Dietary Habits and Perceived Barriers to Healthy Eating
Students were asked how often they ate meals. Breakfast is the most commonly missed meal. Responses (% of participants) are as follows: Breakfast- never (8), seldom (25), sometimes (21), usually (24), always (23); Lunch- never (1), seldom (2), sometimes (16), usually (44), always (37); Dinner- never (0), seldom (1), sometimes (4), usually (30), always (65). There are no differences between male and female participants.
Students were asked about frequency of snacking and consumption of soda and alcohol. Most students (63%) are inclined to snack one to two times per day. There are gender differences in the reasons for snacking, types of snacks, and the frequency of soda and alcohol consumption, see Table 2. While “boredom” is the most frequently cited reason for snacking, men state “partying” as a reason for snacking more frequently than women and women state “emotional” more frequently than men. Most students snack on chips, crackers, or nuts; but men snack on fast foods more and on ice cream, cookies and candy less frequently than women. Men consume larger quantities of both soda and alcoholic beverages than women. Men also use higher fat dairy products, eat more lean and high fat meats, and eat fewer vegetables and canned and whole fruits than women (see Table 3). Fifty-eight percent of participants state they eat vegetables less than once per day and 64% eat whole or canned fruit less than once per day.
When asked to rate the “healthiness” of their eating habits, 51% of participants state “poor” or “fair." When asked to state the reasons for poor eating habits, 40% state “lack of time,” 22% state “lack of money,” 15% state “taste preferences” and 24% state other reasons. Some of the other reasons stated include “no motivation” (n = 21), “convenience” (n = 20), and “dine at student cafeteria” (n = 17). Forty-two percent of women state “lack of time” compared with 36% of men, whereas 3% of women state “don’t care” compared with 11% of men (χ2, p < 0.05).
Exercise Habits, Body Image and Perceived Barriers to Exercise
Eighty-four percent of participants stated they currently exercise and the same percentage state they exercised prior to attending college, however, 42% state they exercise less since attending college. Men exercise more frequently and at a greater intensity level than women, see Table 4. In regard to type of exercise, women do more aerobics and less strength-training and partake in fewer competitive sports than men. Men appear to be more confident with their body image. The most commonly cited reason why the participants exercised is “health” (n = 251). There are other stated differences between men and women, see Table 5. Women exercise for reasons of weight and stress reduction and men exercise for enjoyment and gains in muscle and strength. The most commonly cited barriers to exercise are “lack of time” (n = 171), “lack of motivation” (n = 103) and “lack of willpower” (n = 45). There are no differences in barriers to exercise by gender.
Healthy Lifestyle in a College Population. Part 2
A total of 471 college students enrolled in the study during the spring semester 2002. Participants were recruited using a stratified random sample of classes from upper and lower division general education classes. Final class selection was dependent on obtaining instructor permission to enter classes. A proportionate number of students from lower and upper division classes were selected. The study protocol and survey instrument were approved by the university’s institutional review board for the protection of human subjects.
All participants were asked to complete a survey designed to assess the dietary and exercise habits and perceived barriers to following a healthy lifestyle of college students. The current survey was adapted from a University of North Florida’s survey of diet and exercise of freshman (Rodriguez, 1999). The survey had 38 questions and was divided into three sections. The first section (six questions) asked for anthropometric and demographic data. The second section (20 questions) asked participants about their current dietary habits and perceived barriers to eating a healthy diet. The third section (nine questions) asked participants about their current physical activity patterns, perceived body image and perceived barriers to an active life. The survey took approximately 15 minutes to complete.
Statistical Analyses
We used the SPSS package (LEAD Technologies, Inc.) for Windows, release 11.0, to analyze the data. Frequencies were used as descriptors of the student population. Chi-square (χ2) statistics were used to examine differences in frequencies of responses to questions on dietary and exercise habits and perceived barriers to following a healthy lifestyle by gender.
Results
Approximately 60% of the participants were female and most were aged 18-21 years (Table 1). There were very few graduate students represented in this sample. Thirty-one percent of the population had a body-mass-index (BMI) greater than 25 based on self-reported height and weight data, indicating a high percentage of overweight (BMI 25 – 29.9) and obese (BMI > 30) individuals in such a young population. Forty percent of men compared with 20% of women had a BMI greater than 25. One question on the survey asked participants if they had lost, gained or had no change in weight in the last few years. Of the 414 participants who responded to this question, 46% stated they had gained weight, 30% had no change in weight, and 24% had lost weight. Of those that had gained weight, the average ± SD gain was 12 ± 10 pounds (range: 2 – 100 pounds).
Healthy Lifestyle in a College Population
The authors assessed the diet and exercise habits and perceived barriers to following a healthy lifestyle of 471 college students. Sixty percent of the participants were female and 31% had BMIs > 25. Breakfast was the most commonly missed meal and 63% of students snacked one to two times per day. Fifty-eight percent of participants ate vegetables and 64% ate whole or canned fruit less than once per day. Men consumed more soda and alcohol and used higher fat dairy, ate more meat, and ate fewer vegetables and fruits than women. Over half of the subjects rated their diet as poor or fair with “lack of time” listed as the number one barrier to eating well. Men exercised more frequently and at greater intensity than women and were more confident with their body image. The most common barrier to exercise was “lack of time.” The results of this study have implications for the design of general and specific diet and physical activity interventions among college students.
Diet related diseases including cardiovascular disease, cancer, and stroke are consistently among the top three leading causes of death (American Cancer Society, 2000). A new report, issued by the Institute of Medicine (IOM) of the National Academy of Sciences, suggests that to save the most lives from chronic disease, policy makers, health care providers and researchers should focus their efforts on helping people to stop smoking; maintain a healthy weight and diet; exercise regularly; and drink alcohol at low to moderate levels (American Cancer Society, 2003). Most college students may not achieve the nutrition and exercise guidelines designed to reduce the risk of chronic disease, typically consuming diets high in fat, sodium, and sugar and low in fruits and vegetables (Anding et al., 2001; Dinger & Waigandt, 1997; Grace, 1997; Hiza & Gerrior, 2002; TLHS, 2000). These poor eating habits may result from frequent snacking, excess dieting, and consumption of calorie dense but nutrient poor snacks and meals, such as those provided by fast food restaurants (Georgiou et al., 1997). In addition, despite the recognized benefit of exercise, surveys of college students’ health habits indicate that only 35% have a regular schedule of physical activity and that a slightly higher proportion of men (40%) than women (32%) regularly exercise (Pinto et al., 1998). However, college students are at a time and place in their lives where their behavior is conducive to change. In fact, the students’ social role of learner is largely defined by a readiness to change (NIH, 1998). Therefore, college campuses serve as crucial settings to overcome perceived barriers to healthy diet and exercise habits, and implement effective interventions (Wallace et al., 2000). Ideally, if college students make positive changes in exercise and dietary habits, these changes could persist into adult years. The purpose of this survey was to assess the diet and exercise habits and perceived barriers to following a healthy lifestyle of college students and to determine if differences exist by gender. The results may have implications for the design of effective general and gender specific interventions for college students.
Alternative Medicine Attitudes and Practices of U.S. College Students. Part 4
The inverse relationship observed between alternative medicine use and levels of exercise is worthy of note. Does this suggest a high reliance on substances to ameliorate pain and discomfort rather than alternative non-pharmacological related strategies to improve health? Unfortunately, this survey did not include a measure of other substance use, as it would be interesting to determine the association between alternative medicine use and the use of psychotropic or illicit substances. A small proportion of students (4%) indicated that their choice of alternative therapy was marijuana. Consistent with other studies of the use of health services, higher female use of alternative medicines was related to lower levels of exercise compared to male associations. This more likely reflects the trend in our culture for females to attend to health concerns and seek alternative or additional health services more frequently than males (Cherniack, Senzel, & Pan, 2001; Gotay, Hara, Issell, & Maskarinec, 1999; Ni, Simile, & Hardy, 2002).
This study has several limitations. This was a purposive sample and the colleges within which student populations were sampled represented five geographical regions within the United States, but the sample may not be representative of all U.S. college students. Students completed the survey voluntarily and were not given extra credit for completing the questionnaire. The questionnaire was administered in various health classes to students from a wide variety of undergraduate and some graduate majors. No sampling strata were applied. The only eligibility criteria were that students be enrolled in a formal college health course.
In conclusion, this paper has explored alternative medicine use among a convenience sample of college students. As a result, the survey uncovered more questions perhaps than answers. Among those questions that could be explored further would be what types and frequency of use for particular remedies were most popular; what is the correlation of alternative medicine use with use of other substances, e.g., tobacco, alcohol, illicit substances; what are the parameters of the alternative medicine use/exercise relationship? Is it merely a reflection of a secular trend of age group physical activity or gender differences in physical activity, or is the relatively high use of alternative medicine masking a reliance on an easily administered therapeutic substance? As the continued growth in the use of alternative medicine climbs in the U.S., it will be important for future studies to identify when this trend begins, e.g., at high school, college, or early adulthood and when it is likely to end.
Alternative Medicine Attitudes and Practices of U.S. College Students. Part 3
Seventy-five percent of the sample reported participating in vigorous aerobic exercise three or more time per week. Users of alternative medicine were significantly less likely to exercise than non-users. Females, who as noted earlier were more likely to use alternative medicine, were also less likely to exercise. Exercise level was significantly correlated with better self-reported health status.
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This study adds to the extant literature aimed at assessing attitudes of students toward the efficacy and use of alternative medicine. Most of this research has focused on students in the health sciences, e.g., pharmacy, medicine, and nursing. This study has attempted to assess responses from a wider student audience. In addition, most previous studies did not explore individual level variation in the use of alternative medicine, particularly with regard to gender, year of study, or geographical variables. This study fills an important gap.
The results show high levels of advocacy for alternative medicine plus a propensity to identify a need for scientific acceptability and proof of effectiveness. This suggests that these students may be discerning in their use of particular alternative medicines, which have been substantiated by at least some scientific evidence. The relatively minor exposure of students in this sample to any formal courses of alternative medicine (only 6% indicated having taken any courses), lends weight to the call for inclusion of such courses on college campuses (Patterson & Graf, 2000). Compared to previous studies of advocacy and use of alternative medicine by university health faculty (Lamarine, Fisher & Sbarbaro, 2003), support for scientific evidence was similar (93% of faculty vs. 90% students) and use was considerably lower by students (44% of students vs. 66% of faculty) in this sample. In the qualitative analysis, the most frequently utilized alternative medicine practices used by students were similar to those of faculty with herbs ranked first for both groups (21% of faculty vs. 47% of students), dietary supplements were second for students (fifth for faculty), and chiropractic third for students (fourth for faculty), followed by acupuncture/ acupressure.
The relatively high use of alternative medicine combined with conventional medicine may indicate a determination to ameliorate the discomfort and threat of serious illness, as much as a concern for personal health. With more than a quarter of the sample indicating at least one serious illness in the last five years, combined with moderate to high fear of relapse, public health concerns are raised for these young adults, most of whom are only in their third or fourth year of college.
Alternative Medicine Attitudes and Practices of U.S. College Students. Part 2
A short, 16-item written survey developed for use in an earlier study (Lamarine, Fisher, & Sbarbaro, 2003) was adapted for the present study. Alternative medicine was selected as the operational variable, in lieu of CAM, in an attempt to examine therapies that might be selected in place of traditional (allopathic) medicine, rather than as complements to it. For this research a widely cited definition was employed defining alternative medicine as “a heterogeneous set of practices that are offered as an alternative to conventional medicine, for the preservation of health and the diagnosis and treatment of health related problems: its practitioners are often called healers” (Murray & Rubel, 1992, p. 61). The major approaches encompassed by alternative medicine, as described in the literature, were listed. Conventional (allopathic) medicine was defined by the researchers as “medical practices and procedures commonly employed by physicians and other certified health workers.”
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The survey comprised a number of items utilizing a Likert scale (1=low; 5=high). These items examined attitudes and practices related to both alternative and conventional medicine. Other variables examined included the importance of scientifically based evidence, the health of the respondents, whether they had experienced a serious illness within the last five years, and their exercise patterns. In addition to demographic data subjects were asked to list alternative therapies they had used and their frequency of use. Reliability and validity of the instrument were established during the initial pilot study, which preceded the earlier research (Lamarine, Fisher, & Sbarbaro, 2003).
Attitudes and Practices Toward Alternative Medicine
Eighty percent of the students reported that they would always or sometimes advocate for the use of alternative medicine, while 44% had used alternative therapies. The most commonly used alternative therapies were herbs (47%), dietary supplements (22%), and chiropractic (16%). Nearly half (49%) of the users of alternative medicine reported that they were somewhat or very satisfied with these therapies.
A large majority (90%) of the sample reported that scientific evidence was somewhat or very important in their decision to support an alternative therapy. Eighty-five percent stated that only occasionally or never would it be ethical to advocate for the use of untested or unproven therapies, while 91% noted that it was usually or absolutely essential that all new therapies be scientifically tested.
Conventional Medicine
Moderate to high levels of confidence were reported in scientifically tested, conventional medicine by 92% of the sample and 89% were somewhat or very satisfied with conventional medicine.
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Gender Differences
Four statistically significant gender differences using Chi Square analyses were noted. Males were more likely to report that they would advocate for alternative medicine (79% versus 67%; p=.051) while females were significantly more likely than males to use alternative medicine (50% versus 35%, p=.000). However, differences between the sexes disappeared with regard to the need for scientific evidence to support decisions related to using alternative therapies, as both groups supported this issue (mean=89%). Finally, males reported better health status and greater likelihood to participate in aerobic exercise at least twice a week (78% versus 72%, p = .007).
Alternative Medicine Attitudes and Practices of U.S. College Students
This study determined attitudes and practices, including gender differences, of college students regarding advocacy and use of alternative medicine. A convenience sample of students enrolled in undergraduate health classes from universities in five separate regions of the United States was surveyed using a written questionnaire. A total of 561 undergraduate and graduate students volunteered for this study. Results of this survey indicated that the majority of college students favor the use of alternative medicine and the majority of users reported satisfaction with alternative medicine. Significant gender differences were uncovered regarding use of, and advocacy for, alternative medicine.
Interest in and use of alternative medicine has increased significantly in recent years (Eisenberg, 2001; Zolman & Vickers, 1999a). The characteristics of users of alternative medicine include above average education and affluence and below average health status and satisfaction with conventional (allopathic) medicine (Eisenberg, et al., 1998; Zolman & Vickers, 1999b). Users of alternative medicine are more likely than non-users to view conventional medicine as ineffective, expensive, and disease rather than health oriented (Astin, 1998; Ottolini, Hamburger, & Loprieto, 1999).
A number of recent studies have measured attitudes and practices of students related to alternative medicine. A majority of pharmacy students, in one study (Kreitzer, Mitten, Harris, & Shandeling, 2002), stated that the best of complementary and alternative medicine (CAM) practices should be integrated into conventional medical care. Wilkinson and Simpson (2001) found that 78% of nursing, pharmacy, and biomedical science students had used complementary therapies during the preceding year and 56% had visited a complementary therapy practitioner. The most commonly used therapies included vitamins, minerals, and other supplements. Practitioners who dispensed such therapies were visited the most often, followed by chiropractors. The majority of these students felt that complementary therapies enhanced the quality of life. No significant gender differences were noted.
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A recent study of third year medical students revealed that the majority believed that some CAM therapies were useful (Chez, Jonas, & Crawford, 2001). These students did not perceive CAM therapies as threats to public health. Most reported insufficient understanding of the safety of CAM therapies and suggested that they would not refer patients to, nor discourage patients from, these therapies. Significant gender differences were not observed. In another study, Baugneit, Boon, and Ostbye (2000) found that, compared to other students in the health professions, medical students in their final year reported the lowest level of knowledge about CAM therapies, and viewed these therapies as less useful than conventional medicine. Medical and pharmacy students were more likely than students from other health professions, to support the need for scientific evaluation before acceptance of CAM therapies.
The present study surveyed students enrolled in undergraduate health classes from a national, purposive sample of universities from five separate regions across the United States, to determine student attitudes and practices related to alternative medicine. In addition to attitudes and practices the study examined advocacy for alternative medicine, and gender differences related to alternative and conventional medicine.
Sexually Transmitted Infections. Part 5
It is well-known that several STIs, such as non reportable trichomoniasis and genital herpes, increase the risks of transmitting and acquiring HIV (Centers for Disease Control and Prevention, 1998; McClelland et al., 2007; Serwadda et al., 2003; Wald & Link, 2002; Wasserheit, 1992). Historically, little emphasis has been placed on prevention and control of non-reportable STIs in HIV prevention efforts. Our incidence estimates show that genital herpes and trichomoniasis account for 50% more infections than do Chlamydia, gonorrhea, and syphilis combined. Thus, these two non reportable STIs should be included in cost-savings calculations and in policy and program dialogue about STI/HIV prevention and control efforts in California.
We relied on various assumptions in our calculations of incidence and cost estimates. Therefore, the estimates we have derived should be considered approximations. Our analyses are subject to the same limitations as were the methods and cost-per-case estimates on which we relied in our calculations. For example, the assumptions included rates of underreporting, proportion of STIs among young people, treatment guidelines, previous cost estimates, non exhaustive direct medical costs, and others. In addition, although estimates of the cost burden of HPV-related health outcomes can vary substantially (Insinga, Dasbach, & Elbasha, 2005), it is important to note that many possible adverse health outcomes attributable to HPV, such as anal, vaginal, and vulvar cancers, were not included in the HPV cost estimated by Chesson et al. (2004). Further discussion of these limitations can be found in the studies cited in the Methods section.
In our calculation of the incidence of Chlamydia we used the 2002 NSFG (Centers for Disease Control and Prevention, 2006a) to estimate the number of sexually active women who are at risk for acquiring STIs. The 2002 NSFG does not include anal sex in its question about sexual activity and number of partners; therefore, any females who reported only anal sex in the past year would not be counted, but are still at risk for STI transmission. We relied on NSFG data in our calculations because California lacks reliable data on adolescent sexual behaviors at the county level and at the local school-district level. A coordinated, representative, statewide system for collecting local-level data on adolescent sexual behavior via standardized questions compatible with those used in national surveys of adolescents would facilitate future estimates.
California has a robust surveillance system for reportable STIs, including prevalence-monitoring projects in family planning clinics. These data were used in our calculation of the incidence of chlamydia and gonorrhea and in our distribution of state-level estimates to the county level. Nevertheless, sentinel family planning sites, the source of the chlamydia prevalence-monitoring data, are not a random sample of all family planning providers across California, clinics that participate in the prevalence monitoring project might not collect data on every person being tested, and some young women might not access care at family planning clinics, all of which could lead to either underestimation or overestimation of the true prevalence of Chlamydia in the population of young women in California.
Sexually Transmitted Infections. Part 4
The most commonly used marker for the impact of STIs is the number of cases reported to local health departments. As was reinforced by our analysis, however, the reported number of cases of newly acquired STIs considerably underestimates their true incidence. This undercounting is most likely due to incomplete screening coverage of at-risk populations, underreporting of infections by medical and laboratory providers, and presumptively treated infections that are not confirmed by testing (California Department of Health Services, 2006c).
Furthermore, as was shown by our analysis, the cost of treating acute infections and their sequelae can be considerable, whether due to the high cost per case of some STIs, such as HIV, or due to the high incidence of other STIs, such as HPV. The high lifetime cost of HIV infection is well-known; however, the lifetime cost of other STIs is less well documented. The cost estimates from this analysis represent only a portion of the total economic burden of STIs among young people in California, as not all STIs were considered and direct non medical, indirect, and intangible costs were not estimated. Nevertheless, the estimates derived from this analysis suggest that the economic burden of newly acquired STIs in 2005 among young people in California exceeded $1 billion in direct medical cost.
The wide range of incidence and cost estimates across counties results from county variations in STI incidence rates, together with county variations in the size of the 15-24-year-old age cohorts. Some of the major factors contributing to differences in STI incidence rates include variations in poverty levels; differences in sexual practices and social-sexual networks between urban, rural, and suburban populations; variations in the proportion of racial or ethnic populations in different counties; and differing levels of access to care (Aral & Holmes, 1999; California Department of Health Services, 2006c; Centers for Disease Control and Prevention, 2006b, 2007; Sapolsky, 2005).
Although non reportable infections account for a majority of the cost of STIs other than HIV, the incidence and cost of these non reportable infections have been largely absent from discussions about policy and funding at the state and local level in California. Here, and in most other states, STI prevention and control efforts have focused on reportable bacterial infections (Chlamydia, gonorrhea, and syphilis) that can be easily diagnosed and treated. Yet, our estimates show that these three STIs account for less than 20% of the calculated incidence for all STIs among 15-24-year-olds in 2005 and less than 7% of the direct medical cost for all STIs (other than HIV) for this age group. Given the substantial incidence and costs associated with non reportable STIs, greater emphasis is needed on primary prevention, as well as monitoring, of these “hidden” STIs among youth, as well as all other age groups. Nevertheless, obstacles exists to preventing and monitoring non reportable STIs such as genital herpes, as no proven programs exist for preventing it, and vaccine trials are incomplete. In addition, mass screenings and using antiviral medications for everyone who is infected would be expensive.