Mindfulness and Nutrition in College Age Students

Primary Objective: The obesity rate among young Americans is now almost 25% with higher rates found in minority populations; lack of exercise and poor eating habits are some of the leading causes. The collegiate environment provides a unique opportunity to share nutrition-related knowledge while enhancing students’ awareness, both of which may ultimately lead to changes in health-related behaviors. Mindful eating is associated with a lower Body Mass Index (BMI) and an increased intake of fruits and vegetables. A semester-long nutrition course may result in an increased awareness of eating patterns and may be associated with improvements in dietary intake over time. Methods: Of the 38 students registered for a college-level nutrition course held during an almost four-month-longsemester, 37 self-selected to complete an anonymous Mindful Eating Questionnaire (MEQ) before and after taking the nutrition course; the participants also answered two open-ended questions for qualitative data collection post-test. Results: Of the 37 students 22 were female and 16 male between the ages of 18 and 24; 35 % self-identified as African American, 29% self-identified as white, 22% as self-identified as Latino/Hispanic, 10% self-identified as other and 2% self-identified as Native Hawaiian or Pacific Islander. No significant change in the MEQ score occurred from pre to posttest; however, there was a trend towards improvement. The students’ answers to open-ended questions regarding any shifts in understanding, approach, or changes in eating habits, revealed overwhelming increases in mindful eating and dietary changes Conclusions: A collegiate course taught over a semester is a unique opportunity to introduce nutrition information, emphasizing the connection between nutrition, optimal health, and disease prevention. A student’s exposure to nutrition information while also observing their own eating patterns over time can provide a non-judgmental informed space that allows for the development of a heightened awareness. In turn, the heightened awareness can lead to changes in eating behaviors as evidenced here.


INTRODUCTION
The current college age student is reportedly less physically active and has a higher obesity rate than that of previous generations.Only 1/3 of millennials, defined as the cohort of people born between 1980 and 2005, participate in regular leisure-time physical activity, while poor eating habits also contribute substantially to the prevalence of overweight and obesity [1].The overall obesity rate for Millennials is estimated at 24%, which left unchecked will create a greater risk of mortality throughout their lifespan.Equally concerning is the elevated obesity rate among minority youth, which may be associated with the health inequities in the U.S.Among young people between the ages of 6 -19, the obesity rates are 26.7% of Hispanic males, 25.9% of non-Hispanic black females, 19% of Hispanic females and 18.9% of non-Hispanic black males, while 15.6% of non-Hispanic white females and 18.2% of non-Hispanic white males are obese [2].In general, researchers predict that the Millennials as a cohort may have a shorter lifespan than that of their parents; it will be the first time this has occurred in American history [3].Obesity is associated with an increased risk of heart disease, some forms of cancer, and type II diabetes [4].The incidence of type II diabetes alone is projected to grow to1 in 3 American adults by 2030 [5].The adoption and maintenance of optimal health behaviors in order to reduce the rate of obesity is a major issue in America.
The academic environment provides an ideal opportunity to increase a young-adults' aptitude for health-enhancing behaviors, keeping in mind that 62% of Millennials have attended some college [6] and in 2008 39.6% of all college-age-young-adults were enrolled.A study investigating the relationship between mindfulness and health behaviors in college students found that there was an association between the extent to which a college student is mindful and positive health behaviors [7].Mindfulness is described as, "bringing one's complete attention to the present experience on a moment-to-moment basis" [8].The ability to practice mindfulness can be developed through meditation, "…which is defined as the intentional self-regulation of attention from moment to moment" [9,10].The concept of intentionally regulating one's focus from moment to moment is not a practice with which solely meditators engage.Mindfulness exercises such as breath focus and body scan, which entails moving the attention to various locations on the body, are practiced among athletes during extensive training and competition, and with women during child birth to manage the pain in a less reactive manner [11].A competitive athlete who participates in vigorous and long-term training bouts can develop the ability to direct their mind away from the pain generated by extreme physical strain or direct their focus to a focal point or breathing rhythm in order to endure their challenging training.
Research suggests that the more accomplished the athlete, the more likely they are to participate in psycho-regulatory techniques [12].Likewise, since the 1940's women have studied and practiced mind-directing techniques presented in a comprehensive program called Lamaze to prepare them for the rigors of child birth.Currently during Lamaze preparation, expectant mothers are schooled in mindfulness techniques, informed about the stages and progressions of labor, and practice various agreeable positions and methods of accepting and working with the pain and discomfort involved in the laboring process [11].
Focusing mindfully on rising emotions or thoughts associated with eating or "feeding" (used synonymously here), can allow for the non-judgmental recognition of a pattern or behavior as it occurs.Research suggests there is a positive linear relationship between mindful eating and vegetable and fruit intake, and an inverse relationship between mindful eating and BMI [13][14][15].Becoming aware of feeding patterns in a moment to moment capacity provides an opportunity to observe, become familiar with, and perhaps adjust these patterns at will.The ability to self-direct attention toward eating behavior creates an opportunity to observe our conditioned patterns surrounding food, such as eating when stressed, bored, lonely or anxious, in response to social cues, or overfeeding well beyond the point of satiation.Again, observing our feeding in a nonjudgmental way affords us the opportunity to become familiar with and accept what patterns are present, while also to observe maladaptive feeding behaviors if they exist.
College students, who generally participate in an academic course for several months, are uniquely positioned to experience and reflect on a nutritionbased education that highlights the connection between optimal nutrition, health, and disease prevention.Over that extended period of time, a student gains exposure to nutrition guidelines as well as the psychological and social aspects of feeding behaviors.In turn, the student may bring this new knowledge to the moment by moment feeding choices that occur on average three times per day, while this increased awareness may also highlight their habitual feeding patterns.In essence, mindful eating involves an awareness of feeding choices without judgement and a sensitivity to one's rote feeding patterns.The question becomes, is this new knowledge transposed in to awareness; does it promote an ability to be more mindful or aware of feeding behaviors in the present moment--during the processes and thoughts that surround feeding?Secondarily, does this heightened awareness have any impact on feeding behaviors?

METHODS
The research for the current study was conducted at Saint Peter's University following approval from the Saint Peter's IRB.Students who were enrolled in a semester-long 100-level course entitled Nutrition in Health and Disease, were given the option to anonymously participate in the study working with a proctor during the pre and post test data collection.The nutrition course lasted three months and twenty days, meeting three times per week for 50 minutes.Of the 38 students in the class, 37 opted to participate.The course curriculum was centered on a text entitled Nutrition for Healthy Living by W. Sciff, published by McGraw Hill in 2013.Among the many required course activities, the students kept a food diary for three weeks, investigated a host of popular diets and assessed their nutrient and weight management value, and were lectured to and tested on dietary requirements for optimal health and disease prevention.
At the beginning of the semester, after students self-selected to participate in the research study, they completed two numerically coded surveys: a short demographic survey asking their sex, age, race/ethnicity and a Mindful Eating Questionnaire (MEQ).The MEQ is a 28-item questionnaire that includes the domains of disinhibition, awareness, social cues, distraction, emotional response and distraction as they relate to feeding practices.The MEQ has good internal consistency reliability with a Cronbach's alpha at 0.64 [16].At the close of the semester, the students again self-selected to participate in the post test data collection, completed the MEQ, and additionally answered two qualitative research questions pertaining to their nutrition-class experience.The first question was, "After studying nutrition this semester, how if at all, have your eating habits changed, please explain in detail."The second question was, "After studying nutrition this semester, how has your understanding and approach to eating changed, if at all?"

RESULTS
The demographic data is found in Table 1.There were 37 student participants, 22 female and 16 male between the ages of 18 and 24, 35 % self-identified as African American, 29% self-identified as white, 22% as self-identified as Latino/Hispanic, 10% self-identified as other and 2% self-identified as Native Hawaiian or Pacific Islander.In the final data collection 32 students chose to participate in the post testing.The MEQ data were analyzed with SPSS through a paired T test with no significant difference detected in the scores from pretest to post.There was a trend towards improvement as each domain in the MEQ improved slightly other than that of the external cues which decreased slightly.The statistical results for each facet of mindfulness and the total MEQ score can be found in Table 2.The two qualitative questions were coded and analyzed through Dedoose for emerging themes; see Table 3 for total of excerpts in each theme.The overarching emerging themes from the qualitative data were in descending order: awareness, overarching improvement in health behavior related to nutrition, decrease in unhealthy food items, portion size/amount of food, vegetable and fruit intake, improved approach to protein, connect nutrition to health of body, improved quality of carbohydrate, fiber intake, share nutrition knowledge with others, and improved energy levels.The most reported theme was increased awareness.This included statements such as, "I am more aware of what exactly I am eating", "..more mindful of what I eat" "I have become more mindful of my eating habits", "It has made me more aware of all of the diseases that can be brought on if one consumes unhealthy foods"(also coded for connect nutrition to the health of the body)..The second most reported theme was an overarching improvement in health behavior related to nutrition with statements like, "my eating habits have improved" "I slowed down on eating certain foods just because they are available", "I try and gauge how much food I eat every day as well as keep track of how and which foods I need", and " I notice the reasons for me eating that are other than hunger like stress or boredom and try to control that."The third most reported theme was a decrease in unhealthy food items.This included statements such as, "Trying not to consume too many fats", … "not as many sweets", "(switch from)..unhealthy foods to healthy ones" "…less saturated fats".These and the remaining themes accompanied by examples of their excerpts can be found in Table 4.In general, the students showed evidence of making changes to their nutrition/feeding patterns from an improved and better informed stand point impacting everything from the types of carbohydrates and proteins ingested to increasing fiber intake and sharing nutrition knowledge with others.

DISCUSSION
The college classroom may provide a unique opportunity to present optimal nutritional information and practices over the course of a semester allowing for self-reflection and perhaps change to occur.Mindful eating, or becoming aware of feeding behaviors in the present moment without judgement, can be experienced by providing relevant information and the opportunity to bring attention to and then observe, feeding practices over time; all as a means of selfunderstanding.An increased awareness can lead to changes in nutritional habits as evidenced here.The data in this study demonstrate that students reported becoming more aware or mindful 42 times in answer to the two qualitative questions posed.In addition to this increased awareness, many feeding behaviors and practices were reported as changed over the course of the semester.Although the MEQ did not detect a meaningful change in mindful eating score from pre test to post test, a trend of increased score was evident in three of the MEQ four domains.In previous research among yoga and cycling participants, the MEQ score    "I look at how much" "I need to "feel and hear" my body, and "listen" "I have been more cautious when it comes to the foods I decide to eat." "I have learned to pay attention to the foods I eat"

Overarching improvement in health behavior related to nutrition
"I try to eat as healthy as possible" "my eating habits have become healthier" "My eating habits have improved" "unhealthy foods to healthy ones" "My eating habits changed" "I slowed down on eating certain foods just because it is available." "Before learning nutrition, I would eat a lot of food and snacks late at night." "I also try to gauge how much I eat every day as well as keeping track of how and which foods I need" "My eating habits have matured to a more nutritious approach." "I familiarize with myself with the amount of carbs, proteins, and fats that I intake." "I tend to eat more healthy food" "My eating habits have changed" "I feel like I am more causes to choose a healthier alternative." "try to snack on healthy foods" "I notice the reasons for me eating that are other than hunger, like stress or boredom and try to control that." "My eating habits slightly changed" "avoid the major unhealthy foods now.""Yes they have changed in a positive way" "it made me choose my food wisely.I eat better things"

Decrease unhealthy food items
"cut out a lot more unhealthy sugars from my diet" "not as much sweets".
"switched from white bread to 100% whole wheat" "try not to consume too much fats" "taken out a lot of food out of my diet.""unhealthy foods to healthy ones".
"I have cut down on the amount of sugar-filled foods that I eat." "Secondly, I decreased my intake from white flour foods" "rather than junk food" "less saturated fats: "Instead of having a plain bagel with a lot of butter" "rather than junk.""stay away from junk." "I eat way less processed foods and red meats" "less unhealthy fried foods" "I used to eat a lot of unhealthy foods," "I know it's not good to eat too much beef because it is high in fats, but to eat meat like chicken and fish." (Table 4).Continued.Improved approach to protein intake "I eat more fish" "I pay attention to protein intake" "8 ounces of protein" "protein I need for my every day activities.""I am more mindful with my protein" "I eat less processed foods, red meats and proteins" Portion size/amount of food "eat less portions" "I pay attention to portion size" "six portioned meals a day.""I also try to gauge how much I eat every day" "eat smaller portions but also I eat more often during the day" "what I eat and how much I eat." "I watch my portion sizes" "what I'm eating and how much" "I'm a lot more conscious of the quantity of the food I should eat and the size of each portion" "learned food portion is way too much" "I have started eating smaller portions" "noticed how much of it I'm eating" "improved portions" "changed portion size" "aware of quantity of food" Vegetable and fruit intake "I eat more greens" "I eat more fruits and vegetables" "more fruit and vegetables" "incorporate vegetables" "include a variety of colors in my meals" "eat many vegetables" "Now I always eat spinach" "have also picked up veganism" "Meals are full of color.The more color the better it is for you.""Vegetable intakes are key."" I eat a lot more vegetables than I did before" Improved energy levels "foods I need to eat to get the energy" "I have stable energy levels throughout the day, which is something that I've never had before."

Share nutrition knowledge with others
"I also started to help my mom watch what she eats because she wants to lose weight.""What I do a lot now is I teach others about what I learned here.""By helping and teaching others".
(Table 4).Continued.fiberintake "more fiber" "eat fiber-rich foods" "more mindful of my fiber" improve quality of carbohydrate "aware of the kinds of carbs I eat" "only eat whole grain or multigrain bread.""more whole grains" likewise trended towards improvement but was only significant in relation to an actual decrease in the MEQ score of the control group; unfortunately no control group was used in this current research [11].It is possible that the tool is less responsive to mindful eating changes than previously considered, as the qualitative data in this study strongly suggests a change was evident.The students reported that they saw a connection between their nutrition behaviors and their overall health and the prevention of disease.This is a critical finding as we face an obesity epidemic, astronomical health-care costs associated with obesity, and ultimately a predicted shorter lifespan.In addition, 71% of the participants self-identified as non-white; these important findings are applicable across segments of our population that often suffer from health-inequities and have been unrepresented or under-served in our health care system.Future research should replicate this work and include a control group as well as other measurement tools to further capture the effects of nutrition studies in college students.

"
more aware of what exactly I am eating" "I watch what I eat more than I used to" "pay attention" "more mindful of what I eat" "I am more mindful.""more aware of what I eat" "I began to notice the things I eat" "I have also become a little more aware of what I eat daily.""I pay attention to my diet more.""I am more aware" "I'm more mindful" "I am very aware of what I eat before I eat it now" "I've become more mindful of my eating habits.""I am now aware of what I eat and how I can make my meal healthier" "I'm more aware"

Table 4 : Emerging Themes and Excerpts Awareness
"I didn't notice how bad my food choices affected me before taking this course" "Helped me see what is good and health for my body and what is not" "In other words this nutrition class has me aware of my food choices."

Connect nutrition to health of body "
I didn't notice how bad my food choices affected me before taking this course.""I have felt better mentally, physically, and spiritually ever" "I take into consideration how harmful certain foods are to the body and now I focus on foods that can better my state of health.""learned the benefit or damage that they(food choices) can do to my body" "being honest(with myself) about what I put in my body.""understand nutrients I really need to remain or become healthy.""convinced to say that proper nutrition is the key to healthy living.""I now know the harmful effects that some foods may cause" "I know what is and what is not healthy for me.""I now think about how the food I eat affects my body.""Now, I understand what the food is doing to my body" "Eating poorly can affect your life.""Me knowing how to feed my machine so it could work for me during physical activity" "I understand a lot more about what to put in my body.""It has made me aware of all the diseases that can brought on if one consumes unhealthy food" "It helped me understand why I need to eat healthy."