DISSERTATION DEVELOPMENT AND EVALUATION OF THE AMERICA ON THE MOVE PROGRAM FOR UNIVERSITY STUDENTS Submitted by Maryam Dadkhah Department of Food Science and Human Nutrition In partial fulfillment of the requirements For the Degree of Doctor of Philosophy Colorado State University Fort Collins, Colorado Fall 2013 Doctoral Committee: Advisor: Jennifer Anderson Co-Advisor: James Hill Chris Melby Marilee Long 0 ABSTRACT DEVELOPMENT AND EVALUATION OF THE AMERICA ON THE MOVE PROGRAM FOR UNIVERSITY STUDENTS Background The prevalence of overweight and obesity in adolescents has more than tripled since 1960.1-3 Overweight and obesity also significantly affect college students.4,5 Multiple surveys suggest that the unhealthy dietary habits and low physical-activity patterns of many college students predispose them to weight gain.6 The college years can be an opportune time to prevent obesity by teaching young adults about eating healthy and being physically active.7 Development of online approaches to weight management appears to be promising, given that college students are turning to the Internet for information about diet and physical activity.8,9 Few studies have examined weight-gain prevention in college students using an internet approach. Therefore, evaluating this approach to promote healthy eating and activity behaviors to limit weight gain in college students is timely and important.10 Objective The goal of this project was to design, evaluate, and disseminate an interactive, engaging, and effective weight-gain-prevention program for college students using the resources and educational materials of America On the Move (AOM). Also additional resources were developed and used to help improve dietary and physical activity behaviors of college students aimed at arresting weight gain. ii Methods A minimum of eight separate focus groups were held for male first-year students (n = 2), for female first-year students (n = 2), for nonwhite female first-year students (n = 2), and for nonwhite male first-year students (n = 2). Full-time, first-year students (n = 122) from 17 to 22 years of age through recruitment stations placed at dining hall entrances. We expected to have 8- 12 students at each focus groups. However, only two of the focus groups met the minimum required participants. Phase II, the CSU Weight Gain Prevention Program was a quasi-experimental, one- group, pretest-posttest project that was used to attenuate weight gain in first-year students, increase physical activity, and reduce energy consumption. The CSU Weight Gain Prevention Program is an enhanced America On the Move program for university students, available on a Facebook page that was based on the social-ecological model, findings from phase I, and an in- depth literature review. Eighty-eight first-year students were recruited during fall of 2011. Four assessments, two each semester, were scheduled during the 2011-2012 academic year. CSU Fit (phase III) was an experimental pretest-posttest to attenuate weight gain in first- year CSU students with a primary focus on increasing their walking by 2000 steps/d, or decreasing their energy intake by 100 Kcal/d. CSU Fit included a Facebook page component, group sessions, and feedback designed to prevent weight gain in first-year students of CSU, with a 7-month follow-up. Two hundred twenty-five first-year CSU students were recruited at the beginning of fall semester of 2012. Three assessments in September 2012 (pre-test or baseline), January 2013 (midpoint), and April 2013 (post-test or final) were scheduled during the 2012- 2013 academic year. Weight, body composition, body circumferences, blood pressure, and dietary intake were measured and recorded at each of the three time points. Participants iii completed online surveys to provide data on self-reported physical activity, nutrition and physical activity knowledge and self-efficacy. They also recorded their steps by using pedometers. Two hundred sixteen students who completed baseline online surveys were randomly stratified based on their gender and residence halls into either the CSU Fit (intervention group) or the Association for Student Activity Programming (ASAP) at CSU (control group) Facebook page. The development of the CSU Fit page was guided by the social- ecological model, focus-group discussions with CSU first-year students (phase I), an in-depth literature review including American On the Move tools, and the CSU Weight Gain Prevention Program pilot study (phase II).11 ASAP, which is funded by CSU‘s student fees, organizes and implements various entertainment events around campus including films, concerts, lectures, comedy shows, and special events.12 The intervention, which targeted healthy eating and physical activity, was conducted through a Facebook page, group sessions, and feedback. SPSS 19 and SAS 9.3 software were used for descriptive data, and SAS 9.3 was used for inferential statistics (analysis of variance and correlation). Results Twenty-five full-time, first-year CSU students (60% male and 64% non-White) aged 17 to 22 years (18.04 ± 0.46 years old) participated in phase I focus groups. Students cited ―all-you-can-eat‖ dining halls, unstructured/busy schedules, availability of unhealthy choices, and absence of monitoring parents as reasons that lead to weight gain among first-year students. Students suggested the posting of nutrition information on menu items, greater food variety with healthier options in dining halls, and coordination of university based activities as ways to improve healthy eating and physical activity. Participants unanimously liked the idea of posting healthy-eating and physical-activity tips on a Facebook page. iv Six (23%) males and 20 (77%) females (18 ± 0.37 years old) completed all components of all four assessments at phase II. Among participants, weight increased significantly between September and April of the 2011-2012 academic year (mean ± SE = 2.48 ± 0.44 kg, P < .0001). One hundred sixty-one subjects (18.13 ± 0.04 years old) predominately female (65%) and White (80%) completed the phase III study. There was a significant main effect of time such that the mean weight gain was 1.29 kg (SE = 0.31) for the intervention group and 1.29 kg (SE = 0.34) for the control group from baseline to final assessments (95% CL: 0.88-1.74, P < 0.05). The results in Table 4 reveal that the waist-to-hip ratio decreased for the intervention group from baseline to midpoint and stayed the same for the control group (0.83 vs. 0.81, P < 0.05). However, this group difference in the waist-to-hip ratio was not significantly different at the end of the study. There were not significant group by time interactions or main effects of group or time for any other anthropometric variables or blood pressure. The reported dietary intake of the students in both groups reflects that they consumed fewer calories, carbohydrates, and sugar as reported in the final 24-hour-recall and CSU usual- intake assessments compared to the data reported for the same measures at the baseline assessment (time effect; respectively, P < 0.05, P < 0.01, and P < .0001). Only fat intake at baseline was significantly related to weight gain (r = 0.17, P = 0.038). The ANOVA indicates that the only difference in self-reported activity was that the intervention group had significantly less mild leisure-time activity compared to the control group at midpoint (P < 0.05). Conclusion This research is the only study investigating the impact of a Facebook page targeting weight gain prevention in first-year students that used an experimental pretest - posttest design. The results from this research suggests that a Facebook page offering daily educational v information coupled with additional educational modalities targeted at weight gain prevention for first-year students does not improve dietary and physical activity behaviors and fails to attenuate weight gain. vi ACKNOWLEDGEMENT Over the last five years, I have received support and encouragement from many individuals. I would like to express my very great gratitude to Professor Jennifer Anderson, my advisor, for her patient guidance and devoted presence, enthusiastic encouragement, and useful critiques of this research work. I would also like to thank for her advice and assistance in keeping my progress on schedule. I would never have been able to be here without Dr. Jennifer Anderson‘s guidance who provided me with caring guidance and following up on my admission to CSU. I would like to express my great appreciation to Professor Chris Melby for his invaluable, constructive, and eye-opening suggestions and critiques during the development and implementation of CSU Fit. His willingness to give his time so generously has been very much appreciated. I would never have been able to pursue an idea to a full project without Dr. Melby‘s support who admitted me to the program and generously devoted his time to guide my project. Special thanks should be given to Professor Hill, my research project co-advisor for his professional guidance and valuable support. I would never have been able to defend today without Dr. Hill‘s encouragement who was one of the founders of America On the Move and who responded to my first email enthusiastically and promptly and expressed his interest in having me as one of his mentees. I would like to thank Dr. Long for adding valuable insights and comments to this project. I would never have been able to finish writing my dissertation without her sincere engagement and interest in my project. vii My grateful thanks are also extended to Mr. Jim zumBrunnen for his guidance in handling data and his help in doing the statistical data analysis. His commitment to fulfill my requests was exemplary. I am particularly grateful for the assistance given by John Wilson in developing online questionnaires, diet analysis, and multi- media set-up, Cliff Choury for assistance with processing funding, and Paula Coleman and Pam Cox to assist with administrative work.