sztainer, 2014;
Oswald et al., 2017; Stites et al., 2015; Warren et al., 2017).
Strengths and Limitations
This pilot study exploring MBT effects on adolescents snacking intakes is subject to many strengths and limitations. It is the first to analyze whether or not yoga and meditation practices, with and without nutrition education, would inadvertently guide seventh and eighth grade students to consume different t snack nutrient intake choices.
Even though MBT has not been heavily adopted by adolescents (Black, 2015), the 100% participant compliance rate strengthens the use of MBT in this age group. With the growing research on MBT, this study was meant to explore adolescents current snacking issues. Snacking intakes documented using digital photography (DP), rather than with participant-self questionnaires, can be considered a strength as it provides consistent measurements and more accurate representations of intakes (Barnes et al., 2016; Popkin
& Duffey, 2010; Williamson et al., 2003). The possible common errors associated with inaccurate self-reporting, including imprecise estimation of portion sizes and the inability
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for participants to clearly remember or describe all ingredients consumed, are not present with the use of DP (Thompson et al., 2010; Williamson et al., 2003). Another strength of this research study was the diverse demographics of the participants who were based in two different states (California and Ohio) and from two different school types (private and public). Most studies that related MBT with eating behaviors had focused on overweight, obese, or disordered eating participants, whereas this study was focused solely on and was intended to be a good representation of general school-age adolescents.
Limitations included non-randomized participant selection and relatively small sample sizes for each school; CPS had 29 and OPS had 19 participants total. The small sample size cannot be considered an accurate reflection of the general population and could have interfered with the statistical results due to higher chances of disparity. DP could have also posed potential risks involving inaccurate data readings, specifically through potential researcher bias and the inability to provide an overall daily intake
(Williamson et al., 2003).
Another limiting factor that could have impacted the study were the snack items provided. First, budget constraints interfered with the ability to provide a greater variety of snacks and drinks. Secondly, snack items were required to be Smart Snack compliant which meant the selection of items were restricted. In addition, the overall nutrient content of the snack items provided could be considerably healthier than competitive food items available outside of the schools as they are typically lower in essential nutrients and higher in calories, mainly from fat, sodium, and sugar contents (Evans et al., 2015; Larson et al., 2016a; Popkin & Duffey, 2010).
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The length of the study was comparatively short, approximately 30 to 45 minutes a day with only two days of MBT interventions. Research on eating based mindfulness training (some including yoga and meditation) that demonstrated positive dietary behavior changes were performed for more extended periods of time, these studies ranged from six to twelve-weeks and had six to twelve months follow-ups (Barnes et al.,
2016; Dalen et al., 2010; Daubenmier et al., 2011). The timing of the snacks provided was between breakfast and lunch, during the participant's PE class, at a time when snacks are generally not provided. The snack timing could have led to eating when not hungry, which could have accounted for the poor diet behaviors (Bellisle, 2014; Hess et al., 2016;
Larson et al., 2016a; Wang et al., 2018).
Application
Students often go to schools where many stressors arise from issues involving diets, family/peer-interactions, socio-economic status, and susceptibility to physical and mental health risk factors (Meiklejohn et al. 2012). Proper nutrition during state testing is a common practice in U.S. schools to ensure students are well fed during these times, yet the anxiety and stress involved have not been addressed. MBT has shown to reduce stress (Gurgevich et al., 2014), which improves metabolic health and results in less disordered eating (Radin et al., 2016). Depending on the individual, excessive stressors have shown to be problematic in terms of health affecting adolescent’s growth and brain development, which could lead to lifelong problems in learning, behavior, and overall wellness (Meiklejohn et al. 2012).
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School programs should be tailored around participants age ranges, interests, special needs, and desired outcomes. Schools should develop plans that utilize MBT in conjunction with their existing nutrition education (health and gym) as programs like the
Smart Snack standards cannot independently change adolescents’ snack nutrient intakes.
MBT and positive dietary behavior research have both shown to be interconnected in treating similar health issues involving psychological (depression, improved cognitive performance, mood/emotions, and self-esteem), physical (increase cardiovascular health and decrease hypertension, coronary artery disease, headaches, insomnia, and other diseases), and social (better academic, social, and classroom interactions) concerns (Astin et al., 2003; “Childhood Nutrition,” 2017; HHS & USDA, 2015; McClafferty et al., 2016;
Reedy & Krebs-Smith, 2010; Renshaw, Fischer, & Klingbeil, 2017; Sahoo et al., 2015;
Wisner, 2017). Short but regular MBT combined with positive nutrition education practices, can strengthen adolescents innate capacities to apply these beneficial practices later in life (Meiklejohn et al. 2012).
Adolescents have been reported to display MBT benefits if practiced for just 10-
15 minutes a day (Wisner et al., 2010), making the implementation into school schedules relatively easy. Students can also benefit from including some form of nutrition education in conjunction with the MBT as they can potentially produce healthier nutrient intakes (Barnes et al., 2016). For example, MBT and nutrition education can be incorporated through posters in student hallways or daily school announcements as a way to reinforce healthier behaviors into the school’s environment. MBT can be practiced in any space and could be provided in a designated area to encourage adolescents use of
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yoga and meditation; for instance, teachers could volunteer time during recess or homeroom to supervise or guide MBT practices. These should be done before adolescents snacking occasions to promote mindfulness while eating. MBT practices and nutrition education resources can be easily accessed through many online resources for free. This study had successfully implemented free online guided mindfulness meditation for adolescents (“Guided Meditations,” n.d.). Yoga can also be included during physical education courses for stretching or aerobic exercises. Potiaumpai et al., 2017, research found certain yoga practices have been found to meet aerobic recommendations for physical activity when performed with three to five-second transitions in between poses.
The results produced from this short pilot study did not demonstrate a shift towards better-snacking intakes for all nutrients assessed. However, the addition of nutrition education to the practice of MBT demonstrated to have significant nutrient intake changes for PUFA, MUFA, and sodium. These practices can be enjoyable for adolescents, easy to implement, and are considered cost-effective (Barnes et al., 2016; de
Visser et al., 2016; Greenberg & Harris, 2012; Khalsa et al., 2012; Zoogman, Goldberg,
Hoyt, & Miller, 2015). The participation rate for this study was one-hundred percent, displaying students’ inclination to practice yoga, meditation, and engage in nutrition education. These practices can be enjoyable for adolescents, easy to implement, and are considered cost-effective (Barnes et al., 2016; de Visser et al., 2016; Greenberg & Harris,
2012; Khalsa et al., 2012; Zoogman, Goldberg, Hoyt, & Miller, 2015). Therefore, to support adolescent’s proper growth and development through healthy behaviors, school settings would be the ideal environment to utilize MBT and nutrition education.
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Recommendations for Future Research
Further research will be needed in order to assess different approaches to both
MBT and nutrition education. Assessments should be made to determine which programs complement current health and physical education curriculums for adolescents.
The individual aspects of MBT (e.g., measuring time, frequency and type of practice) should be investigated in order to create uniform methods or programs before implementation begins. Effects of MBT concerning adolescents eating behaviors could then be weighed and analyzed. Thus, future researcher is encouraged to incorporate greater food variety, larger randomized sample sizes, and longitudinal studies in order to identify the effects they have on snacking nutrient intakes versus those produced in this study.
Conclusion
MBT, with and without the inclusion of a small nutrition education lesson, produced inconclusive results in relation to seventh and eighth grade students’ nutrient and snack intake at different IT. The short span of the study demonstrated this group of adolescents did not meet the Smart Snack and DGA recommendations, instead they more closely resembled their current national snack average intake. MBT and proper nutrition both have health implications, although it is still unknown at this time how the two are related. Therefore, more research is needed to understand the underlying relationships between adolescents eating patterns and their yoga and meditation practices to justify the possible specific applications for the school systems to implement along with their current health education programs.
APPENDICES
APPENDIX A
PARENTAL CONSENT FORM
Appendix A Parental Consent Form
102 103
APPENDIX B
INFORMED CONSENT TO PARTICIPATE IN A RESEARCH STUDY
Appendix B
Informed Consent to Participate in a Research Study
105 106
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