Project EAT: What has been learned from 20 years of research on what helps diverse young - PowerPoint Presentation

Project EAT: What has been learned from 20 years of research on what helps diverse young Minnesotans to eat healthy and feel good about their bodies?Nicole Larson, PhD, MPH, RDN, LDSchool of Public Health, University of Minnesota MINNESOTA ACADEMY OF NUTRITION & DIETETICS 2019 ANNUAL MEETING APRIL 24 – 26, 2019

Funding acknowledgmentMaternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human ServicesGrant R40 MC 00125 Grant R40 MC 00319 National Heart, Lung, and Blood Institute, National Institutes of HealthGrant R01HL084064 Grant R01HL093247Grant R01HL116892 Grant R01HL127077 Grant R35HL139853

Research programteamDianne Neumark-Sztainer (PI)Marla EisenbergJerica BergeSusan MasonDaheia Barr-Anderson Melanie Wall Katie Loth Laura Klein

ObjectivesDescribe what is known regarding disparities in eating and weight-related problems among Minnesota youth and shifts over time during the transition from adolescence to adulthood.Synthesize recent evidence addressing what supports for healthy eating and weight-related health are of importance to address in counseling the families of adolescents and preparing young people for the transition to adulthood.Discuss what additional evidence is still needed to better inform the design of messaging, programming, and policies designed to support young people in eating healthy.

OverviewProject EAT: Research aims, study phases, and population samplesDisparities in eating and weight-related problems Life course trajectories of eating and weight-related behaviorsSupports for healthy eating behaviors Supports for maintaining a healthy weight and related attitudes Identifying evidence gaps

Project EAT Research Aims

Conceptual framework guiding program of research: multilevel influences across the life course

What is Project EAT?EAT-I 1998-99 Surveys and measurements of 4,746 diverse middle and high school students in Minnesota (ages 11-18) EAT-II2003-04 Surveys of 2,516 high school students and early young adults 5-year longitudinal follow-up (ages 17-23) EAT-III 2008-09 10-year follow-up on early and middle young adults (N=2,287; ages 21-27) EAT-IV 2015-16 Follow-up on young adults (N=1,830; ages 27-33), participants’ significant others (N=733), and participants’ preadolescent and adolescent children (N≅260; ages 9-18) EAT 2010 2009-10 Recruitment of 2,793 new middle and high school students (ages 11-17) and surrounding environments F-EAT 2009-10 Assessment of parents of 2,000 adolescents (N=3,709) EAT 2018 2017-18 Follow-up on young adults and their families, friends, school/worksites, and neighborhoods EAT 2024 2018-24 Ongoing follow-up to inform multilevel explanatory models and interventions to reduce eating, activity, and weight-related problems http://www.sphresearch.umn.edu/epi/project-eat/

1996Project EAT timeline Focus groups to inform baseline survey Baseline EAT surveys in 31 MN metro schoolsMail & phone surveys with some parentsEAT-II follow-up mail surveys EAT-III follow-up web & mail surveys EAT-IV follow-up web & mail surveys Web & mail surveys with a significant other Mail & web surveys with a child EAT 2010 surveys in 20 MN metro schools Mail & phone surveys with both parents EAT 2018 follow-up web & mail surveys Follow-up 2018 mail, phone, & web surveys with parents School surveys & neighborhood GIS Neighborhood GIS EAT I-IV Cohort 1998 2000 EAT 2010-2018 Cohort 2002 2004 2006 2008 20182016201420122010

Where were participants in Project EAT living in 2015-2016?n=1830; of these about 70% are located in the Twin Cities metropolitan area

Project EAT population samples for analysis of secular trends 1999 Sample 2010 Sample n%n%Ethnicity/race White 1029 33.5 525 18.8 Black 723 23.6 808 28.9 Asian 753 24.5 555 19.9 Hispanic 243 7.9 472 16.9 Native American 133 4.3 102 3.7 Mixed/other 191 6.233111.8Socioeconomic status Low68322.2107238.4 Low-middle60119.559521.3 Middle75524.647116.9 High-middle or high87128.455019.7EAT-I (1999)27 schoolsN=3072Full EAT-I Sample31 schoolsN=4746 EAT 2010 (2010)20 schools N=2793

Disparities in weight-related problems:Trends among young people in MN

How have the eating and weight-related behaviors of adolescents changed since the start of the 21st century?

Prevalence of high BMI (>95th percentile) among MN youth: Secular trends% Neumark-Sztainer, Wall, Larson , Story, Fulkerson, Eisenberg, Hannan. Prev Med. 2012;54:77-81****

Prevalence of weight-related behaviors among MN youth: Secular trends % Neumark-Sztainer, Wall, Larson , Story, Fulkerson, Eisenberg, Hannan. Prev Med. 2012;54:77-81*****

Eating Breakfast >5 days/week: Secular trends Larson , Story, Eisenberg, Neumark-Sztainer. J Acad Nutr Diet. 2016;116:240-250%Sex Ethnicity/race** * * *

Eating Breakfast >5 days/week: Secular trendsLarson , Story, Eisenberg, Neumark-Sztainer. J Acad Nutr Diet. 2016;116:240-250%School level Socioeconomic status** * *

Intake of energy-dense snack foods and sugary drinks: Secular trendsDecreased intake in overall sampleSnack foods: 1999=2.6 servings/day, 2010=2.2 servings/daySugary drinks: 1999=1.2 servings/day, 2010=0.8 servings/daySimilar trend observed in all sociodemographic groupsIntake was highest at both time points among subgroups Ethnicity/race identified as Black, Native American, or mixed/other Socioeconomic status categorized as low or low-middle Larson, Story, Eisenberg, Neumark-Sztainer. J Acad Nutr Diet. 2016;116:240-250

Fast-food restaurant use: Secular trendsFrequency decreased modestly among adolescents and maternal caregiversAdolescents: 1999=25%, 2010=19%Maternal caregivers: 1999=17%, 2010=11%Fast food frequency remained highest (about 2 times/week) and did not decrease among Black or Native American young people. Fast food intake did not decrease over time among the lowest socioeconomic status group and was most frequent among youth in this group in 2010 (1.8 times/week). Frequent fast food purchases (3+ times/ wk) for family meals did not decline overall; however, large decreases occurred among Hispanic familiesPopulation sample: 1999=17%, 2010-11%Hispanic families: 1999=18%, 2010=6%Larson, Hannan, Fulkerson, Laska, Eisenberg, Neumark-Sztainer. Am J Public Health. 2014;104:e62-e69.

Frequent family meals (>5 days/week): Secular trendsNeumark-Sztainer, Wall, Fulkerson, Larson. J Adolesc Health. 2013;52:201-206.% of sampleSex Ethnicity/race

Frequent family meals (>5 days/week): Secular trendsNeumark-Sztainer, Wall, Fulkerson, Larson. J Adolesc Health. 2013;52:201-206.% of sampleSchool level Socioeconomic status*

Weight-related health across the life course:Adolescence to young adulthood

How do you expect physical activity and dietary patterns to change as young people enter adulthood?

Trends in low, moderate-to-vigorous physical activity (%) from adolescence (Wave 1) to young adulthood (Wave 4) at 5-year intervalsNeumark-Sztainer , Wall, Chen, Larson, Christoph, Sherwood. Am J Prev Med. 2018;55(2):133-141P<.001%

Trends in high fast food intake (%) from adolescence (Wave 1) to young adulthood (Wave 4) at 5-year intervalsWave Neumark-Sztainer , Wall, Chen, Larson, Christoph, Sherwood. Am J Prev Med. 2018;55(2):133-141%

Fruit intake: Percentage of participants meeting MyPlate recommendationsChristoph, Larson, Winkler, Wall, Neumark-Sztainer. Am J Clin Nutr. In press.% of sample

Vegetable intake: Percentage of participants meeting MyPlate recommendationsChristoph, Larson, Winkler, Wall, Neumark-Sztainer. Am J Clin Nutr. In press.% of sample

Whole grain intake: Percentage of participants meeting MyPlate recommendationsChristoph, Larson, Winkler, Wall, Neumark-Sztainer. Am J Clin Nutr. In press.% of sample

Dairy intake: Percentage of participants meeting MyPlate recommendationsChristoph, Larson, Winkler, Wall, Neumark-Sztainer. Am J Clin Nutr. In press.% of sample

Dietary intake in adulthood (30+ years) by adolescent intakeParticipants’ dietary intake tracked over the 15-y developmental transitionFemales within each quartile of adolescent dietary intake had higher intakes as compared to males within the same quartile rankParticipants who started in the lowest quartiles as adolescents generally continued to have the lowest mean intake for each marker in adulthood Christoph, Larson, Winkler, Wall, Neumark-Sztainer. Am J Clin Nutr. In press.

Vegetable intake in adulthood (30+ years) by adolescent intakeChristoph, Larson, Winkler, Wall, Neumark-Sztainer. Am J Clin Nutr. In press.Average # of daily servings

How do you expect weight control attitudes and behaviors to change as young people enter adulthood?

Trends in high body dissatisfaction (%) from adolescence (Wave 1) to young adulthood (Wave 4) at 5-year intervalsNeumark-Sztainer , Wall, Chen, Larson, Christoph, Sherwood. Am J Prev Med. 2018;55(2):133-141P=.001%

Trends in past-year dieting (%) from adolescence (Wave 1) to young adulthood (Wave 4) at 5-year intervalsHaynos, Wall, Chen, Wang, Loth, Neumark-Sztainer. Int J Eat Disord. 2018;51:1090-1097.%P<.001

Trends in unhealthy weight control behaviors (%) from adolescence (Wave 1) to young adulthood (Wave 4) at 5-year intervals% Neumark-Sztainer , Wall, Chen, Larson, Christoph, Sherwood. Am J Prev Med. 2018;55(2):133-141

Trends in extreme weight control behaviors (%) from adolescence (Wave 1) to young adulthood (Wave 4) at 5-year intervals Haynos, Wall, Chen, Wang, Loth, Neumark-Sztainer. Int J Eat Disord. 2018;51:1090-1097.%

Trends in obesity prevalence (%) from adolescence (Wave 1) to young adulthood (Wave 4) at 5-year intervals Neumark-Sztainer , Wall, Chen, Larson, Christoph, Sherwood. Am J Prev Med. 2018;55(2):133-141P<.001%

Neumark-Sztainer, Wall, Chen, Larson, Christoph, Sherwood. Am J Prev Med. 2018;55(2):133-141

Building the evidence:Recommendations for health care providers and families

Recommendations for health care providersInform adolescents that dieting, and particularly unhealthy weight control behaviors, may be counterproductive. Instead, encourage behaviors that can be maintained on a regular basis.Do not use body dissatisfaction as a motivator for change. Instead, help adolescents to care for their bodies so that they will want to nurture them through healthy eating, activity, and positive self-talk. Encourage families to have regular, and enjoyable, family meals. Encourage families to talk less about weight and do more to help adolescents achieve a weight that is healthy for them.Assume overweight adolescents have experienced weight-related stigma and address with adolescents and their families.Neumark-Sztainer D. Journal of Adolescent Health. 2009;44:206-213 J. Adolesc. Health. 2009;44(3):206-213.

Recommendations for families of adolescentsModel healthy behaviors for your child(ren) e.g ., Avoid dieting, or at least unhealthy dieting behaviors Provide an environment that makes it easy for your child(ren) to make healthy choices e.g., Make healthy food choices readily availableFocus less on weight, instead focus on behaviors and overall health e.g., Encourage your child(ren) to adopt healthy behaviors without focusing on weight lossProvide a supportive environment with lots of talking and even more listening e.g., When your child talks about fat, find out what’s really going on Neumark-Sztainer. “I’m, Like, SO Fat!” Helping your teen make healthy choices about eating and exercise in a weight-obsessed world. New York; The Guilford Press, 2005

What type(s) of nutrition advice do you most often provide to families and young people to prepare them for the transition to adulthood?

Developments in understanding what is needed to support healthy e ating behaviors

Family, home, and neighborhood supports for healthy eating Adolescent eating behavior & dietary intake Home healthful food availability Parent healthy food modelingParent encouragement of healthy eatingFocus on healthy behavior vs weightFrequent family mealsChild involvement in food preparationWarm parent-child communicationHigh family functioning Adult eating behavior & parenting practices

Home environment profiles: adolescent fruit & vegetable intakeLoth, MacLehose, Larson, Berge, Neumark-Sztainer. Appetite . 2016;96:80-86. Average # of daily servingsHIGH healthy home food availabilityLOW healthy home food availability

Home environment profiles: adolescent intake of low nutrient, energy dense snack foodsLoth, MacLehose, Larson, Berge, Neumark-Sztainer. Appetite . 2016;96:80-86. Average # of daily servingsHIGH healthy home food availabilityLOW healthy home food availability**

Home environment profiles: adolescent intake of sugar-sweetened beveragesLoth, MacLehose, Larson, Berge, Neumark-Sztainer. Appetite . 2016;96:80-86. Average # of daily servings HIGH healthy home food availabilityLOW healthy home food availability**

Family meals, parenting practices, & adolescent fruit & vegetable intake (mean servings/day)Parenting Practice Infrequent Family Meals ( <2 times/wk) n=864Frequent Family Meals (>5 times/wk) n=1,093Parent communication Low3.53.7 High 3.3 4.2 Home availability of fruits and vegetables Never/rarely 3.0 3.0 Usually/always 3.6 4.1 Home accessibility of fruits and vegetables Never/sometimes 3.0 3.2 On a regular basis 3.6 4.2 Parent encouragement for healthy eating Never/somewhat 3.3 3.5 Very much 3.6 4.4 Watts, Loth, Berge, Larson, Neumark-Sztainer. J Acad Nutr Diet. 2017;117:707-714.

Healthful neighborhoods enhance the positive influence of supportive families on FV intakeBerge, Wall, Larson, Forsyth, Bauer, Neumark-Sztainer. Health and Place. 2014;26:69-77. Family environment: (high family functioning, frequent family meals, parent encouraging healthful eating) Neighborhood environment: (low density of fast food, nearby supermarket) X

How many times did you help make dinner for your family in the past week? Adolescent involvement %Berge, MacLehose, Larson, Laska, Neumark-Sztainer. J Adolesc Health. 2016;59(5):530-536.Who usually prepares food for your family?Mothers: 88.3%Fathers: 40.4%

Meal preparation and adolescent diet qualityAdolescent involvement linked to higher intake:FruitVegetablesIronCalcium Folate Vitamins C, D Fiber Fast foodParent involvement not related to intake of food group servings, vitamins, or mineralsBerge, MacLehose, Larson, Laska, Neumark-Sztainer. J Adolesc Health. 2016;59(5):530-536.

Adolescent involvement and past week family meal frequencyFamily meals Berge, MacLehose , Larson, Laska, Neumark-Sztainer. J Adolesc Health. 2016;59(5):530-536.

Food Preparation Behaviors in Emerging Adulthood by Involvement in Food Preparation during Adolescence Adolescent Involvement Never (n=420)At least 1-2 times in past week (n=892)P value% report engaging in behavior 1+ times/week as emerging adultBuying fresh vegetables19.4%33.9%<0.001Writing a grocery list 12.0% 21.4% <0.001 Preparing a green salad 29.1% 28.5% 0.83 Preparing a dinner with chicken, fish or vegetables 44.9% 52.3% 0.01 Preparing an entire dinner for 2+ people 28.5% 41.0% <0.001 Laska, Larson, Neumark-Sztainer, Story. Public Health Nutr . 2012.

Dietary Behaviors in Young Adulthood by Perceived Adequacy of Cooking Skills during Emerging AdulthoodFull sample: perceived adequacy of cooking skills in emerging adulthood was linked to…Preparing a meal with vegetables on most daysIdentifying as a usual food preparerEating 3+ servings/day of vegetables Less frequent fast food consumption Parents: perceived adequacy of cooking skills in emerging adulthood was linked to…More frequent family mealsLess frequent fast food for family mealsFewer perceived time and energy barriers to plan and cook meals for children Utter, Larson, Laska, Winkler, Neumark-Sztainer. J Nutr Educ Behav . 2018;50:494-500.

Fruit and vegetable intake in young adulthood varies by attitudes, behaviors, and supports in emerging adulthood Larson, Laska, Neumark-Sztainer. J Acad Nutr Diet. 2012;112:1216-1222. Concern about health (FV, +) Perceived time barriers (FV, -) Perceived benefits of healthy eating (V, +) Self-efficacy for healthy eating (V, +) Taste preferences (FV, +) Breakfast frequency (F, +) Snack frequency (F, -) Eating on the run (F, -) Fast food consumption (FV, -) Young adults’ fruit and vegetable intake Friends’ healthy eating attitudes (F, +) Significant others’ healthy eating attitudes (FV, +) Home FV availability (FV, +) Home availability of unhealthy foods (FV, -)

Which food and mealtime practices are carried forward from adolescence to parenthood?Females:Healthy home food availabilityUnhealthy home food availabilityEating dinner with televisionExpected to be home for dinner Males: Healthy home food availability Watts, Berge, Loth, Larson, Neumark-Sztainer. J Nutr Educ Behav. 2018;50:141-147.Family meal frequency in adolescence was not related to the frequency of eating together with all or most household members in adulthood.

Family meal frequency in parenthood by partners’ meal frequency during adolescence (n=380 couples) Average family meals/ wk Watts, Berge, Loth, Larson, Neumark-Sztainer. J Nutr Educ Behav. 2018;50:141-147.High family meal frequency is defined by >5 meals/wk

Developments in understanding what is needed to support weight-related health

What type(s) of advice are you most often asked for by families and young people to help them manage their weight-related health through the transition to adulthood?

Healthful neighborhoods enhance the positive influence of supportive families on BMIBerge, Wall, Larson, Forsyth, Bauer, Neumark-Sztainer. Health and Place. 2014;26:69-77. Family environment: (frequent family meals, parent modeling of healthful eating) Neighborhood environment: (low density of fast food, no nearby convenience store) XAB

Focus on Project EAT participants with a baseline BMI <85th percentileExamined longitudinal associations with change over time in factors representing personal, behavioral, and environmental (social, physical) characteristicsModeled 26 factors over ~15 years from adolescence to adulthoodModeled 35 factors over ~5 years from third to fourth decade of life Larson, Chen, Wall, Winkler, Goldschmidt, Neumark-Sztainer. Preventive Medicine 2018;113:80-90.

Strongest and most consistent predictors of “healthy” weight maintenance included:Body satisfactionAvoidance of dieting and unhealthy weight control practicesLess exposure to dieting norms (parents, significant others, peers)Support for healthy eating and physical activity (parents, significant others, coworkers, peers) Larson, Chen, Wall, Winkler, Goldschmidt, Neumark-Sztainer. Preventive Medicine 2018;113:80-90.

Characteristics supportive of a favorable weight status change from adolescence to young adulthoodReducing fast food intakeReducing screen media timeIncreasing fruit/vegetable intakeIncreasing moderate-to-vigorous physical activity Increasing family meals, serving vegetables at dinner Increasing home fruit/vegetable availability Avoidance of dietingReduction in weight teasing exposureImprovements in body satisfaction, depressive symptoms, self-esteem Watts, Loth, Peterson, Boutelle , Neumark-Sztainer. J Adolesc Health. 2016;58(4):403-409. 32% of adolescents who were at a high BMI ( > 95 th percentile) experienced a favorable weight status change during the transition to young adulthood

Family functioning and parenting practices are linked to disordered eating behaviorsHigher family functioning, parent connection, and parental knowledge about child’s whereabouts were linked to lower dieting, unhealthy weight control behaviors, and binge eatingParent psychological control was linked to greater likelihood of dieting, unhealthy weight control behaviors, and binge eatingParent psychological control weakened the protective relationship between family functioning and disordered eating Berge, Wall, Larson, Eisenberg, Loth, Neumark-Sztainer. J Behav Med. 2014;37:205-217.

Mothers’ eating and weight-related conversations in adolescence and disordered eating% Berge, MacLehose , Loth, Eisenberg, Bucchianeri, Neumark-Sztainer. JAMA Pediatr. 2013;167(8):746-753.Adolescents at higher BMI (>85th percentile)

Fathers’ eating and weight-related conversations in adolescence and disordered eating% Berge, MacLehose , Loth, Eisenberg, Bucchianeri, Neumark-Sztainer. JAMA Pediatr. 2013;167(8):746-753.Adolescents at higher BMI (>85th percentile)

Experiences of weight teasing in adolescence% Sex Weight status in adolescence Puhl , Wall, Chen, Austin, Eisenberg, Neumark-Sztainer. Prev Med. 2017;100:173-179.

Experiences of weight teasing in adolescence and weight-related outcomes in adulthoodFemales:Higher BMIEngaging in binge eatingUse of unhealthy weight control practicesEating to copePoor body image Past year dieting Males: Higher BMIEating to copePoor body imagePuhl, Wall, Chen, Austin, Eisenberg, Neumark-Sztainer. Prev Med. 2017;100:173-179.The observed linkages took baseline weight status in to account along with ethnicity/race, socioeconomic status and age.Peer and family-based teasing were important for females and peer-based teasing for males.

SummaryStrategies are needed to reduce disparities in the nutritional and weight-related health of MN young people.The majority of adolescents and young adults report less than optimal eating, activity, or weight-related health outcomes. T he stability of nutritional patterns and weight-related problems is high across critical developmental stages.Nearly half of adolescents become overweight during the transition to adulthood suggesting that healthy lifestyle interventions are likely to benefit individuals who are not overweight in adolescence.

Summary, continuedHealthy home food availability and multiple dimensions of parenting are critical to promote the development of healthful weight-related behaviors, and the impact of positive parenting may be enhanced by a supportive neighborhood environment.It will be important to evaluate preventive interventions designed to eliminate weight-related teasing, support the maintenance of positive body image, reduce restrictive weight control behaviors, and provide social support for healthy behaviors. Certain features of the home environment during adolescence (e.g., parental encouragement to diet) tend to be carried forward to the home environment that individuals provide for their children.

Evidence GapsIdentify supports that may mitigate the intergenerational transmission of weight-related problemsRefine understanding of the long-term influence that weight-related problems and experiences of stigma in adolescence may have on cardiovascular disease risk in adulthoodIdentify supports that may enhance resilience to weight-related stigma at different developmental stagesGrow evidence regarding how neighborhood/school/work contextual factors may enhance the impact of a supportive family/home environment on weight-related health

What are common questions from families and young people that have not been addressed?

Contact InformationNicole LarsonSchool of Public Health, University of MNEmail: larson@umn.eduPhone: 612-625-5881Website: http://www.sphresearch.umn.edu/epi/project-eat/