1 w ' ; ‘ w 1 r W? ~ i‘1 w! * M I M W [h I L 0 1 W I I “I i' i‘ i ‘ I! 5 My .‘l 311 136 175 THS USING SELF-ESTEEM AS A CONCEPT FOR GUIDING __ If 1 EARLY ADOLESCENT FEMALES TOWARD HsALIHx — - EATING BEHAVIORS: A LEARNING MODULE - _, _ Scholarly Proie ct for the Degree of. M, 3.: N. - f j ' - ‘ _ _ l MICHIGAN STATEUNIVERSITY . . ‘ . SUE E, HAGER- * ' 1998 LIBRARY Michigan State University COLLEGE or NU ACADEMIC MEET?“ PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE MAYITSd 10 30954 6/01 c:lClRC/DateDue.p65-p. 15 USING SELF-ESTEEM AS A CONCEPT FOR GUIDING EARLY ADOLESCENT FEMALES TOWARD HEALTHY EATING BEHAVIORS: A LEARNING MODULE By Sue E. Hager A SCHOLARLY PROJECT Submitted to Michigan State University in partial fiilfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 1998 ABSTRACT USING SELF -ESTEEM AS A CONCEPT FOR GUIDING EARLY ADOLESCENT FEMALES TOWARD HEALTHY EATING BEHAVIORS: A LEARNING MODULE By Sue E. Hager Healthy People 2000: National Health Promotion and Disease Prevention Objectives recommend that by the year 2000 seventy-five percent of primary health care providers should be providing nutrition assessment and counseling. This learning module is designed to help the Advanced Practice Nurse (APN) meet this goal as it applies to early adolescent females. The APN needs to be aware of behaviors specific to early adolescent fenmles and focus on primary prevention with an emphasis on self-esteem, self-eficacy, and healthy eating rather than the potential harm of dieting. Many factors, particularly physical growth, emotional development, self-esteem, peer pressure and the media influence the adolescent diet. The concept of self-esteem as it relates to healthy food choices for the early adolescent female is emphasized in the module. The Revised Health Promotion Theory guided the development of the module. It is an approach-orientated theory which allows the APN to include characteristics and experiences unique to young adolescent females. The module provides an educational tool which offers measurable outcomes within the APN role and the economic constraints of managed care. TABLE OF CON TENTS LIST OF FIGURES ..................................................................................................... v CHAPTER 1 INTRODUCTION ....................................................................................................... I Background of the Problem ................................................................................... l Adolescents and Nutrition. ..................................................................................... l Self—esteem and the Early Adolescent ..................................................................... 2 Barriers to Adolescent Healthy Diets ..................................................................... 3 Statement of the Problem ...................................................................................... 3 Goal of the Module ............................................................................................... 4 Theoretical Framework .......................................................................................... 4 CHAPTER 2 LITERATURE REVIEW ............................................................................................. 6 Historical Perspective ............................................................................................. 6 The Effect of the Media/American Culture on Teenage Diets .................................. 6 Self-esteem Perspective .......................................................................................... 8 Obesity in Adolescence .......................................................................................... 11 Current Nutritional Trends of Adolescent Females ................................................. 12 Growth and Development ...................................................................................... 13 Teaching Adolescents about Nutrition. ................................................................... 14 Food Guide Pyramid ............................................................................................... 16 Summary ................................................................................................................ 17 CHAPTER 3 REVISED HEALTH PROMOTION THEORY ........................................................... 18 Definition of Terms ................................................................................................ 20 Individual Characteristics and Experiences ............................................................. 20 Behavior-Specific Cognition and Afi‘ect .................................................................. 21 Behavioral Outcomes ............................................................................................. 22 CHAPTER 4 THE LEARNING MODULE ....................................................................................... 24 Goals ...................................................................................................................... 24 Expected Outcome ................................................................................................. 24 The Instructor ........................................................................................................ 24 Setting/Cost ........................................................................................................... 24 Time Frame ............................................................................................................ 25 iii The Group .............................................................................................................. 25 Part 1: Objectives .................................................................................................... 25 Background for the APN ........................................................................................ 26 Health Promotion. .................................................................................. 26 The Efi‘ect of Western Media .................................................................. 26 Self-Esteem and Teaching a Healthy Diet ................................................ 27 Growth and Development ....................................................................... 28 Teaching the Adolescent ......................................................................... 28 Outline of the Module: Part I .................................................................................. 29 Activities/Group Discussion .................................................................................. 29 Evaluation of Objectives ......................................................................................... 30 Part II: Objectives .................................................................................................. 31 Background for the APN ........................................................................................ 31 Immediate Competing Demands or Preferences ...................................... 31 Activities and Group Discussion ............................................................................. 31 Evaluation of Objectives ......................................................................................... 34 Resources ............................................................................................................... 34 References for the Tool ........................................................................................... 36 CHAPTER 5 IMPLICATIONS FOR THE APN ................................................................................ 38 Research Opportunities ........................................................................................... 4O Surmnary ................................................................................................................ 40 LIST OF REFERENCES ............................................................................................. 58 APPENDIX Example of teaching tool ......................................................................................... 42 iv LIST OF FIGURES Figure 1 - Guiding Early Adolescent Females Toward Healthy Eating Behaviors Using the Revised Health Promotion Model ............................................................. 19 Chapter 1 INTRODUCTION W In the United States, increased consumption of refined carbohydrates and fats is a major health problem. The over-consumption of excess amounts of fats, cholesterol, sugar, and salt has been linked to a number of chronic diseases that contribute to disability and mortality (Bendich & Deckelbaurn, 1997; National Research Council, 1989). The National Research Council Committee on Diet and Health found that there was a strong link between diet and atherosclerotic cardiovascular diseases and hypertension. They also concluded that there was a highly suggestive link with certain forms of cancer, especially those of the gastrointestinal tract, breast, lung and prostate. Healthy People 2000: National Health Promotion and Disease Prevention Objectives recommend that by the year 2000 seventy-five percent of primary health care providers should be providing nutrition assessment and counseling or referral to qualified nutritionists or dietitians (US Public Health Service, 1991). As primary health care providers, advanced practice nurses nwd to be aware of this recommendation and implement nutrition counseling and teaching to all age groups, including adolescents. Won Adolescents are at a time in their life when they require a healthy diet more than ever. It is a time of high nutritional demands because of the onset of menses, puberty, and 2 increased growth rates (Bendich & Deckelbaum 1997; Orvin, 1995; Peterson & Lefert, 1996; Weiner & Elkind, 1972). Attaining and maintaining the health of adolescents is a responsibility that requires attention to the multifaceted components of mind, body and spirit. This is a responsibility that requires the advanced practice nurse (APN) to have knowledge of adolescent developmental levels, to view teens as they see themselves, and to understand the health beliefs and barriers that young people encounter. WW Teaching teens about healthy diet, however, is not enough. Several studies have shown that many factors influerce a teen diet, particularly growth and development, self- esteem, peer pressure and the media(Fallon, Katman & Wooley, 1994; Fraser, 1997; Garner & Garfinkel, 1997; Wiseman, Grey, Mosimann, & Ahrens, 1992). Adolescence is a transitional time between childhood and adulthood in which many teens struggle with questions of identity and experience self-doubt. Any attempt to modify behavior or educate a teen who is in this stage of development must address self-esteem. According to Pipher (1994), women today have come ofage in a time when the media is sernralized and limiting to the development of a woman as a whole person. As a result, a proponent ofhealthyeatingmustconhadictthehensefocusofthemediaonfihapism” andredirect the focus of diet efl‘orts towards health and nutrition (Button, Loan, Davies, &- Sonuga- Barke, 1997; Emmons, 1994; French, Perry, Leon, & Fulkerson, 1995; Ogden & Evans, 1995;). Self-esteem is a major factor of adolescent development and behavior and should beaddressedbytheAPNwitheveryhealthissue, including healthyeatingmegel, etal., 1994; Orvin, 1995; Fender, 1996). E . E l l H l 1 11° According to Gracey, Stanley, Burk, Corti and Beilin (1996) important barriers to healthy eating in adolescents are: lack of suitable foods at home and school, inability to influence food choices at home, and ignorance about mrtrients. Many of the students evaluated in this study were correctly able to answer general questions about nutrition but wereunableto discernfoodswhichwere highinfat. Graceyetal., recommendsthat nutrition education for adolescents include self-eficacy, relevant health values and buriers-to—clnnge, education about nutrients, and improved access to healthy foods. With the change in family structure evidenced by single-parent homes and two- income families, quickly prepared meals have become more a necessity than a choice, resulting in reliance on less nutritional but more convenient items. Even in two-parent homes community involvement, after school activities, and fiiendships increase the demands on shared fimily time and limit formal meals. Choosingadiet lowerin fitmaybediflicultfortheteento achieveat school. The School Nutrition Dietary Assessment Study shows that school meals provide adequate minerals and vitamins, but are high in fit ie., 38% ofenergy from fat and 15% fiom saturated fit (Parmell, 1995). “ ast” foods, which are popular with adolescarts, are fiequentlyhighinfats, sugarsandrefinedcarbohydratesmendich&Deckelbamn, 1997). Wabbit) Adolescentswho areatrisk ofunhealthydietaryintakerequirenutrition curriculathat includes information and teaching methods which are tailored to their specific needs. Interventions of the APN should include skill development around early dietary behaviors. Presently there are no written curricula available for the APN which teaches a healthy diet 4 to adolescents while including self—esteem as a major component of the plan. finalnflhaMnduls The goal of this module is to enable the APN to teach healthy eating habits to young female adolescents while emphasizing self-esteem as a major component. According to Prochaska’s Model of Change (Prochaska, DiClemente & Norcross, 1992), in order to change behavior the APN must first give the knowledge and create an awareness of the probleminthetarget audience. This moduleisdesignedtobeusedbytheAPNasonepart of an approach to health promotion The learning module is designed to promote intervention prior to adulthood in order to prevent chronic diseases and their resultant morbidity and mortality through modification of diet behavior. The first section of the module consists of exercises designed to examine and promote self—esteem. The second section exploresthefood pyramid andhowteenscanapplyittotheirdailylives. The expected outcome ofthe nutrition education module is to increase awareness in young adolescent females oftheimpactthatwesternculturehasontheirself—esteernandhow they can use this information to make better diet choices. Themoduleis designedtobean overview oranintroductionratherthananin—depth coverage of nutrition. It is meant to “get their attention” and help adolescents begin to consider developing healthy “achievable” dietary goals rather than unrealistic and potentially dangerous ones. The goal for the students in this module is to develop a foundation of knowledge, the beginnings of awareness, and new thinking so as to increase the potential for a change to healthier eating. W The Revised Health Promotion framework is an approach-oriented model which does 5 not include “threats” therefore it is easily adapted to teaching nutrition to all ages including adolescents (Pender, 1996). Since self-esteem is an integral part of this teaching module, inclusion of a positive view of health behavior, and personal fictors such as growth and development, current diet behaviors, and perceived benefits and barriers is optimal. The Revised Health Promotion Model (RHPM) addresses the requisite that the APN be aware of barriers that the teen may face when changing diet. The RHPM also includes self-efficacy, an essential ingredient to making healthy/wise choices about diets. This is particularly important to the adolescent who is faced with peer pressure to eat “junk” food or engage in unsafe weight loss methods. A more extensive review of how the RHPM relates to teaching a healthy diet to early adolescent females is discussed in chapter 3. Chapter 2 LITERATURE REVIEW Hi . l E . Throughout western history, women’s identity and worth have been closely linked with appearance. In the past, as food was less accessible, being larger-sized was a sign of secure economic status (Fraser, 1997). Later, as food became more accessible to peeple of modest means, another body type was needed to distinguish the rich from the poor. Slenderness became the new symbol of class distinction and of high morality (Fallon, Katzman, & Wolley, 1994; Fraser, 1997). Fashion dictated distortions of the female body requiringrigid corsetsandbustles. The Gibsongirlwasone ofthefirst ofthemedia blitzes idealizing a perfect-shaped woman. She was based on a drawing, however, rather thanarealperson; underscoringthefactthatthisideal shapewasunattainableforthe average woman. The Gibson girl was followed by the “Flapper” who was even more slender, and later by models Twiggy and Kate Moss (Frazer, 1997). Wiseman, Grey, Mosimann, and Ahrens (1992) have found that role models such as Miss America and the Playboy centerfolds have become thinner and dinner over the years while the average woman’s size has gradually increased. These authors note that only five percent of women are genetically prepared to achieve the type of body style now prevalent in television and magazines. In spite of the evidence that very few can achieve the media’s ideal body style, restrictive eating has been a national trend among teenagers. Harrison and Cantor (I997) surveyed 232 female undergraduate students in a large Midwestern university. They 6 7 found that about 15% of the women met criteria for disordered eating. The women in this study who frequently read fitness magazines for reasons other than fitness and dieting (beauty and fashion), displayed greater signs of disordered eating than women who rarely read them at all. A significant relationship was found between reading fashion magazines and the woman’s drive for thinness and her dissatisfaction with her body. Magazine reading in general had little efl'ect on body dissatisfaction The American media has for many years suggested to the public what changes the average female should make to correct physical flaws and wlmt product is needed and available to correct these imperfections. Shisslak and Crago (1994) found that while men have been valued for traits such as character, strength or economic potential, women have traditionallybeenjudged bytheirlooks. Theseauthorsalso reportthatthinnessisoften equated with beauty, health and most importantly personal value. According to Kilbourne (1994) the ultimate failure of the average woman to achieve the fashion industry’s representation of the ideal female repeatedly exposes them to an unachievable goal and a negative self-image. Brumberg (1997) compared the self- improvement plans of adolescent girls in an assortment of teenage diaries fiom the late 19th century to the late 20th century. This historical perspective describes how centuries ago the emphasis was on “good works” rather than “good looks,” as compared with young girls today who refer to their bodies as “projects.” According to Brumberg, “More thatanyothergroupinthepopulation, girlsandtheirbodieshavebornethebruntof twentieth-century social change, and we ignore that fact at our peril” (p. 214). Although the idea that you can never be too rich or to thin has been evolving for a long time, during the last fifty years concern about weight has accelerated among 8 Americans, especially young women (Garner & Garfinkle, 1997). American media has inundated the population with messages that equate thinness and personal appearance to happiness. At the same time the media portrays how the “ideal” teenager should look, the media is a source for advertisement of high~fit fast foods. Television portrays healthy and happy people having fun while they are eating fast food. However, contrary to the impression left by television advertisement, a disproportionately decreased metabolic rate has been noted among overweight children while watching television (Nader, 1993). Thefashionindustry, television, moviesandparticularlymagazinesarefilledwith youngwomenwhoareverythin Shapeandlooks, whichareunattainableforthe averasefemale, mmedasthe‘idfll” healthy, WWWW Grey. Mosimann, & Ahrens, 1992). American media/culture presents an unachievable goal to American youth which can result in a cycle of lower self-esteem and dieting (Fallon, Katzrnan., Wolley, 1994). “Given the proformd cultural pressures on women to diet, it is perhapspertinenttoaskwhyallwomendonotdevelopsomelevelofdisordered eating,” (Garner & Garfinkel, 1997, p. 148). W Self-esteernhasbeendefinedasthevalueatm’butedto selfandisbasedonaperson’s conceptofhisorherdesirableandundesirableattributes, strengths, weaknesses, achievements and success in interpersonal relationships (Pender, 1996). Self-esteem is changeable, devel0ped over time, and is ongoing throughout adolescence (Orvin, 1995). Megel, et al (1994) evaluated the relationship between self—esteem, health promotion, nutrition and weight in a group of 57 older adolescent females. These authors demonsfiatedfifiseh‘eneanmmesewomenwasposifivdyassodatedwnhmepracfice 9 of healthy behaviors and satisfiction with their present weight. However, in this study group the students’ satisfaction was only elevated when they were restricting their diets. These authors found that there was a positive relationship between satisfaction with weight and caloric intake when the caloric intake was 21.6% below RDA recommendations. This implies that the young women were positively reinforced by restrictive eating rather than healthy eating. Young impressionable females who are targeted by the “lookism” aspect of American culture may try to achieve a body weight other than what their genetic make-up will allow. This may result in a disparity which leads to dissatisfaction, guilt, self-consciousness about their bodies, and a drive to become thinner (Levine & Hill, 1991). French, Perry, Leon, and Fulkerson (1995) looked at 1030 females ages 12 to 15 over a three year period and found connections between self-concept and dieting. This group found that scales evaluating psychologic variables such as ineffectiveness, maturity fears, perfectionism, fiiendship and self-concept uncovered negative feelings in fi'equently dieting adolescent females In this group the strongest behavioral traits observed in frequent dieters included unhealthy weight control practices such as vomiting, diet pill, laxative, and alcohol use. Psychological measures related to appearance also revealed greater adverse changes over time among the frequent dieting group. This group also found that although dieting is more prevalent in individuals of higher body mass index (BMI), dieters of normal weight actually outnumbered overweight dieters. A conclusion of this study was that poor self-image may predispose young females to diet and that interventions should include skill development around early dieting behaviors. Emmons (1994) evaluated 1269 high school seniors to determine predisposing fictors l O which differentiated dieting fiom non-dieting adolescents. Although dieting did not have much efi‘ect on males, self-esteem scores were lower in female dieters, particularly white females. It was rmclear whether those with less self-esteem dieted more often or that struggles related to dieting lower a person’s self-esteem. This author recommended that adolescent dieters, most of whom were not overweight, were less in need of weight reduction programs than of diet counseling which would help them accept more realistic weights. Ogden and Evans (1995) studied 74 adults to compare the efi‘ect of measuring weight to the social norms on self-esteem, mood and body dissatisfiction. Subjects were dispersed into under-weight, overweight or average weight groups according to fictional weight and height charts. Subjects allocated to the overweight group evidenced a lowered self-esteem. The authors concluded that when the individual arrives at an unfavorable comparison of self with the social norms, a detrimental and worsening efl‘ect on an individual’s self-concept can occur. In addition to glorifying thinness American culture also sends messages that fat is dangerous, unhealthyandcausedbylackofpersonalcontrolfiatrina,King,&Hayes, 1996) . Prejudice against larger sized people is one of the last socially acceptable forms of bigotry in America today (Katrina, King, & Hayes, 1996). Overweight peeple may be reminded either verbally, or more fi'equently non-verbally, that they are faulty. This pervasive and accepted discriminationcanleadtoanunrealisticfearofeventhe smallest weight gain in still-developing adolescents (Garner & Garfmkel, 1997). l 1 W The health implications of obesity related to a poor diet are clear. Diets high in fat have been linked to diabetes, hypertension, cardiovascular disease, and certain cancers (Harlan, 1993; National Research Council, 1989). It is estimated that 27% of children and 15% of adolescents are overweight in the United States (Pender, 1996). In Michigan, it was estimated that in 1996, nearly one-third of adults were overweight ('MDPH, 1996). Blue Cross and Blue Shield of Michigan has sponsored a study which evaluated a non- random sample of 36,281 males and females, ages 5-18 in 45 Michigan schools during the 94—95 school year. This group found that of 11 to 18 year olds, 20.6% met the criteria for obesity ( Kuntzleman, et al., 1996). These researchers also found that the average Michigan 11 to 18 year old female is 3.9 to 8.1 pounds heavier than her U.S. counterparts. Long term follow-up studies of children and adolescents indicate that the risk of adult obesity is about twofold greater for those who were overweight when younger, compared with individuals who were not overweight (Must, 1996). According to Must, although there are longterm healthrisksto increasedweightforteens, themost prevalent iimnediate consequences of being overweight as an adolescent are psychosocial. Social isolation and peer problems can also occur for children who are overweight. According to L. Spence PhD. (personal communication, April 2, 1998), psychological studies have indicated that discrimination against overweight children is very prevalent. Dietingandfearoffatmaybeginataveryearlyage. Inastudyof494middle—class girls between the ages of 9 and 10, thirty percent of the nine-year-olds reported worrying that they were currently too fat or feared becoming fat in the fixture. Eighty percent of the 1 2 10-year-olds reported restrained eating and higher self-esteem while dieting. Several of these young girls reported purging in order to control their weight (Mellin, Irwin, & Scully 1992). An additional study by French, Perry, Leon, and Fulkerson (1995) looked at 1,015 female 9th-12th graders to examine weight loss behaviors and restrained eating practices. Theseauthorsfoundthat41% ofthegroup hadbeendietingwithinthepastyear. Ten percent reported a modest weight loss, most frequently achieved by skipping meals and increasing activity. Eighty-one percent of the study group were considered normal weight. Although these findings suggest that many adolescent females are adOpting healthy behavioral changes, theystillvalidatetheneed forgreaterawareness ofweight- related behaviors which can develop into unrealistic weight concerns or excessively lean body weight standards. The authors did not address self-esteem or self-concept issues. Peters, Amos, Hoerr, Koszewski, Huang and Betts (1996) found that although young femaleshaveahigherprevalenceofdieting, youngadultsofbothgendershad questionable eating behaviors. In this study, methods to control weight were diet pills, powders, and restrictive eating. Many of these young people reported repeated periods of weight loss and regain (yo-yo dieting). These authors recommend early intervention which minimizes weight concerns and emphasizes self-acceptance and healthful eating Yo-yo dieting practiced by many adolescents results in weight gain over time and increased health risks. According to Gaesser (1996), higher rates ofheart disease have beenfmmd in thosewho reported yo-yo type dieting Gaesserfirrtherreportsthatweight cycling by dietary means plays a primary role in the development of chronic diseases such as diabetes. hypertension and cardiac disease. 13 W The major tasks of developing girls in their early adolescent years, (ages twelve to fifteen), include focusing on the self and the task of becoming comfortable with body changes and appearance. The adolescent may begin trying to separate from parents through less involvement in family activities and increased criticism of parents. Conformity and acceptance of peer group standards gain increased importance. The female peer group consists mostly of same sex friends, however there is an increased interest in males (Barkausas, Stoltenberg-Allen, Baumann & Darling-Fisher,1994; Orvin, 1995; Weiner & Elkind, 1972). The individual is working to overcome feelings of insecurity and inadequacy and to move toward self-assurance and independence (Barkausas, Stoltenberg- Allen, Baumann, & Darling-Fisher, 1994; Weiner & Elkind, 1972). According to Elkind (1970), adolescents are continually constructing or relating to an imaginary audience which plays a role in the teen’s self—consciousness. This “imaginary audience” is continuously observing not only the teens’ actions but that of her family and fiiends. The feeling that everything the adolescent does is under constant scrutiny supports the need to conform to the norm of the peer group. Adolescents also maintain a belief in a personal fable, which is a belief in the personal uniqueness of the teen’s own feelings and a belief of their own immortality. In addition to these teenage attributes, adolescents are developing the ability to introspect (using formal operations) and evaluating themselves from the perspective of others (Elkind, 1970). These developmental tasks may make young females susceptible to the culture and any of its messages that devalue their self-esteem. 14 Eccles et al. (1996) reported that the early adolescent years mark the beginning of a downward spiral for some individuals. This trend may be evidenced by negative motivation, learned helpless responses to failure and a focus on self-evaluation rather than task mastery. Teenagers struggle with an evolving self-concept and a strong need for autonomy and independence ( Elkind, 1970; Loghmani & Rickard, 1994; Weiner & Elkind, 1972). This dichotomy between the need for independence and the nwd for conformity with peers is a hallmark of adolescence (Pipher, 1994). It is not just a period of rapid physical growth and major changes in physical appearance, but a time of increasing liberation from family ties and a continuing shift from home to peers (W einer & Elkind, 1972). Because teenage social activities often revolve around food, the adolescent needs a flexible plan that allows for choice and spontaneity; one that allows them to eat as theirpeersdo, yetmaintainahealthydiet. I l . l l I E] H . . Cognitive and reasoning capacity emerges gradually over the adolescent decade, making younger adolescents less capable than older adolescents of efl‘ective reasoning (Petersen & Lefl'ert, 1995). Material must be adjusted not only so that it is understandable to the younger adolescent, but also because their inexperience can increase their anxiety about an issue that would not efl‘ect someone older. Making clear the right of the adolescent to refuse to discuss particular issues should increase their comfort with the material and may permit more honest response to discussion (Petersen & Lefi‘ert, 1995). Killian et al. (1993) evaluated the efl’ectiveness of a prevention curriculum designed to modifyeatingattitudesandunhealthyweight practicesin967 sixth and seventhgrade girls. These girls were instructed in harmful efl‘ects of unhealthy weight reduction, healthy l 5 weight regulation through sound nutrition and regular exercise, and developing coping skills to resist socio-cultrnal influences that appear linked to obsessive thinness and dieting. The goal of these authors was to decrease unhealthy eating practices in young adolescent girls. After the teaching interventions there was no change between the study and control groups. These authors suggested that prevention curriculum should be targeted to “at risk” girls only. The “at risk” subgroup was defined as 11-12 year old girls with higher prevalence of substance abuse, unhealthy weight regulation strategies, and depressive symptoms. Questionable dieting practices of adolescents can have long term negative efi‘ects on health and can lead to eating disorders and obesity, particularly in females. Behaviors associated with eating disorders serve powerfirl emotional fimctions and create strong barriers to their reduction (Murray, Touyz & Beumorrt, 1990). Eating disorder prevention should comprise some part of every adolescent’s education, however there is some evidencetlratteaching directly abouteatingdisorders mayactuallyprecipitatethe disorders in susceptible teens (Grodner, 1991; Fallon, Katzman& Wolley, 1994). Murray, Touyz and Beaumont (1990) interviewed 149 people under the age of 30 and fotmd that the media was the major source of the subjects’ information about eating disorders. Over one-third of the females reported that their knowledge of eating disorders had afi‘ected their own eating attitudes in some way. These authors suggest that health professionals need to be aware ofthese behaviors and focus on primary prevention and early intervention with an emphasis on self-esteem, self-eflicacy, and healthy eating rather than the potential harm of restrictive eating. Fries and Croyle (1993) reported that the individual’s diet-based stereotypes can 16 predict their reactions to a nutrition education message. Individuals who held negative stereotypes of people who eat low-fit diets responded more skeptically to information promoting the benefits of a low-fat diet. These authors recommend that the nutrition educator dispel, or at least acknowledge, current stereotypes before giving dietary advice. Discussion on existing stereotypes may increase receptivity to diet information Murphy, Youatt, Hoerr, Sawyer, and Andrews, (1994) found in a survey of 270 filth eighth, and eleventh grade students that the most popular strategies for learning about healthy diets actively involve students: these included games, food experiments,’ and computer games. Passive methods of learning, individual projects, and information presented by the teacher were the least preferred methods of instruction. E l G . l E . l The Food Guide Pyrarrrid was developed to assist healthy Americans to make food choices for total diets which maintain good health (US Dept. Agriculture, 1992). The pyramid has replaced the Basic Four Food Groups and is usefirl for simple dietary screening and as a foundation for general nutrition education (Pender, 1996). Both nutritional adequacy and overnutrition are addressed in relation to three major messages: dietary variety; moderation of fats; oils and sugars; and dietary proportions (Achterberg, McDonnell, & Bagby, 1994). A diet guided by the Food Guide Pyramid is expected to meet the Recommended Dietary Allowances (RDAs) for all nutrients, contain moderate amountsoffatand sugar, and provideanadequateenergytomaintainahealthyweight (Bendich & Deckelbaum, 1997; Schuette, Song, & Hoerr, 1996). l 7 Summary It is important that that the APN acknowledge , and if possible, dispel current stereotypes before giving dietary advice to increase receptivity of teens to diet teaching. Peers have a major impact on adolescent attitudes and actions. Among adolescents popular methods of teaching include interactive games and activities. Actually teaching about restrictive dieting or eating disorders may precipitated the disease in some susceptible adolescents. These concepts have been used to tailor the RHPM for young teenage girls. The literature review for this learning module is a base for developing concepts which afi‘ect young female adolescent diets within the Revised Health Promotion Model. Chapter 3 THEORY BMW The Revised Health Promotion Model (RHPM) is a competence or approach- orientated theory that can be used by the APN to teach a variety of health issues to individuals across the life span. The RHPM is an attempt to depict the multi—dimensional nature of persons interacting with their environment as they pursue health (Pender, 1996). The RHPM is composed of three major areas. The first area, Individual Characteristics and Experiences, permits each person to be perceived as a unique individual. Behavior- Specific Cognition and Afl‘ect is considered to be of major motivational significance. The variables in this category are individual specific and constitute an important source for tailored interventions. The third major category, Behavioral Outcomes, evaluates how the committing to a plan of action and coping with immediate competing demands effects health promoting behavior. The perspective of the RHPM coordinates well with a holistic nursing position. According to Pender (1996) perceived self-eficacy, and identification of benefits and barriers are strong predictors of health behaviors and are important factors when using the RHPM. According to Pipher (1994) and Elkind (1970), adolescents are still “magical thinkers.” They may believe that the potential for firture health events such as chronic disease does not exist for them. Since the RHPM does not include fear or threats as sources of motivation for health behavior, the RHPM is particularly useful for adolescents and young adults who may perceive themselves as invulnerable to disease, particularly chronic disease. 18 Guiding Early Adolescent Females Toward Healthy Eating Behaviors Using the Revised Health Promotion Model Individual Behavior—Specific Behavioral Characteristics Cognitions Outcomes and Experiences and Affect Perceived Benefits ofAction Immediate Competing Demands (low control) and ' d' b f : rmme rate ene ”5 _.. preferences (high COHthl) healthier lifestyle feel better Prior Related Behaviors higher energy ' Low Control: high fat diet 7’ minors high cholesteral diet ddepcrlidancy or; others ' eve o menta issues GENE? [diet -—> Perceived Barriers to ACtion P 0.16:) daieiiii media/cultural stereotypes High Control: Y y g availability of high ,glf.cstc,,m cholesterol self-efficacy high fat foods — decreased availability __ of fruits &vegetables lack of planning time attitudes money a Perceived self—efficacy performance attainment observing others — encouragement from Others - physiologic States V (anxiety vs. tranquility) each teen is unique Commitment Health to a Plan of Promoring Action Behavior Activity-related affCCt . . identify usable subjective feelings strategies l l l d o o o I posrtive/negauve ma H) [Ct attitude food pyramid Personal Factors Interpersonal Influences ‘ family, peers adolescence ngth health care providers PhYS‘Cal development ——.>» support systems home enyrronment norms, modeling family influences socio—cultural environemental ’ Situational Influences self-esteem .. .. . . . fast food restaurants emotional thinking . peer-related socral magical thinking . . . acuvrucs school lunches Figure l Adapted from RHPM (Pcndcn I996) 61 20 Adolescent girls also engage in emotional reasoning, with a limited ability to sort facts from feelings (Pipher, 1994). When emotional reasoning is used, the adolescents’ current emotional state has an impact on the decisions they make. In order to impact adolescents who use this type of reasoning, the APN can utilize the RHPM, which accommodates factors unique to adolescents when teaching health promoting behaviors. Figure l is representative of how teaching a healthy diet to teenage females works within the RHPM. D E . . [I For the purposes of this project self-esteem is defined as a person’s view of self which is changeable over time. This self-concept includes both positive and negative attributes which are affected by external influences such as social norms and internal ones such as growth. Early adolescent females refers to girls, twelve to fifteen, who are becoming aware of the changes in their bodies as they reach puberty and are starting to make decisions which can affect these changes. Healthy eating behaviors are based on the National Dairy Council’s Food Guide Pyramid recommendations for daily nutrition intake. The RHPM allows for each person to be treated according to their unique characteristics as well as their experiences, which afi‘eet their perspective on health This model is therefore particularly useful for adolescents. Prior related behaviors, such as the teen’s current diet practices and habits, along with personal factors, such as growth and development, home environment, family influences, socio-culttn'al environment factors, self-esteem, emotional and magical thinking, are evaluated in the beginning. Evaluation of 21 these characteristics allows the APN to tailor a teaching plan and include variables which are specific to the adolescent and the planned outcome: a healthier diet. El'-S 'fi: .. Hm Anticipated benefits of a healthy diet provides a motivation to learn the diet. For an adolescent, having more energy for sports and other recreations may provide the motivation, or just feeling better may be enough Beliefin an immediate positive outcome isanimportantmotivatingfactorandwillincreasethe chancethattheteenwillinvesther time and resources in the plan. Perceived barrias toaction referstoanyvariable, eitherreal orimagined, thatmay impairordelaytheadolescent fromattaininghergoal. Whenreadinesstoactislowand barriers are high, action is unlikely to occur. Barriers my arouse motives of avoidance in relationtothegoal. Barriersmayincludelimited accessorlackoftimetopreparehealthy foods, orintensemediaor social pressureto consumehighfat, high cholesterol snacks. Perceived self-eficacy is the judgement of personal capability to accomplish a certain level of performance or task (Pender, 1996). Perceptions of competence in a particular areasuchas dietmayprovide motivationto achievethegoal. Encouragementfiomothers thattheteendoeshavetheskillsneededtoachievethegoal, alongwithobservingothers whoareinfluentialtothetecn(suchaspeers, farnilyandevenhealthpmviders)whoare comfortable and confident with a healthy diet will also promote self-eficacy. Physiologic states such as anxiety as opposed to tranquility provide the enviromnent fi'om which the adolescent views her self-eficacy. Self-eficacy will encourage achievement of a healthy dietdirectlythrough eficacyexpectationsand indirectlybyafl’ectingperceived barriers andhowreadilytheteen maypursuethegoal. 22 Activity related afi‘ect describes any subjective feelings the teen may have ascribed to achieving the goal of a healthy diet. How the adolescent feels about changing her diet, the lesson plan itself, or even the APN, either before, during, or after the lesson influences the effect of the teaching plan on the adolescent. According to Pender (1996), any clues to the learner’s emotional state, feelings, or attitude may give the teaching APN valuable information as to the learner’s self-efficacy, commitment to the plan and ultimately, goal achievement. Both interpersonal and situational influences can facilitate or impede behavior (Pender, 1996). Feelings of skill and accomplishment in choosing a healthy diet are likely to encourage the teen to engage in healthy eating behaviors more frequently. An adolescent’s selfieficacy may be influenced by the feedback they get fi'om others such as peers and family; their level of development and their cognitive abilities; all of which efl'ect how they view the world. Situational influences include the teen’s perceptions of her available options and the features of the environment in which the healthy diet is to occur. High fat school lunches, “fast” food restaurants and other social occasions frequented by their peers may provide situations which seem incompatible with the goal of a healthy diet. Finding ways to help the adolescent recognize and deal with these influences will have an important efl‘ect on goal achievement, the healthy diet. Behardnralflrtsnmes “Immediate competing demands or preferences” refers to thoughts or behaviors that arise irmnediately before the goal behavior and may compete with the goal behavior. An adolescent who is about to eat an apple when a fiiend arrives and ofl‘ers a candy bar is 23 exposed to an immediate competing preference. If she is in a high control situation (perhaps high self-esteem and self-efficacy) she can pass on the candy bar and continue with the apple. Another example of a high control situation is if the adolescent is eating the apple and no competing situation (such as a candy bar) occurs. She has high control over the situation because there is not a competing preference. Competing demands for a teenager are situations which arise in which she perceives that she has little or no control. Because teens are still dependent on others to care and provide for them, some may feel decreased control over what choices they have over meals at home and school. Additionally, adolescents may be predisposed developmentally to be more easily influenced to make choices other than their planned one. One method of combating this problem is by implementing a plan of action. Commitment to a plan of action requires that the plan of action is clear and understood by all participants. The plan should be well thought out and include strategies for assessing, performing the task and reinforcing the behavior. The Revised Health Promotion Model is a theory which includes interpersonal, situational and behavioral influences which efl‘ect how an individual may approach learning a healthy behavior. It applies across the life span so it can easily be tailored by the APN when teaching healthy behaviors to adolescent females. Chapter 4 THE LEARNING MODULE finals The goal of this module is twofold. The first goal is to increase the awareness of early adolescent females ages 12 to 15 as to the impact that the American culture has on their self-esteem and body image. The second goal is to show adolescents how they can use information in this module to make better diet choices. This module is designed to be an overview or an introduction rather than an in-depth coverage of nutrition. It is meant to i “get the adolescents’ attention” and help adolescents begin to consider developing healthy “achievable” dietary goals rather than unrealistic and potentially dangerous ones. W The expected outcome of the module is that the adolescent female will have a foundation of knowledge and a beginning awareness of how to incorporate healthy eating indailylife, soastoincreasethepotentialforachangeto healthiereating. W This learning module is designed for use by an APN however other health care providers may find it easy to incorporate this tool in their practice. Other professionals who have contact with adolescents such as teachers, counselors and social workers may also find this tool useful. Co-teaching this module with an adolescent girl who can be viewed as a peer by the students may increase participation and learning of the group. W The setting for this program should be in a comfortable well-lit room. A schoolroom, an ofice lobby after hours, or a living room would be suitable. Since discussion and 24 25 groupworkisthecore ofthemodulethe seats shouldbeirracircleandatdistancesapart which are conducive to listening. Materials required for this module are minimal and easily accessible. This module can provide efl‘ective health guidance at a negligible cost. Costs may include room rental and salary of the APN during the time of instruction. Iirnefimme This module is designed to be ofi‘ered in two one-hour sessions. Modifications may be made according to thejudgement ofthe APN to accommodate any limitations which may arisesuchasroomavailabilityandlearnerneeds. 11113120132 Participants for the module may come fiom several sources. The APN in a family practicemaydrawfi'omhisorherpractice, forexample, adolescerrtswhocomeintothe ofice for camp or sports physicals. Local schools, churches and youth groups may also expressaneedformrtritionedueationfowsedonyoungadolescent females. The module is designed to promote group interaction and exchange of ideas. Groups largerthaneightwouldnmkeflresefleracfionsmorediffiwhandlesspersoml soarenot recommended. Young adolescents in particular who are sensitive to peer pressure and an w . l' ”mayfindl groups'l'l" Through groupactivitiesanddiscussiontheparticipantswillbeableto: l) Describeatleasttwopositiveattributesoffemalefiiendsthatarenotrelatedto physical characteristics. 2 6 2) Discuss at least two ways in which self-esteem, particularly of young women, has been impacted by the media and afl‘ects lifestyle. 3) Discuss what personal characteristics are an accurate gauge of a person’s value or talents. WW Hmhhhnrnntinn: In the United States increased consumption of refined carbohydrates and fats is a major health problem. The over-consumption of excess amounts of fats, cholesterol, sugar, and salt has been linked to a number of chronic diseases that contribute to disability and mortality (1). The National Research Council Committee on Diet and Health found that there is a highly suggestive link between diet and certain forms of cancer, especially those of the gastrointestinal tract, breast, lung and prostate. In addition to the long term health risks of increased weight for teens, the most prevalent immediate consequences of overweight during adolescence are psychosocial. Social isolation and peer problems fi'equently occur in overweight children (2). Healthy People 2000: National Health Promotion and Disease Prevention Objectives recommend that by the year 2000 seventy-five percent of primary health care providers should be providing clients with nutrition assessment and counseling or referral to a qualified nutritionist (3). APN’s need to be aware of this recommmdation and implement nutrition counseling and teaching to all age groups including adolescents. W Magazines and advertisements geared toward females tend to focusonchangingthefemalebody. Thinnessisoftenequatedwithbeauty, health, and, most importantly, personal value. The American media for many years has suggested to the public what changes the average female should make to correct her physical flaws, and 2 7 what product is needed and available to correct these imperfections. The fashion industry, television, movies and particularly magazines are filled with young women who are very thin. Shape and looks which are unattainable for the average female are portrayed as the “ideal” healthy happy person (4). Only five per-cent of the population is genetically prepared to achieve the type of body style now prevalent in television and magazines (5). The American media/culture, with its focus on “lookism,” presents an unachievable goal to American youth which can result in a cycle of lower self-esteem, self- consciousness about one’s body and a drive to become thinner rather than healthier (6). In addition to promoting thinness, the media is also a source that promotes high fat fast foods. Television portrays healthy, energetic, and happy people having fun because they are eating fast food. Ironically, a disproportionate decreased metabolic rate has been noted among overweight children while watching television (7). Western culture also send messages that fat is dangerous, unhealthy and caused by lack of personal control. Prejudice against larger size people is one of the last socially acceptable forms of bigotry in America today (8). This pervasive and accepted discrimination can lead to an unrealistic fear ofeven the smallest weight gain in still- developing adolescent girls (9). W: The basic premise of this module is that higher self-esteem enables self-eficacy of girls and as a result the adolescent is able to make good food choices and avoid negative behaviors such as high fat consumption, restrictive eating or yo-yo dieting. It is unclear whether adolescents with less self-esteem diet more often or that struggles related to dieting lower a person’s self-esteem (10). Interventions to promote healthy adolescents need to inchrde skill development around 2 8 early dieting behaviors. Specifically teaching about the risks of dieting or eating disorders have actually precipitated the disorder in susceptible adolescents therefore this module does not address restrictive eating or eating disorders (11,12). Health professionals need to be aware of high risk behaviors and focus on prevention and early intervention with an emphasis on self-esteem and self-efficacy (13). W: Adolescent females from ages 12 to 15 are at an age when they are focusing on the self and the task of becoming comfortable with body changes and appearance (14). The adolescent begins to separate fi'om parents through less involvement in family activities and increased criticism of parents. Conformity and acceptance ofpeer group standards gain increased importance (14). The female peer group consists mostly of same-sex fiiends, however there is an increased interest in males (14). Adolescents are continually constructing or relating to an “imaginary audience” which plays a role in their self-consciousness (15). The feeling that everything the adolescent does is under constant scrutiny supports the teen’s need to conform to the norm of the peer group. Adolescents struggle with an evolving self-concept and a strong nwd for autonomy and independence. This dichotomy between a need for independence and needfmconfoanwithpeersisahaflmm'kofadolescence(16).Becausethdr social activities ofien revolve around food, teenagers need a flexible plan that allows for choiceandspontaneitysotheycaneatastheirpeersdo, yetmaintainahealthydiet. WW: Cognifiveandmsoninscapadtyemusessraduaflyomthe adolescent decade, making younger, less experienced adolescents less capable than older adolescents of efl‘ective reasoning(l7). Making clear the right of the adolescent to refirse to discuss the particular issues should increase her comfort with the material and may 29 permit more honest response to discussion (17). The most popular strategies for learning about healthy diets actively involve students: games, food experiments, and computer games. Passive methods of learning, individual projects, and information presented by the teacher were the least preferred method of instruction (18). W I. Introductions A APN B. The students 1. Self-introductions a. Optional game: Sitting in a small circle everyone states their me once. Passabaflfiompersontopersonanywhereinthecircle. Astheballis passedtoeachpersontheymuststatetheirnameandthenameofeach personwhohadtheball beforetheminorder. TheAPNmaybeincluded. 2. Nametags-optional II. The media and self—esteem A. What should we look like? B. Pass out magazines 1. Activities and group discussion E . . . [G D' . Group discussion can increase critical thinking and promote new paradrgms' of thought. This section of the model provides time for discussion and exchange of ideas. One or all of the questions can be used. Exercise 1. Pass out magazines such as “Seventeen”, “People” and “YM”, ask the group 3 0 to discuss how the advertisements may promote increased size anxiety and decreased self- esteem. 1) Do they encourage the need to conform to a set standard? Whose standard? 2) How would you change the ads? What words would you use? 3) How many difl‘erent sizes and shapes are pictured in the models? Exercise 2. Think about someone important to you, or that you admire or care about. 1) What are some of the qualities of that person that you like or love? 2) When you first meet someone what makes up your first impression? 3) What is really important? Exercise 3. Tape a piece of paper on the back of each adolescent. Have each person write something they like about the person wearing the paper that is not related to appearance. Each girl should write on the back ofevery other girl. What the girls are done allow them to read their own paper. 1) How does it make them feel? 2) What are some ways that we can feel good about who we are every day? 2) What about a “bad day”? At the end of this discussion the group leader should summarize some of the ideas and use the objectives to evaluate the discussion. Have each adolescent spend a few minutes answering each objective. The adolescents may prefer to answer each question together as a group or write a strategy to meet each objective. 3 1 I . . E II If the module is to be separated into two sessions, ask the group to increase their diet by adding one fruit a day. They are to come back to the next group meeting and tell what fiuit they picked and how they were able to able to do it. Through group activities and discussion the participants will be able to: 1) List three foods found at “fast food” restaurants that can be considered healthy. 2) Identify which two groups in the food pyramid which should comprise most of our daily diet and which two food groups we may need less of. 3) Identify two healthy foods that each participant likes and will increase in his/her daily diet. .- : “Immediate competing demands or preferences” refers to thoughts or behaviors that arise immediately before the goal behavior and may compete with the goal behavior (19). An adolescent who is about to eat anapplewhenafiiend arrivesandofi‘ersacandybarisexposedtoanimmediate competing preference. Ifshe is in a high control situation (perhaps high self-esteem and self-emcacy) she can pass on the candy bar and continue with the apple. Another example of a high control situation occurs if the adolescent is eating the apple and no competing situation (such as a candy bar) arises. She has high control over the situation because there is not a competing preference. Competing demands are situations which arise in which an adolescent perceives that 32 he/she has little or no control (19). Because teens are still dependent on others to care and provide for them, some may feel decreased control over choices they have in meals at home and school. Additionally, adolescents may be predisposed developmentally to be easily influenced to make choices other than their planned one. One method of combating this problem is by implementing a plan of action. Commitment to a plan of action requires that the plan of action is clear and understood by all participants. The plan should be well thought-out and should include strategies for assessmg,’ performing the task, and reinforcing the behavior. I] F. l E . l A Materials: Michigan Dairy Council (800) 24l-Milk 1. Catalog with posters, teen magazrnes,’ and charts. Most materials are fiee. B. Each adolescent should have a copy of the food pyramid if possible. If not, one foodpyramidchart shouldbeplacedwhereeveryonecanviewiteasily ! . . . l G D. . Activity 1. Byearly adolescencemost studentsarefamiliarwiththefood pyramid. Ask the group a few questions to asses their familiarity. 1) Havetheyusedthepyramidathomeatorat school? 2) What food groups are important to eat most often? 3) Which group should be used least? Activity 2. Alter each person has viewed the food pyramid ask the following: 1) Relate some benefits of eating a healthy diet that would encourage them to eat healthier. (Sports, feel better, increased energy). 2) Whatarethethingsthatmakeithardtoeat“good”foodsinstead ofhighfat 3 3 foods? (Barriers: media/culture, availability and attraction of high fat, high cholesterol foods, decreased availability of fruits and vegetables, taste preferences, school lunches, planning time). mm Pass out capies of the Food Pyramid and Combination/Fast Food information sheet that accompany this module. Ifextra copies are not available for all, have one copy in a centralplacethateachgirlcaneasilysee. Haveeachgirlchooseadifl‘erentfastfoodthat shelikesanddescribewhereitscomentsfitwithinthefood pyramid. Questions: 1) Ofthefoodsthatyouchose,whichonesseemhealtlner? Why? 2) What parts of the food pyramid should you make more choices fiom? 3) Didanyofthefoodthatyou chose comefromthetopofthefood pyramid? Activity3. Dividethegroupinto two orthreegroupsandgiveeachgroupone ofthe following scenarios. Allow approximately 10 minutes for the girls to prepare their skit/role play. Have each group present their skit to the other groups. Discuss role play scenarios depicting situational influences including high control and low control situations. Slut 1: Role play a trip to Wendy’s or McDonald’s. Have someone take the orders as an anployeewhfletheothasaaasagroupofgidswhoarefiiardsandordaingfood. What situations would encourage you to pick healthy foods? Less healthy foods? Skit2: Whileorderingorangejuiceormilkandabaked potatoatWendys; afiiendsays “Have you tried the flies here? Everybody always eats fi'ies here.” Do you change your order? Whatdotheothergirlsinthegroupsay? Skit3:Youhaveafiiendoverafierschoolandaredecidingonasnack. Youhavebeen 34 anxious to have this fiiend over for a long time and she is finally here. What are you going to do? Questions for the whole group: What strategies have they identified? What are the factors that may have prevented good food choices? What factors helped to make good food choices? What makes you want to choose healthier foods? Estimation At the end of this discussion the group leader should summarize the ideas and use the objectives to evaluate the discussion. Have each adolescent spend a few minutes writing an answer for each objective. The adolescents may prefer to answer each question together as a group or write a strategy to meet each objective. Bummer. Michigan Dairy Council (800) 24l-Milk 2163 Jolly Rd. Okemos MI, 48864 Catalog with posters, teen magazines, and charts. Most materials are free. Banks Reviving Ophelia: Saving the Selves of Adolescent Girls by M. Pipher, 1994 Ballantine Books Case studies of adolescent girls who exhibit negative self-esteem related to growth and development issues. Cultural issues are addressed The Body Project: An Intimate History of Americmr Girls by J. Brumberg, 1997 Random House Explores the historical roots of the societal and psychological pressures on adolescent girls through the use of diaries dating from 1830 to present. Self Esteem Comes in All Sizes by C. Johnson, 1995 Doubleday Explores the relationship between body size and self-esteem in women. 35 Feminist Perspectives on Eating Disorders, by P. Fallon, M. Katzman, and S. Wolley, 1994 Guilford Press Includes chapters which describe how western media and culture have afl‘ected womens view of themselves. II . IE . I D . . . Eating Disorders Awareness and Prevention (EDAP) 603 Stewart Street #803 Seattle, WA 98101 (206) 382-3587 FAX: (206) 292-9890 Web site: http://members.aol.eom/edapinc/home.html. National Eating Disorders Organization (NEDO) 6655 South Yale Tulsa, OK 74136 (918) 481-4044 Web site: http://wwwlaureatecom/nedo-conhtml Council on Size and Weight Discrimination, Inc. PO. Box 305 Mt. Marion, NY 12456 (914) 679-1209 W Healthy People 2000 http://odphp.oash.dhhs.gov/pubs/hp2000/ 1995Dietary Guidelines for Americans http://odphp.sosphdhhsgov/pubs/dietguid/defaulthtm Health Prevention Issues http://os.dhhs. gov choose healthfinder, then search for any topic HUGS International http://ww.hugs.com/ Food Pyramid Guide http://wwwganesacom/foodfmdexhtml REFERENCES 1. National Research Council, Committee on Diet and Health, Food and Nutrition Board (1989). .J -1 = '.1 .-. . . . O D C. National Academy Press. 2. Must, A (1996). Morbidity and mortality associated with elevated body weight rn children and adolescents ArrtrrrzicanJarintaLotS21imcal.I:lmr:itirzn._6:i(3 SUPPI ) 445 S- 4478. 3. US Department of Health and Human Services. Healthy people 2000: National health promotion and disease prevention objectives. Washington DC: US. Public Health Service (PHS 91-50212) 1990. 4. Shisslak,C., &Crago, M (1994). Towardanewmodelforthepreventionofemng disorders. In Fallon, P ,,Katzman M, & Wolley, S. (Eds.,) mm mm 419-435). New York: GuilfordPress. 5. Wrseman,C., Gray,J., Mosiman,J., &Ahrens, A (1992). Culturalexpectationsof thinness In women An Update W 85-89 6. Levine, M.,& Hill, L. (1991). . 12,, : Harding Hospital, Inc. 7. Nader, P. (1993). The role ofthe family rn obesity prevention and treatment. W W 147-153 8. Kratina, K, King, N., & Hayes, D. (1996). W Lake Dallas, TX: Helm Seminars. 9. Garner, D., & Garfinkel, P. (Ed). (1997). New York: The Guilford Press. 10. Emmons, L. (1994). Predisposing factors difi‘erentiating adolescent dieters and non- dieters. . ~ . . '..z ' 7), 725-731. 11. Grodner, M (1991). Using the health beliefmodel for bulimia prevention W W 107-112 12. Fallon, P., Katzman, M, & Wolley, S. (Ed) (1994). W disorders, New York: Guilford Press. 13. Murray, 8., Touyz, S. ,& Beumont, P. (1990). Knowledge about eating disorders 1n 37 14. Barkauskas, V., Stoltenberg-Allen, K. ,Baumann, L. & Darling-Fisher, C. (1994). W St Louis Mosby-Yw Book, Inc 15. Elkind,D.(1970). ' 2 z . : York: Oxford University Press. 16- Pipher. M (1994). W New York: Ballantine Books. 17. Petersen, A, & Lefi'ert, N. (1995). Developmental issues influencing guidelines for adolescent health research: a review. W6), 298-305. 18. Murphy, A, Youatt, J., Hoerr, S., Sawyer, C. & Andrews, S. (1994). Nutrition education needs and learning preferences of Michigan students in grades 5, 8, and 11. W7), 273-278- 19- Fender. N- (1996)- Healthntomcficninmsinamm (3rd at)- Stanford. CT : Appleton & Lange. Chapter 5 IMPLICATIONS FOR THE ADVANCED PRACTICE NURSE Healthy people 2000: National Health Promotion and Disease Prevention Objectives recommends that by the year 2000 seventy-five percent of primary health care providers should be providing nutrition assessment and counseling or referral to qualified nutritionists or dietitians (US Public Health Service, 1991). As a primary health care provider, the advanced practice nurse needs to be aware of this recommendation and implement nutrition counseling and teaching to all age groups including young adolescent females. The family APN is in an excellent position to guide early adolescent females toward healthy eating behaviors, since the primary role of the APN is to interact with clients and facilitate a holistic approach to health. Education is a key aspect of preventative health care. The APN may have many opportunities to influence young adolescent females because adolescent social groups may look to him/her for guidance in teaching healthy lifestyle practices. The APN as a change agent can give young adolescent females new information or strategies related to diet that are geared to improve their lifestyles and health through a systematic learning tool. As an assessor and leader, the APN can evaluate each teaching group separately to tailor the sessions to achieve optimum impact. Today’s primary health care system serves as a point of entry, screening area, and education arena with the ultimate goal to preserve health and prevent disease in a cost conscious climate. This learning module can provide a low cost too] for use by the APN in the role of educator. The salary of the instructor and any room charges are the primary 38 39 costs of this tool. To reduce the cost, other health providers or lay persons could also be trained to utilize this learning module. This tool provides for measurable outcomes and attainable objectives within the APN role and the economic constraints of managed care and capitation. Measurements such as the number of fi'uits and vegetables that have been added to the teen’s diet, or the amount that intake of candy and high fat foods has been decreased could be used to evaluate the efl‘ectiveness of the module. In addition to promoting a basic awareness of healthy eating, this module emphasizes self-esteem. Nursing and nutrition literature lmve indicated that higher self-esteem can empower young adolescent females and improve their self-efficacy. Conversely, focusing on eating disorders and the dangers of restrictive dietary intake can actually precipitate restrictive eating in susceptible young girls. Through self-emcacy, by incorporating the benefits and the barriers that impact healthy eating, this module can provide a foundation for young adolescent girls to continue to choose healthier foods for a lifetime; enabling the adolescent to assume increased responsibility for her own health There are potentially many adolescent groups which may look to the APN for nutrition guidance. Members of the community such as schools, scout groups and church groups and members of her/his own practice may invite the APN to participate in an education group as part of a pro-active approach to health. Such organizations dealing with adolescent females may develop or already have in place policies which require healthy diet education as a part of their services or curricula. The APN in his/her role as educator may influence the educational policy of these organizations to include self-esteem in their health curricula. 4 O E l D . . Pender (1996) recommends that the Revised Health Promotion Model (RHPM) be tested empirically alter measures of specific health behavior variables are developed. Because this learning module incorporates constructs such as perceived benefits of actions, perceived self-efiicacy, interpersonal influences and perceived barriers to action, this tool could be tailored for use in a health promotion intervention study to evaluate the RHPM. Reliable tools specific for measurement of self-esteem or self-eficacy given before and after the teaching intervention may contribute more information about these variables and how they efl‘ect young female adolescent diets within the RHPM. Quantitative data related to specific diet variables may also be useful. Comparisons between numbers offluits and vegetables per day, quantity of“junk” food per week or soft drinksperday couldbemeasuredbeforeand aflerinterventionwiththisleaming module to evaluate the module’s efl‘ectiveness. Previously validated questionnaires designed to measure satisfaction or quality of life related to lifestyle changes may also be useful for comparison before and alter the learning module to test its impact. Longitudinal studies that evaluate the impact of dietary instruction over time would also be useful. Summit! Teaching healthy eating to young adolescent females is a task which requires the APN to use sound research and theory-based strategies in order to maximize success. Advanced practice nurses need to be aware of high risk behaviors in adolescent females and focus on prevention and early intervention with an emphasis on self-esteem and self- eficacy. Interventions to promote health in adolescents need to include skill development around early dieting behaviors. There are barriers specific to this population which must 4 1 be addressed. By using the RHPM to help identify pertinent barriers and develop tailored strategies, the APN can impact one part of the female adolescent lifestyle and set the stage for firture healthier living. This learning module has been evaluated by a Pediatric Nurse Practitioner, a Family Nurse Practitioner, four adolescent girls ages 11, 12, 13, and 14, and two secondary school teachers. One of these teachers teaches eighth grade English and the second substitutes in a variety of junior and senior high classrooms. Each of the adult evaluators wereaskedto reviewtheleamingmodule asto itsrelevanceand achievability. Thenurse practitioners felt that the module could be easily utilized, was very pertintant and did not have finther recommendations. The teachers also liked the idea that the module could be easilyutilizedandthatitwastailoredforadificultaudience. Theteachershad suggestions related to making the objectives clearer for the educator/muse. The young adolescansevaluafionscemMmimpmvingtheacfivifiesandrdephyscenados. All oftheirsuggestions havebeentakenintoaccountandthemodulehasbeenadjusted accordingly. APPENDIX _ USING SELF-ESTEEM AS A CONCEPT FOR GUIDING EARLY ADOLESCENT FEMALES TOWARD HEALTHY EATING BEHAVIORS: A LEARNING MODULE By Sue Hagar RN. INTRODUCTION Healthy People 2000: National Health Promotion and Disease Prevention Objectives recommend that by the year 2000 seventy-five percent of primary health care providers should be providing nutrition assessment and counseling. This learning module is designed to help the Advanced Practice Nurse (APN) meet this goal as it applies to early adolescent females. The APN needs to be aware of behaviors specific to early adolescent females and focus on primary prevention with an emphasis on self-esteem, self-efficacy, and healthy eating rather than the potential harm of dieting. Many factors, particularly physical growth, emotional development, self—esteem, peer pressure and the media influence the adolescent diet. The concept of self-esteem as it relates to healthy food choices for the early adolescent female is emphasized in the module. The Revised Health Promotion Theory guided the development of the module. It is an approach-orientated theory which allows the APN to include characteristics and experiences unique to young adolescen’i females. The module provides an educational tool which ofl‘ers measurable outcomes within the APN role and the economic constraints of managed care. 43 THE LEARNING MODULE Goals The goal of this module is twofold. The first goal is to increase the awareness of early adolescent females ages 12 to 15 as to the impact that the American culture has on their self-esteem and body image. The second goal is to show adolescents how they can use information in this module to make better diet choices. This module is designed to be an overview or an introduction rather than an in-depth coverage of nutrition. It is meant to “get the adolescents’ attention” and help adolescents begin to consider developing healthy “achievable” dietary goals rather than unrealistic and potentially dangerous ones. W The expected outcome of the module is that the adolescent female will have a foundation of knowledge and a beginning awareness of how to incorporate healthy eating in daily life, so as to increase the potential for a change to healthier eating. W This learning module is designed for use by an APN however other health care providers may find it easy to incorporate this tool in their practice. Other professionals who have contact with adolescents such as teachers, counselors and social workers may alsofindthistooluseful. Co—teachingthismodulewithanadolescentgirlwho canbe viewed asapeerbythe studentsmayincrease participation and learning ofthegroup. West The setting for this program should be in a comfortable well-lit room. A schoolroom, an ofice lobby after hours, or a living room would be suitable. Since discussion and group work is the core of the module the seats should be in a circle and at distances apart 44 45 which are conducive to listening. Materials required for this module are minimal and easily accessible. This module can provide efl'ective health guidance at a negligible cost. Costs may include room rental and salary of the APN during the time of instruction. mm This module is designed to be ofi’ered in two one-hour sessions. Modifications may be made according to the judgement of the APN to accommodate any limitations which may arise such as room availability and learner needs. Ihesmnn , Participants for the module may come from several sources. The APN in a family practice may draw from his or her practice, for example, adolescents who come in to the ofice for carnp or sports physicals. Local schools, churches and youth groups may also express a need for nutrition education focused on young adolescent females. The module is designed to promote group interaction and exchange ofideas. Groups largerthaneightwould maketheseinteractionsmoredificultandlesspersonal, soarenot recommended. Young adolescents in particular who are sensitive to peer pressure and an “imaginary audience” may find large groups inhibiting. Through groupactivitiesanddiscussiontheparticipantswillbeableto: l) Descnbeatleasttwoposifiveatnibutesoffanalefiiendsthatamnotrdatedto physical characteristics. 4 6 2) Discuss at least two ways in which self-esteem, particularly of young women, has been impacted by the media and afl‘ects lifestyle. 3) Discuss what personal characteristics are an accurate gauge of a person’s value or talents. W W: In the United States increased consumption of refined carbohydrates and fats is a major health problem. The over-consumption of excess amounts of fats, cholesterol, sugar, and salt has been linked to a number of chronic diseases that contribute to disability and mortality ( l). The National Research Council Committee on Diet and Health found that there is a highly suggestive link between diet and certain forms of cancer, especially those of the gastrointestinal tract, breast, lung and prostate. In addition to the long term health risks of increased weight for teens, the most prevalent immediate consequences of overweight during adolescence are psychosocial. Social isolation and peer problems fi'equently occur in overweight children (2). Healthy People 2000: National Health Promotion and Disease Prevention Objectives recommend that by the year 2000 seventy-five percent of primary health care providers should be providing clients with nutrition assessment and counseling or referral to a qualified nutritionist (3). APN’s nwd to be aware of this recommendation and implement nutrition counseling and teaching to all age groups including adolescents. WW Magazines and advertisements geared toward females tend to focus on changing the female body. Thinness is ofien equated with beauty, health, and, most importantly, personal value. The American media for many years has suggested to the public what changes the average female should make to correct her physical flaws, and 4 7 what product is needed and available to correct these imperfections. The fashion industry, television, movies and particularly magazines are filled with young women who are very thin. Shape and looks which are unattainable for the average female are portrayed as the “ideal” healthy happy person (4). Only five per-cent of the population is genetically prepared to achieve the type of body style now prevalent in television and magazines (5). The American media/culture, with its focus on “lookisrn,” presents an unachievable goal to American youth which can result in a cycle of lower self-esteem, self- consciousness about one’s body and a drive to become thinner rather than healthier (6). In addition to promoting thinness, the media is also a source that promotes high fat fast foods. Television portrays healthy, energetic, and happy people having fun because they are eating fast food. Ironically, a disproportionate decreased metabolic rate has been noted among overweight children while watching television (7). Western culture also send messages that fit is dangerous, unhealthy and caused by lack of personal control. Prejudice against larger size people is one of the last socially acceptable forms of bigotry in America today (8). This pervasive and accepted discriminationcanleadtoanunrealisticfearofeventhesmallestweightgaininstill— developing adolescent girls (9). ' : Thebasicpremiseofthismoduleisthat higher self-esteem enables self-eficacy of girls and as a result the adolescent is able to make good food choices and avoid negative behaviors such as high fat consumption, restrictive eating or yo-yo dieting It is unclear whether adolescents with less self-esteem diet more often or that struggles related to dieting lower a person’s self-esteem (10). Interventions to promote healthy adolescents need to include skill development around 4 8 early dieting behaviors. Specifically teaching about the risks of dieting or eating disorders have actually precipitated the disorder in susceptible adolescents therefore this module does not address restrictive eating or eating disorders (11,12). Health professionals need to be aware of high risk behaviors and focus on prevention and early intervention with an emphasis on self-esteem and self-efficacy (13). W: Adolescent females from ages 12 to 15 are at an age when they are focusing on the self and the task of becoming comfortable with body changes and appearance (14). The adolescent begins to separate fi'om parents through less involvement in family activities and increased criticism of parents. Conformity and acceptance ofpeer group standards gain increased importance (14). The female peer group consists mostly of same-sex friends, however there is an increased interest in males (14). Adolescents are continually constructing or relating to an “imaginary audience” which plays a role in their self-consciousness (15). The feeling that everything the adolescent does is under constant scrutiny supports the teen’s need to conform to the norm of the peer group. Adolescents struggle with an evolving self-concept and a strong need for autonomy and independence. This dichotomy between a nwd for independence and need for conformity with peers is a hallmark of adolescence (16). Because their social activities often revolve around food, teenagers need a flexible plan that allows for choicemdsponfindtywfieycaneatasthdrpeusdo,yetmaintainahealthydiet. W: Cognitive and reasoning capacity merges gradually over the adolescent decade, making younger, less experienced adolescents less capable than older adolescents of efl‘ective reasoning(l 7). Making clear the right of the adolescent to refuse to discuss the particular issues should increase her comfort with the material and may 4 9 permit more honest response to discussion (17). The most popular strategies for learning about healthy diets actively involve students: games, food experiments, and computer games. Passive methods of learning, individual projects, and information presented by the teacher were the least preferred method of instruction (18). W I. Introductions A APN B. The students 1. Self-introductions a. Optional game: Sittinginasrnallcircleeveryonestatestheirnameonce. Passaballfiompersonto personanywhereinthecircle. Astheballis passedtoeachpersontheymuststatetheirnameandthenameofeach personwhohadtheballbeforetheminorder. TheAPNmaybeincluded. 2. Nametags-optional 11. The media and self-esteem A. What should we look like? B. Pass out magazines 1. Activities and group discussion 5 . . . [E D . . Group discussion can increase critical thinking and promote new paradigms of thought. This section of the model provides time for discussion and exchange of ideas. One or all of the questions can be used. Exercise 1. Pass out magazines such as “Seventeen”, “People” and “YM”, ask the group 5 O to discuss how the advertisements may promote increased size anxiety and decreased self- esteem. 1) Do they encourage the need to conform to a set standard? Whose standard? 2) How would you change the ads? What words would you use? 3) How many different sizes and shapes are pictured in the models? Exercise 2. Think about someone important to you, or that you admire or care about. 1) What are some of the qualities of that person that you like or love? 2) When you first meet someone what makes up your first impression? 3) What is really important? Exercise 3. Tape a piece of paper on the back of each adolescent. Have each person write somethingtheylike aboutthepersonwearingthepaperthatisnotrelatedto appearance. Each girl should write on the back of every other girl. When the girls are done allow them to read their own paper. 1) How does it make them feel? 2) What are some ways that we can feel good about who we are every day? 2) What about a “bad day”? At the end of this discussion the group leader should summarize some of the ideas and use the objectives to evaluate the discussion. Have each adolescent spend a few minutes answering each objective. The adolescents may prefer to answer each question together as a group or write a strategy to meet each objective. 5 l I . . E II If the module is to be separated into two sessions, ask the group to increase their diet by adding one fiuit a day. They are to come back to the next group meeting and tell what fiuit they picked and how they were able to able to do it. Through group activities and discussion the participants will be able to: 1) List three foods found at “fist food” restaurants that can be considered healthy. 2) Identify which two groups in the food pyramid which should comprise most of our daily diet and which two food groups we may need less of. 3) ldentifytwohealthyfoodsthateachparficipantlikesandwillincreaseinhis/herdaily diet. “Immediate competing demands or preferences” refers to thoughts or behaviors that arise immediately before the goal behavior and may compete with the goal behavior (19). An adolescent who is about to eat an apple when a fiimd arrives and ofl‘ers a candy bar is exposed to an immediate competing preference. Ifshe is in a high control situation (perhaps high self-esteem and self-eficacy) she can pass on the candy bar and continue with the apple. Another example ofahigh control situationoccursiftheadolescentiseatingtheappleandno competing situation (such as a candy bar) arises. She has high control over the situation because there is not a competing preference. Competing demands are situations which arise in which an adolescent perceives that 52 he/she has little or no control (19). Because teens are still dependent on others to care and provide for them, some may feel decreased control over choices they have in meals at home and school. Additionally, adolescents may be predisposed developmentally to be easily influenced to make choices other than their planned one. One method of combating this problem is by implementing a plan of action. Commitment to a plan of action requires that the plan of action is clear and understood by all participants. The plan should be well thought-out and should include strategies for assessing, performing the task, and reinforcing the behavior. W A Materials: Michigan Dairy Council (800) 241-Milk 1. Catalogwithposters, teenmagazines, and charts. Mostmaterials arefiee. B. Each adolescent should have a copy of the food pyramid if possible. Ifnot, one food pyramid chart should be placed where everyone can view it easily Activity 1. By early adolescence most students are familiar with the food pyramid. Ask the group a few questions to asses their fimiliarity. 1) Havetheyusedthepyramidathomeatorat school? 2) What food groups are important to eat most often? 3) Which group should be used least? Activity 2. After each person has viewed the food pyramid ask the following: 1) Relate some benefits ofeating a Mthy diet that would encourage them to eat healthier. (Sports, feel better, increased energy). 2) What are the things that make it hard to eat “good” foods instead of high fit 5 3 foods? (Barriers: media/culture, availability and attraction of high fat, high cholesterol foods, decreased availability of fruits and vegetables, taste preferences, school lrmches, planning time). WW Pass out copies of the Food Pyramid and Combination/Fast Food information sheet that accompany this module. Ifextra copies are not available for all, have one copy in a centrnlplacethateachgirlcaneasilysee. Haveeachgirlchooseadifl‘erentfistfoodthat shelikesand describewhereits contentsfitwithinthefoodpyramid. Questions: 1) Ofthefoodsthatyouchose,whichonesseemhealthier? Why? 2) What parts of the food pyramid should you make more choices fiom? 3) Didanyofthefoodthatyou chosecomefromthetop ofthefood pyramid? Activity 3. Divide the group into two or three groups and give each group one ofthe following scenarios. Allow approximately 10 minutes for the girls to prepare their skit/role play. Have each group present their skit to the other groups. Discuss role play scenarios depicting situational influences including high control and low control situations. Skit 1: Role play a trip to Wendy’s or McDonald’s. Have someone take the orders as an employeewhiletheothersactasagroupofgirlswhoarefiimdsandorderingfood What situations would encourage you to pick healthy foods? Less healthy foods? Skit 2: While ordering orangejuice or milk and a baked potato at Wendys; a friend says “Have you tried the flies here? Everybody always eats flies here.” Do you change your order? Whatdotheothergirlsinthegroupsay? 54 Skit 3: You have a fiiend over alter school and are deciding on a snack. You have been anxious to have this fiiend over for a long time and she is finally here. What are you going to do? Questions for the whole group: What strategies have they identified? What are the factors that may have prevented good food choices? What fictors helped to make good food choices? What makes you want to choose healthier foods? Exaluatian At the end of this discussion the group leader should summarize the ideas and use the objectives to evaluate the discussion. Have each adolescent spend a few minutes writing an answer for each objective. The adolescents may prefer to answer each question together as a group or write a strategy to meet each objective. Resources. Michigan Dairy Council (800) 241-Milk 2163 Jolly Rd. Okemos MI, 48864 Catalog with posters, teen magazines, and charts. Most materials are fine. Books Reviving Ophelia: Saving the Selves of Adolescent Girls by M. Pipher, 1994 Ballantine Books Case studies of adolescent girls who exhibit negative self-esteem related to growth and development issues. Cultural issues are addressed The Body Project: An Intimate History of American Girls by J. Brumberg, 1997 Random House Explores the historical roots of the societal and psychological pressures on adolescent girls through the use of diaries dating fi'om 1830 to present. 55 Self Esteem Comes in All Sizes by C. Johnson, 1995 Doubleday Explores the relationship between body size and self-esteem in women. Feminist Perspectives on Eating Disorders, by P. Fallon, M. Katzman, and S. Wolley, 1994 Guilford Press Includes chapters which describe how western media and culture have affected womens view of themselves. ll . IE . I D . . _ Eating Disorders Awareness and Prevention (EDAP) 603 Stewart Street #803 Seattle, WA 98101 (206) 382-3587 FAX: (206) 292-9890 Web site: http://members.aol.com/edapinc/home.html. National Eating Disorders Organization (NEDO) 6655 South Yale Tulsa, OK 74136 (918) 481-4044 Web site: http://wwwlaureatecom/nedo-conhtml Council on Size and Weight Discrimination, Inc. PO. Box 305 Mt. Marion, NY 12456 (914) 679-1209 W Healthy People 2000 htth/odphp.oash.dhhs.gov/pubslhp2000/ 1995Dietary Guidelines for Americans http://odphp.sosph.dhhs.gov/pubs/dietguid/default.htm Health Prevention Issues http://os.dhhs. gov choose healthfinder, then search for any topic HUGS International http://ww.hugs.com/ Food Pyramid Guide http://www.ganesa.com/foodfrndex.html REFERENCES r—s .National Research Council, Committee on Diet and Health, Food and Nutrition Board - - . - r ' . Washington D. C: National Academy Press. 3 2. Must, A (1996). Morbidity and mortality associated with elevated body weight in children and adolescents. WWWG Suppl..), 445 S- 447 S. 3. US Department of Health and Human Services. Healthy people 2000: National health promotion and disease prevention objectives. Washington DO: U. S. Public Health Service (PHS 91-50212) 1990. 4. Shisslak, C. & Crago, M. (1994). Toward a new model for the prevention of eatrng disorders. InFallon, P. ,Katzrnan, M., & Wolley, S. (Eds.,) W W (pp. 419-435). New York: Guilford Press. 5. Wiseman, C. ,Gray, J., Mosiman, J., & Ahrens, A (1992) Cultural expectations of thinness In women: An update. WWII. 85-89 6. Levine, M.,& Hill, L. (1991). - 12, : Harding Hospital, Inc. 7. Nader, P. (1993). Therole ofthefimilyinobesity preventionandtreatrnent. Anmlsgfl W22. 147-153 8. Kratina, K, King, N., & Hayes, D. (1996). W Lake Dallas, TX: Helm Seminars. 9. Garner, D., & Garfinkel, P. (Ed). (1997). . : mluu . New York: The Guilford Press. 10. Emmons, L. (1994). Predisposing factors diflhrentiating adolescent dieters and non- dieters. ., .. ~ - .2 11. Grodner,M (1991).Usingthehealthbeliefmodelforbulimiaprevention1mrmal_of WWW 107-112 12. Fallon, P., Katman, M., & Wolley, 3 (Ed) (1994). W disorders, New York: Guilford Press. 13. Murray, 8., .Touyz, S, & Beumont, P. (1990). Knowledge about eating disorders 1n 57 14. Barkauskas, V. ,Stoltenberg-Allen, K. ,Baumann, L. & Darling-Fisher, C (1994). Wm St Louis Mosby-Yw Book, Inc 15. Ellcind,D. (1970). ' . - York: Oxford University Press. 16. Pipher, M. (1994). W New York: Ballantine Books. 17. Petersen, A., & Lefl‘ert, N. (1995). Developmental issues influencing guidelines for adolescent health research: a review. W6), 298.305. 18. Murphy, A, Youatt, J., Hoerr, S., Sawyer, C. & Andrews, S. (1994). Nutrition education needs and learning preferences ofMichigan students in grades 5, 8, and 11. MW”. 273-273- 19. Ponder, N. (1996)-W61’d ed). Stanford, CT: Appleton & Lange. U") Anyonccaneatforgoodhealdt. 2. Exam Mfimnuch G ETO justfollowdtcselsimplcsteps; foodgrmu. {01:17 1 fibdcmg day bettersouroesofzrmtricmdun“. ‘ Eadrfoodgrmppronmdsywm Byflfinssqveralfoodsfmmeadrfood EATING diffcnmr nutrtems M, W“ w your drama of . mauthcnutnentswumed, Everydayeat: SW3 . S' g 6 MILK 2-4 servings" V MEAT Groupform 2-3 servings 6-11 servings a: M.,... Ready-westerns! may Tmflhroll. nuffin Somcfoodsdon’thavecnmghmmientsmfirinanyofdrele-boderps Therefoodsareealled “"Otlters. 'l‘hesefioodsareokaymeatinmoderadon. Tl'leysbouldnotreplacebodsfrundaeFMFoodGn-oups. ‘mwmmdmaupbot . cc as OTHERS Category Fats and oils, sweets, salty snadcs, alcohol, Other hem and condiments c“ ' .' "" 3 REVIEWED FAVORABLY BY THE mums“. 0 am. on. action. NATIONAL mm councrc. fie; 1, : AMERICAN ACADEMY OF mucus-sate. Mmmfinadhuu m—v . FAMILY PHYSICIANS FOUNDATIO GUIDE TO GOOD EATING Every day eat different foods from each food group. VEGETABLE Group , g. , _ ' 23?: ”~54": .-'. " . . 3 Ssemmgs Eflggw- . .. __., '3 Group 6-11 servings The Guide to Good Eating can be used in conjunction with the Daily Food Guide Pyramid A - -® 0 e“ -(‘.<~\ 696:? $58? 03$ (is-Kg §§§ 4$C§§ \é‘ ChopSuey beefandpork,1cup Chow Mein chidcen, 1 cup Lasagna With meat, Z‘AxZ‘A' Macaroni a Cheese from box, cooked, 1 cup Quiche with bacon, ‘A pie Sandwich, PB] peanut butter and jelly Sandwich. Sub cold cuts/cheese Sandwich. Twlrey whole wheat bread Soup, Chidren Noodle canned, 1 cup Soup, Clam Chowder with whole milk, 1 cup Soup. Tomato with water, 1 cup Soup. Tomato with whole milk, 1 cup Spaghetti/Meat Balls homemade. 1 cup TunaSalad ‘Acup ”Foodsthatconmin ingredientsfrom morethan onefood group 123 221 267 450 254 300 255 398 339 347 400 267 75 330 192 23 26 15 25 26 31 26 14 13 12 11 24 19 16 22 13 10 30 29 45 33 17 17 39 10 1 5 16 24 8 17 10 20 1O 48 15 00 «1} 6600 > 0 O O. >009 ">00 "DO-5) 0’?) s vow > >0 ‘) )OO'”) 0000 G 0900 \. .141 -" Burger King’ 540 8K Broiler’ Sandwich Burger King' 720 BK Big FlSh Sandwidi Burger King“ 730 Whopper,’ w/cheese Dairy Queen' 240 Hot dog Domino's‘ 344 Cheese przza.‘ 2 slices 12" KFC' 482 Colonel's'“ Chidten Sandwich McDonald's‘ 320 Cheeseburger McDonald's‘ 300 Chidten McNuggels (6 pieces) McDonald's’ 290 Egg McMuffin‘ McDonald's‘ 350 McLean Deluxe” McDonald's' 530 Quarter Pounder,’ w/cheese Pizza' Hut“ 205 Cheese puzza,’ 1 slice 12'.‘ thin crust Taco Bell' 390 Bean burrito Taco Bell‘ 180 Beef taco Taco Befl‘ 220 Chidten soft taco 's‘ 470 Broccoli and cheese potato Wendy's“ 200 Grilled Chidren Salad Wendy's“ 420 Single (w/cheese/everything) 15 21 15 19 17 24 28 11 13 10 14 25 26 19 39 36 16 27 37 37 21 10 19 10 37 27 13 18 13 12 12 11 10 14 20 <><:i- 00 9900 600%.) ' ">09 rForrnoreinforrnationonfastfoods.seeFastFood: Today'sGuideto ii Healthy Choices. To obtain a copy of this brochure, contact your local '_z DairyCounaI’orcallt-BOO-426-8271tormeoairyCouncilnearestyou. REFERENCES LIST OF REFERENCES Achterberg C., McDonnell, E. ,& Bagby, R. (1994). How to put the Food Guide Pyramid into Practice.loumal_of1heAmericanDieteticAssociatioL%.1030-1035 Bendich,A, &Deckelbaum,R(Ed..) (1997). a a mu - ' - . Wm]; Totowa, New Jersey: Humana Press Inc. Barkauskas, V. ,Stoltenberg-Allen, K, Baumann, L. & Darling-Fisher, C. (1994). Healthandnhxsiralassesm. St Louisz Mosby-Yttfl1r Book, Inc Brumberg J . (1997). W New York: Random House. Button, E. ,Loan, P. ,Davies, J., & Sonuga- Berke, E. (1997). Self-esteem, eating problems, and psychological well-being m a cohort of schoolgirls aged 15-16: A questionnaire and interview study. . . .. 39-47. Eccles,J., Flamgan,C., Lord,S., Midgley,C., Roeser, R, &Yee, D. (1996). Schools, families, andearlyadolescents: Whatarewedomgwrongandwhateanwedo Elkind,D. (1970). ' . : York: Oxford University Press. Emmons, L. (1994). Predisposing factors difl‘ererrtratrng adolescent dieters and non- 58 59 Fallon.P KatmmM. &Wolley.S (Ed) (1994) W disorders, New York: Guilford Press. . Fraser,.L (1997). _. ' .‘ ‘ MToronto: Duttonlnc. French, 8., Perry, C. Leon, 6., & Fulkerson, J. (1995). Dieting behaviors and weight change history in female adolescents. WW6), 548-555. French, 8., Perry, C., Leon, G, & Fulkerson, J. (1995). Changes in psychological variables and health behaviors by dieting status over a three-year period on a cohort of adolescent females. WW 438-447. Fries, E., & Croyle, R (1993). Stereotypes associated with a low-fat diet and their relevancetonutritioneducation. ~ .. .~ 551-555. Gasser, G. (1996). =- :. Fawcett Columbine. Gamer, D., & Garfinkel, P. (Ed). (1997). New York: The Guilford Press. Gracey, D. ,Stanley, N., Burke, V. ,Corti, B. ,& Beilin, L. (1996). Nutritional knowledge, beliefs and behaviors m teenage school students. WWIQ), 187-204. Grodner, M. (1991). Usingthehealthbeliefmodel forbulimiaprevention W W 107-112 Harlan, W. (1993). Epidemiology of childhood obesity. W W 1-5 Harrison, K. & Cantor, J. (1997). The relationship between media consumption and eating disorders. Ioumalnifiornnmnicationflfl). 40-67. 60 Kilbourne, J. (1994). Still killing us softly: Advertising and the obsession with thinness. In FallortP KatnnanM. &Wolley.5 (Eda) Wanna dimstp. 395-417). New York: Guilford Press. Killian, J., Taylor, C., Hammer, D., Litt, 1., Wilson, D., Rich, T., Hayword, C., Simmonds, B. ,,Kraemer H, &Varady, A. (1993). Anattempttomodifyunhealthfuleating attitudes and weight regulation practices of young adolescent girls. mm WM) 368-384 Kratina, K, King, N., & Hayes, D. (1996). MW Lake Dallas, TX: Helm Seminars. Kuntzleman, C. Poore, E. ,Naughton, J., Ruble, C. ,erkerson, R, French, T. ,& Reifl‘G. (1996). Weight, height, body- -mass index and socio-economic status of Michrgan Youth- 1994-1995 W 1-23.. Levine, M,& Hill, L. (1991). - Harding Hospital, Inc.. LoghmanLE, &Rickard,K. (1994). Alternatrvesnacksystemforchrldrenandteenagers Megel, M, Wade, F., Hawkins, P., Norton, J., Sandstrom, S., Zajic, K, Hoefler, M, Partusch, M., erlrett, K., & Tourek, N. (1994). Health promotion, self-esteem, and weight among female college freshman W4), 10-19. Melin, L. Irwin, C., & Scully, S. (1992). Prevalence ofdisordered eating ingirls: A survey of middle-class children 2 , . . 851-853. MichiganDepartment ofCommunityHealthandtheMichiganPublicHealth Institute (1997). Initial results fi'om the 1996 Michigan behavioral risk factor survey. 1-6. 61 Murphy, A., Youatt, J ., Hoerr, S., Sawyer, C. & Andrews, S. (1994). Nutrition education needsand learning preferences ofMichigan students ingrades 5, 8, and 11.1mmLoi WW7), 273-278. Murray, 8., Touyz, S. & Beumont, P. (1990). Knowledge about eating disorders 1n the oomnmnity W1) 87-93 Must, A. (1996). Morbidity and mortality associated with elevated body weight rn children and adolescents Amarinas.lnuInal.52f_CElinicall\.lrrtritirm._6.‘i(3 Suppl ) 4455-4475 Nader, P. (1993). Therole ofthefamilyinobesitypreventionandtreatment. Amalsgflhe WW 147-153 National Research Council, Committee on Diet and Health, Food and Nutrition Board D.C.: NationalAcademyPress.‘ Ogden,J., &Evans,C. (1996). Theproblemwrthwerghmg Efi‘ectsonmoodself—esteem 272-277. Orvin, G. (1995). W Washington DC: American Psychiatric Press. Pannell, D. (1995). Whyschoolmealsarehighinfatand some suggested solutions. Amnimlmrmalnfflfinimllflutrifimflfl SUPP). 2455-2465 Ponder. N. (1996). W (3rd ed)- Stanford. CT: Appleton & Lange. Peters,P., Amos,R, Hoerr, S., Koszewsld,W., Huang,Y., &Betts,N. (1996). Questionable dieting behaviors are used by” young adults regardless of sex or student 62 Petersen, A., & Lefi‘ert, N. (1995). Developmental issues influencing guidlines for adolescent health research: a review. W16), 298-305. Pipher, M. (1994). _' -' ' ' Ballantine Books. Prochaska, J., DeClemente, C., & Norcross, J. (1992). In search of how people change: Applications to addictive behaviors. W9), 1 102-1114. Sclmette, L. ,Song, W., Hoerr, S. (1996). Quantitative use of the food guide pyramid to evaluate dietary intake of college students. WW W5) 453-457 ShisslaLC, &Crago, M. (1994). Towardanewmodel forthepreventionofeating disorders. InFallon, P. ,Katzman, M., & Wolley, S (Eds.,) W WW- 419-435). New York: Guilford Press. U. S. Departmentongricultm'e, U..S DepartrnentofHealthandenanServices(l990). . w . mus(3rded..)Washington D. C: U. S. Government Printing Ofice (USDA HG-232). U. S. DepartmentofHealthandHuman Services (1991). W " :'=:.‘ mes smut C‘JvVl. ‘-.< W88hiflgt0flD.C.. U. S. PUDHO Health Service (PHS 91-50212). Weiner, 1., & Elldnd, D. (1972)- W New York: John Wiley & Sons Inc.. Wiseman, C. Gray, J., Mosiman, J., & Ahrens, A (1992). Cultural expectations of thinness m women An update" WM 85-89 ll!IWHHHIIHIII'IHIIIHIHllllll'llhllll'lll 1| 31293 02369 9725