Issue No. 10
Spring 2005

Sheri Barke

Promoting Healthy, Balanced Lifestyles on Campus

Sheri Barke and Beverly Kemmerling

Before hiring a nutritionist to work at College of the Canyons health center, we researched the connection between health, nutrition, and student academic success.  Why does a community college health center need a nutritionist? This article illuminates the relationship between nutrition and health and illustrates one way to effectively deliver maximum health promotion to students despite a shrinking budget, without neglecting the health center’s other responsibilities to communicable disease prevention, family planning, safety, and mental health concerns of the campus community.  Visit the “Nutrition Coach” web site at http://www.canyons.edu/offices/Health/NutritionCoach/ to see how this program has enriched our students’ access to accurate information on healthy nutrition and fitness.

Nutrition Concerns of College Students

College students, like the general U.S. population, face four primary nutrition concerns:  1) eating disorders and disordered eating, 2) overweight and obesity, 3) poor nutrient intake, and 4) insufficient physical activity.

Eating Disorders and Disordered Eating

In the United States, as many as 10 million females and 1 million males struggle with anorexia or bulimia nervosa. Approximately 25 million more have binge eating disorder (1).  Among female adolescents and young women in the U.S., the prevalence of anorexia and bulimia nervosa are estimated at about 0.5% and 2%, respectively (2). The prevalence among college students, particularly females, is significantly higher.  In fact, up to 6% of female undergraduates meet the strict DSM-IV diagnostic criteria for anorexia or bulimia nervosa (3).  While the prevalence of binge eating disorder among college students is unknown, it is reported to exist in 3% of the general population (4) and 25% or more of obese individuals (5).

If you consider sub-clinical disordered eating (including extreme worry about weight or body size, food preoccupation, restrictive dieting, emotional overeating, compulsive exercise, and use of dangerous body shaping drugs), a great many more young women and men are affected.  The proportion of adolescents and young adults who engage in fasting, induced vomiting, abuse of laxatives, diuretics, ipecac, and diet pills may be 5-10 times the number who have eating disorders that meet clinical criteria (see Figure 1) (6).  A recent study showed that 6% of teen boys use steroids to build muscle, while an alarming 30% of teen girls use stimulant and/or appetite suppressing drugs to get thin (7).  In the college population specifically, an estimated 25-40% of female undergraduates suffer from sub-clinical disordered eating (3).  While the prevalence in college men is unknown, muscle dysmorphia  (a preoccupation with the idea that one’s body is not muscular or lean enough) appears to be a growing concern in young men.  In one survey of men from gyms in Boston and Los Angeles, 10% of men had prominent symptoms of this (8).  Among college athletes (particularly in sports such as gymnastics, dance, cheerleading, figure skating, rowing, wrestling, and cross country running), the rates of disordered eating are particularly high.  For example, 62% of female collegiate gymnasts and 52% of male collegiate wrestlers engage in at least one pathogenic weight control method (9).

Figure 1:  Prevalence of Disordered Eating Behaviors among U.S. High School Students (6)

• 18.3% girls, 8.5% boys fasted for > 24 hrs.
• 11.3% girls, 7.1% boys took diet pills, powders, or liquids without a doctor’s advice
• 8.4% girls, 3.7% boys vomited or took laxatives

Overweight and Obesity

In the U.S., the rates of overweight and obesity have increased tremendously over the past two decades.  Now, 65% of adults are overweight (BMI > 25), including 30% who are obese (BMI > 30) (10).  Among children and adolescents 6-19 years old, 16% are overweight (BMI for age > 95^th percentile) (11).   In the past 20 years, the rates of overweight among adults have increased 38%, while the rates among children and adolescents have exploded 167% (10,11).  According to 2004 data from the American College Health Association’s National College Health Assessment, 31% of college students are overweight, including 9.4% who are obese (12).  Interestingly, this survey also showed a significant disparity between real and perceived overweight status among college women, with 60% of college women trying to lose weight (12).

Poor Nutrient Intake

Several national surveys show that adolescents and young adults in the U.S. eat too few servings of vegetables, fruits, whole grains, and calcium-rich foods, while they eat too much saturated fat, added sugars, and sodium.  The 2003 Youth Risk Behavior Survey revealed that 78% of high school students don’t eat the recommended 5 servings of vegetables and fruits daily, while 77% of boys and 89% of girls don’t drink 3 or more cups of milk daily (6).  Similarly, the 1995 National College Health Risk Behavior Survey showed that 74% of college students don’t get their “5-a-day,” while 55% of college men and 82% of college women don’t meet their daily calcium needs (13).  The most recent report of “What We Eat in America” found that adolescents get only one serving per day of whole grains (vs. the recommended minimum of 3 servings per day), and 20% of their total calories come from added sugars (vs. the recommended maximum of 7% of total calories) (14). 

Insufficient Physical Activity

In 2002, 40% of all U.S. adults were inactive during their leisure time.  Among 18-44 year olds specifically, 30% of men and 35% of women were inactive (15).  In 2003, one third of high school students (40% of girls and 27% of boys) did not engage in the recommended amounts of vigorous and moderate physical activity 3 to 5 times per week, and nearly 12% did not engage in any physical activity at all (6).  Equally disturbing, a full 38% of these high school students watched three or more hours of TV on school days (6).  In 2004, 60% of college students didn’t get the minimum of 30 minutes of moderate or 20 minutes of vigorous physical activity three times a week (12).   

Negative Consequences

All of the nutrition concerns discussed above can threaten students’ physical and emotional health, interfere with social relationships, and negatively impact academic performance and retention.  Figure 2 outlines some of the negative short-term effects of inadequate calories and nutrients from restrictive eating (either intentional due to disordered eating or weight loss dieting, or unintentional due to stress, depression, financial constraints, or busy schedules).  Many of these effects interfere with academic performance since they can lead to poor concentration and learning from low blood sugar, inadequate sleep, and/or food preoccupation and they can lead to missed school due to sickness, apathy, or fatigue.  Similarly, inadequate physical activity negatively affects energy, mood, self-esteem, and concentration (17,18) – all important for optimal functioning.  In the long-term, poor nutrient intake and insufficient physical activity contribute to numerous chronic diseases, including heart disease, cancer, stroke, diabetes, and osteoporosis (15).  In fact, these lifestyle behaviors are second only to cigarette smoking as the leading preventable causes of death in the U.S. 

Figure 2:  Effects of Restrictive Eating and Dieting (16)

In addition, many of these nutrition concerns are associated with other problems and risk-taking behaviors among college students.  Students with eating disorders often suffer from other medical and psychiatric conditions, including unipolar and bipolar depression, obsessive-compulsive disorder, seasonal affective disorder, post-traumatic stress disorder, attention deficit hyperactive disorder, paranoid schizophrenia, and substance abuse (16).  In fact, the disordered eating behaviors (restricting, bingeing, purging, and/or compulsive exercise) serve as maladaptive coping mechanisms—used to comfort, distract, or numb one’s self from painful or uncomfortable feelings.  Not surprisingly then, students with eating disorders often also engage in other harmful coping behaviors, such as binge drinking, smoking, drug use, unprotected sex, and cutting.  Students who are overweight or obese are also more likely to struggle socially and psychologically.  Being overweight has been associated with increased depression, a history of binge drinking, and peer aggression (19,20,21).  Another problem is that students with weight, body shape, and dieting concerns often start smoking and/or using dangerous “body shaping” drugs (like methamphetamines or anabolic steroids) to suppress appetite, get thin, and/or build muscle (22,7).  Interestingly, students who participate in sports and physical activity are less likely to engage in these harmful behaviors (7,18).

Misguided Focus on Weight and Dieting

Unfortunately, current U.S. public health policy primarily focuses on the “obesity epidemic” without maintaining perspective of the more global nutrition concerns outlined above.  As a result, there is a misguided emphasis among health professionals and the lay public on monitoring weight and controlling food intake with restrictive diets.  This emphasis is problematic for several reasons.

First, weight is a symptom, not the underlying problem.  The underlying problem for many students is an overall unbalanced life – a life where the stresses of school, work, family and other responsibilities are not balanced by appropriate self-care such as regular meals and snacks, physical activity, sleep, relaxation, and social and spiritual connections.  As a result, students may exceed their daily calorie needs and gain weight because they use food inappropriately to stay awake or focused, to receive comfort or companionship, or to distract or numb themselves from uncomfortable feelings.  In addition, because of stress and time constraints, they eat mindlessly and carelessly on-the-run – choosing whatever foods are cheap, convenient, and provide the longest-lasting energy (i.e. calories) to get them through the day—rather than taking time to plan, prepare, and slowly eat tasty, nutrient-dense meals.  Of course, the “toxic food environment” (with fast food establishments on every corner, super-sized portions, value meals, and aggressive advertising by food and beverage companies) greatly encourages and supports this behavior.  Focusing on weight and putting students on restrictive diets do nothing to address these core issues.

Second, weight does not necessarily predict one’s eating and physical activity behaviors, nor does it say very much about one’s overall health and fitness status.  Consider, for example, the large framed student who eats well, exercises regularly, and enjoys optimal blood pressure and cholesterol levels, but is “overweight” per BMI; or the food preoccupied student who smokes, takes diet pills, and consumes nothing but diet Pepsi all day but has a “healthy weight” per BMI.  In truth, health and fitness (as well as disordered eating) come in all shapes and sizes.  Sadly, however, weight prejudice is pervasive in our society, even among health professionals (23). We tend to make unfair assumptions about large people (that they are lazy, gluttonous, unmotivated, stupid, unhealthy, etc.).  As a result, these students often experience extreme social rejection and discrimination by peers, employers, educators, and health care providers.  It’s no wonder that overweight students experience tremendous self-blame, lower self-esteem, and increased depression (23).  Ironically, this bias may actually increase harmful behaviors and worsen health among those most at risk.  For instance, overweight individuals tend to avoid medical care and physical activity because of shame and fear of ridicule, and they may participate in disordered eating behaviors and smoking (in desperate attempts to lose weight at all costs) (23).

Third, the focus on weight and restrictive dieting can inadvertently increase all of the nation’s nutrition problems (eating disorders/disordered eating, overweight/obesity, and poor nutrient intake).  In prospective studies with adolescent girls and college women, up to 2/3 of cases of eating disorders are started by dieting (24).  Moreover, it is estimated that 35% of so-called “normal dieters” may eventually develop disordered eating behaviors; and of those, 20-25% will progress to sub-clinical or even clinical eating disorders (25).  Dieting is associated in prospective studies with increased weight gain and obesity in children, adolescents, and adults (26, 27, 28,29).  Repeated dieting may adversely affect the body’s metabolism and cause changes in hormones and brain chemicals that regulate appetite (e.g. leptin, ghrelin, and serotonin).  Dietary restraint (whether imposed by self or someone else, like a parent) increases the risk for overeating or binge eating (27,28,30).  Finally, adolescent girls who engage in unhealthy weight control behaviors are at increased risk for dietary inadequacy, including lower intakes of fruit, vegetables, grains, calcium, iron, zinc, folate, and vitamins A, C and B6 (31).  Given all the known negative effects of restrictive dieting, its high prevalence among children, teens, and adults is disturbing (see Figure 3).

Figure 3:  Prevalence of People Dieting or Trying to Lose Weight in the U.S.

• Children 9-14 years old:  30% girls, 16% boys are on a diet (28)
• High school students:  59% girls, 29% boys are trying to lose weight (6)
• College students:  60% of women, 32% of men are trying to lose weight (12)
• Adults:  45% women, 25% men are on a diet (24)

New Holistic Approach Focusing on Healthy, Balanced Lifestyles

Clearly, a new public health approach is needed – one that views all nutrition problems within a larger, interrelated perspective; one that focuses on the core issues of an unbalanced life with unmanaged stress; one that emphasizes wellness and being healthy (not just being a certain weight); and one that sends a consistent message to everyone about normal eating (NOT dieting), active living, self-respect, and appreciation of size diversity.  This approach is more positive and holistic, and it is more likely to be cost-effective.  Consider the potential greater impact of pooling all our scarce college health resources together to promote a common health goal, rather than fragmenting them between different health problems (like obesity, eating disorders, alcohol/drug abuse, etc.).

To support this approach, college health care providers, counselors, coaches, and teachers can begin by taking a critical look at their own implicit and explicit attitudes towards overweight students.  The Rudd Institute has free online assessment tools at www.weightbias.org.  In addition, they can de-emphasize weight in their student assessments and instead focus on healthy lifestyle behaviors (e.g. consuming at least 5 servings of fruits and vegetables daily, participating in regular cardiovascular and strength training activities, getting adequate sleep, not smoking, etc.) and true indicators of health and metabolic fitness (e.g. blood pressure, blood lipids, tests for endurance, strength, and flexibility, etc.).  Figure 4 lists some good nonjudgmental questions health and fitness professionals can ask all students (regardless of weight/size) to screen for potential nutrition concerns and problem behaviors. 

Figure 4:  Sample Nutrition Screening Questions

• How do you feel about your eating habits?  Do you regularly eat 3 balanced meals a day?  Do you consume at least 5 servings of fruits and vegetables and 3 servings of calcium-rich foods daily?  Do you ever eat (or not eat) because of emotional reasons (bored, stressed, depressed, lonely, poor body image)?  Do you have any nutrition questions or concerns? 
• Are you doing anything for physical activity?  If yes, what are you doing, at what frequency, and for what duration?  If no, have you ever been physically active, what activities do you enjoy doing, what barriers do you encounter to being more active? 
• How do you feel about your weight or shape?  Have you had any recent change in your weight?  If yes, was this intentional?  If intentional, how did you go about losing/gaining weight?  What do you feel is a healthy weight for you?  Is this number realistic and healthy considering genetic body type, weight history, current eating/activity/lifestyle behaviors? 

In terms of campus-wide efforts, below are a few ways that we plan to help students achieve healthy, balanced lifestyles at College of the Canyons:

New Academic Course:  HLHSCI 149 – Nutrition for Fitness and Balanced Living

This CSU-transferable 2 credit course examines the physiological, social, psychological, and environmental factors that influence a person’s eating behaviors, physical activity patterns, and body image.  And, it empowers students to develop and promote healthy eating and physical activity attitudes and behaviors.  This class goes beyond the science of nutrition and exercise, focusing more on…

• the psychology of eating/activity behavior (stress and disordered eating, body image and weight prejudice, cognitive distortions and self-talk, and the parent-child feeding relationship).
• practical tools for eating well, being active, and feeling good (how to eat on the run, deal with difficult social eating situations, eat for optimal exercise performance, grocery shop and cook, manage stress, and critically evaluate popular diets and supplements).
• strategies to promote healthy eating and physical activity at the community and individual levels (what role the food industry, schools, and government should play in reducing the “toxic food environment” and what specific steps parents, teachers, and health professionals can take to avoid inadvertently increasing disordered eating and weight problems).

New Peer Educator Program:  SNAC - Student Nutrition & Wellness Advocates at COC

SNAC is a student group whose mission is to promote healthy eating, physical activity, stress management, and body image on campus and in the community through education, outreach, advocacy, and community partnerships.  Its goals are to…

• Help students eat well, be active, and feel good.
• Empower students to cope with stress in healthy ways.
• Encourage students to set healthy boundaries with food, exercise, rest, school, work, and play to maintain balance.
• Promote health and fitness at every shape and size, rather than being thin or muscular at any cost.
• Create an environment that supports and encourages positive attitudes and healthy lifestyle behaviors.

New Website:  The Nutrition Coach

This website contains valuable information on nutrition and body image including sections on…

• Nutrition 101 – Get the facts on calories, carbs, protein, fat, supplements, and more!
• Practical Tips & Tools – Analyze your diet here, and learn how to eat on the run, read food labels, shop/cook, control portions, and eat for optimal exercise performance!
• Body, Weight, & Eating Concerns – Find out what’s a healthy weight for you, how to shed fat/build muscle, improve body image, and heal from disordered eating behaviors!
• Ask the Coach – Get answers to your personal questions from a Registered Dietitian! (Access to this service is restricted to currently enrolled College of the Canyons students.)
• Handouts A to Z – Download dozens of free nutrition handouts!
• Campus Resources & Links – Find out where you can go for more info & help!

Conclusion

College students and the general U.S. population face multiple nutrition concerns that threaten health and academic performance: eating disorders/disordered eating, overweight/obesity, poor nutrient intake, and insufficient physical activity.  These problems are closely associated with other health problems and risk-taking behaviors.  In order to effectively promote health and avoid inadvertently increasing problem behaviors among our students, college campuses need to address the global nutrition problem (rather than just the “obesity epidemic”) and the core issues of an unbalanced life with unmanaged stress.  Multiple departments (such as student health and development, health sciences, nursing, athletics, physical education, kinesiology, early childhood education, psychology, and sociology) can work together to challenge the pervasive negative cultural obsession with weight and dieting and instead promote a new culture focused on healthy lifestyle behaviors, metabolic fitness, and holistic health.

References

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