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Running head: OBESITY MANAGEMENT IN COLLEGE STUDENTS 1

DNP Capstone Proposal

Health Coaching Model Focusing on Nutrition and Physical Activity Education for Decreasing

Obese in College Students: A Pilot Study

Mercy Ojumu

Maryville University

Capstone Chair: Dr. Geralyn Frandsen

Capstone Committee Member: Dr. Connie Webster

Date of Submission: December 10, 2018

Table of Contents

Abstract..........................................................................................................................................4

Introduction and Background......................................................................................................5

Problem Statement........................................................................................................................6

Objectives and Aims......................................................................................................................7

Review of Literature......................................................................................................................7

Factors Contributing to Obesity in College Students...................................................................8

Self-Efficacy..............................................................................................................................10

Approaches to Weight and Obesity Management......................................................................11

Students’ Approach to Weight Management.........................................................................11

Interventions for Overweight and Obesity Management in College Students.......................12

Health Coaching Approach....................................................................................................13

Theoretical Model........................................................................................................................17

Project and Study Design............................................................................................................19

Setting and Resources................................................................................................................20

Study Population........................................................................................................................21

Sources of Data..........................................................................................................................21

Data Analysis................................................................................................................................23

Quality........................................................................................................................................23

Results...........................................................................................................................................24

Discussion.....................................................................................................................................25

Limitations.................................................................................................................................26

Implications for Practice............................................................................................................26

Ethics and Human Subjects Protection.....................................................................................27

Timeframes or Timeline..............................................................................................................29

Budget...........................................................................................................................................29

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Strengths and Weaknesses of the Study....................................................................................30

Strengths.....................................................................................................................................30

Weaknesses................................................................................................................................30

Conclusion....................................................................................................................................30

References.....................................................................................................................................32

Appendix A...................................................................................................................................35

Appendix B...................................................................................................................................36

Appendix C...................................................................................................................................38

Appendix D...................................................................................................................................39

Appendix E...................................................................................................................................41

Appendix F...................................................................................................................................42

Appendix G...................................................................................................................................43

Appendix H...................................................................................................................................44

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OBESITY MANAGEMENT IN COLLEGE STUDENTS 4

Abstract

The rate of obesity among college students continues to rise in the United States. There is a need

for an effective method to facilitate weight loss in overweight or obese college students. The

study is to determine the effectiveness of health coaching on weight loss in overweight and obese

college students. The aim is to educate and motivate overweight or obese college student to

facilitate weight loss. The study is a quantitative 4-week descriptive pre- and post-intervention

design. Validated questionnaires were used to collect data from a convenience sample of 15

overweight or obese college students. Data analyses include descriptive statistics and paired t-

test. Results show eighty-seven percent of the participants were females, 60% were African

American, and 33% were freshman college students. Weight loss ranged from 0.2lbs to 8.6 lbs.

A paired t-test shows no statistically significance between both pre- and post-intervention weight

and body mass index (BMI). In conclusion, further study with a larger sample size that includes

more male participants is recommended.

Keywords: Obesity, college students, overweight, weight loss, health coaching

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Introduction and Background

More than 36.5% of adults and 32.3% of young adults ages 20 to 39 are obese in the United

States (Centers for Disease Control and Prevention [CDC], 2017a; Ogden, Carroll, Fryar, &

Flegal, 2015). The prevalence of overweight /obesity among college students aged 19 to 24 was

37.9 % in 2016 (American College Health Association (ACHA), 2017). Obesity is determined by

a body mass index (BMI) of over 30 kg/m2 (CDC, 2016). For adults over age 18, BMI is

calculated by dividing body weight by the height in kilometer squared (CDC, 2016). A BMI of

18.5-24.9 kg/m2 is considered a normal healthy weight, BMI between 25-29.9 kg/m2 is

overweight, and a BMI of over 30 kg/m2 is identified as obese. Obesity is a chronic health

problem and has become an epidemic in the United States (Schwartz & Richardson, 2015).

Obesity is associated with both psychological and physical health consequences that include

depression, low self-esteem, osteoarthritis, cardiovascular diseases, type 2 diabetes, stroke,

cancer, and preventable death (CDC, 2017a).

The rate of obesity continues to increase steadily in the United States despite efforts

being made by many organizations towards reducing the problem. One such organization was the

United States Department of Health and Human Services (DHHS) which created Healthy People

2010 an initiative that focused on reducing obesity and had an objective of reducing obesity in

adults by 15% and 10% in children by 2010 (CDC, 2015). However, the goal of Health People

2010 to reduce obesity was not achieved. Instead, the rates of obesity in both adults and children

increased. Additionally, the medical cost of obesity in 2008 was $147 billion and $149.4 billion

estimated cost in 2014 (CDC, 2017a; Kim & Basu, 2016). Obesity is a complex problem

affecting both male and female, children and adults, and all ethnic groups in the United States

(Marchiondo, 2014).

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College students ages 18 to 20 are transitioning from adolescence to adulthood. The

transition period corresponds with a period when many students are becoming independent of

their parents and are responsible for making decisions that could impact their health and

academic success (Lambert & Donovan, 2016). According to ACHA guideline (2012), healthy

eating and physical activity are recommended for achieving healthy weight which could

contribute to student success in addition to preventing negative consequences associated with

obesity. Health education about healthy eating and physical activity to reduce weight in obese

college students is effective in the short-term, but the change is not sustained (Hamel & Robbins,

2013).

There is a need for an effective individualized weight reduction intervention that is

sustainable. Healthcare providers can bridge the gap by taking action in the practice setting by

implementing the evidence-based approach in educating and motivating obese individuals to lose

weight. The goal of this project is to conduct a pilot project implementing health coaching to

provide health education on nutrition and physical activity and to facilitate behavioral change

that would lead to weight reduction in college students. Health coaching has been used

effectively for managing chronic health problems such as diabetes and hypertension in the

United States (Whyte, 2014).

Problem Statement

The problem statement for the study is What is the effect of a weekly phone call to

provide education on diet and physical activity with health coaching on weight loss in

overweight or obese college students?

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Objectives and Aims

The aim of the project is to engage overweight or obese students as active participants in

their weight reduction and weight management activities by providing them with education and

support needed for a change to occur. The goal is to improve the knowledge and behavior of

overweight or obese college students to facilitate weight reduction and weight management

activities. The objectives of the project are: 1) to educate overweight or obese students to

facilitate lifestyle modifications, and 2) to provide the support and motivation through health

coaching that allows a student to be actively involved in his/her weight loss efforts. Also,

through the implementation of the health coaching, to contribute towards meeting the Healthy

People 2020 objectives of increasing the proportion of adults who are at a healthy weight and

reducing the proportion of adults who are obese.

Review of Literature

A search of the literature was conducted using Maryville online library. The Cumulative

Index to Nursing and Allied Health Literature (CINAHL) and ProQuest databases were searched

for relevant articles. Key terms used to identify articles were obesity, college students, obesity in

college students, health coaching, nutrition, physical activity, and weight management. The

articles were reviewed using the following inclusion criteria: articles published in English,

published within the past ten years (2007-2017), and have abstracts. Exclusion criteria include

articles that were not published in English, articles published more than ten years ago, and

articles without abstracts. A total of 225 articles were retrieved using the terms indicated out of

which 45 were reviewed. Of the 45 articles, 22 were selected as meeting the inclusion criteria

and were chosen for this review.

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The literature reviewed revealed three overarching themes. The themes were factors

contributing to obesity in college students, issue related to a lack of self-efficacy regarding

overweight and obese; and educational modalities and interventions used to facilitate weight loss

in obese college students.

Factors Contributing to Obesity in College Students

Obesity has been associated with inadequate physical activity and poor nutritional

practices (Mackey et al., 2015). The American College Health Association (2015) indicated that

less than five percent of college students consume the recommended amount of servings of fruits

and vegetables per day. About 81.6% of adults do not engage in the recommended amount of

physical activities per day (Downes, 2015). The United States DHHS, Healthy People 2020’s

recommendations for physical activity for adults ages 18 to 64 include engaging in a moderate-

intensity activity for at least 150 minutes per week (CDC, 2015). Downes (2015) conducted a

cross-sectional descriptive correlational survey of 106 college students with the purpose of

exploring the relationship between physical activity, dietary habits, and weight status. The author

studied the motivating factors and barriers to a healthy lifestyle in college students. The

motivating factors examined include personal and environmental factors such as living longer

and social support (Downes, 2015). The personal factors were the desire to live longer, be

healthier, increase energy and for spiritual beliefs. The environmental factors were the

availability of role models, social support, provider counseling, and health information (Downes,

2015).

Additionally, the barriers to a healthy lifestyle that were assessed include lack of

motivation, lack of time, health concern, lack of perceived benefit, safety concerns and lack of

resources (Downes, 2015). The result of the study shows that there is a significant correlation

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between physical activity and motivating factors for weight loss (p < .01) and poor dietary health

practices correlated with the barriers which were the inhibiting factors (p < .05). The study

further shows that participants that score high on the motivation scale are more likely to exercise

more and eat more fruits than those that score high on the barrier scale (Downes, 2015).

A qualitative study was conducted by Smith-Jackson and Reel (2012) examined weight

gain in 30 freshmen college women aged 18 and 19. The purpose of the study was to understand

the impacts and explanations for the "Freshman 15" (Smith-Jackson & Reel, 2012). “Freshman

15” is associated with the belief that an average of 15-pounds weight gain was experienced

during the freshman’s year of college (Smith-Jackson & Reel, 2012). In addition, it was noted

that college students gain between 9.6 to 27 pounds by graduation (Smith-Jackson & Reel,

2012). Reasons for the weight gain were influenced by students’ having to make independent

choices regarding food, and social environmental factors such as peer influence. Smith-Jackson

& Reel (2012) also found that some freshmen women associated their weight gain to poor eating

habit and perceived weight gain as inevitable. The possibility of students gaining weight at the

level indicated in this study could increase the risk of developing obesity-related health problems

in the future.

Furthermore, Vadeboncoeur, Townsend, and Foster (2015) conducted a meta-analysis of

22 studies involving 5,549 students. The study aimed to update the literature on the 15 pounds

average weight gain by first-year college students referred to as “Freshman-15” (Smith-Jackson

& Reel, 2012). The study indicated that 60.9% of the students gained weight during the freshman

year with an average weight gain of 7.5lbs (95 % CI: 2.85 - 3.92) (Vadeboncoeur, Townsend, &

Foster, 2015). Results of this study support findings from a previous study by Smith-Jackson &

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Reel (2012) that indicates the need for interventions to facilitate weight reduction and prevent

overweight and obesity in college students.

In addition, abnormal eating patterns such as binge eating and preoccupation with food

have been observed in overweight and obese college students. Desai, Miller, Staples, and

Bravender (2008) conducted a cross-sectional survey of 4,201 participants with the aim of

assessing abnormal eating perceptions and behaviors of college students. The result of the study

shows a relationship between body mass index (BMI) and abnormal eating such as binge eating,

noting that students that engage in binge eating have higher BMI. Also, the authors identified a

relationship between preoccupation with food and obesity with students who were preoccupied

with food being obese. Similarly, students that were not engaged in physical activity were also

more obese.

Self-Efficacy

Studies indicate that many college students lack self-efficacy for healthy eating and

exercise (Smith-Jackson & Reel, 2012; Stephens, Althouse, Tan, & Melnyk, 2017). Self-efficacy

for healthy eating is the belief that one possesses the ability to make better food choices in a

given situation. Also, self-efficacy for physical activity is the belief in one’s ability to perform

recommended physical activity in a given situation (Stephens et al., 2017). Low self-efficacy in

nutrition and physical activity could impact eating habits and physical activity behaviors.

Stephens, Althouse, Tan, and Melnyk (2017) conducted a descriptive study with 62 college

students to examine gender and race as they relate to nutrition, exercise habits, and self-efficacy.

The authors assessed nutritional knowledge to identify participants’ knowledge of various foods

regarding sodium, saturated fat, vegetable and fruit servings per day; physical activity was also

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assessed. The results of the study showed that high self-efficacy score for healthy eating was

associated with low consumption of sodium, and saturated fat and higher consumption of fruits.

The study showed male students scored lower in self-efficacy for healthy eating. The study

indicates the need for intervention that focuses on increasing self-efficacy for healthy eating to

see a change in eating habits.

Approaches to Weight and Obesity Management

Students’ Approach to Weight Management.

College students are responsible for planning their meals and making appropriate food

choices. However, many students consume an unhealthy diet that is high in fat, sugar, and

sodium (Harring, Montgomery, & Hardin, 2010; Stephens et al., 2017). Poor eating habits and

decrease physical activity contribute to overweight and obesity in college students. Harring,

Montgomery, and Hardin (2010) conducted a study of 97,357 students to determine if inaccurate

body weight perception predicts unhealthy weight management strategies. The authors also

investigated the degree of body weight perception associated with depressive symptoms among

college students in the United States. The study found that some college students engage in

unhealthy weight management practices that include the use of diet pills, laxatives, self-induced

vomiting, and excessive exercise to lose weight. The study found inaccurate perception of weight

by students in that 38.8% of female participants, and 30.8% male participants, described

themselves as overweight or obese while based on their calculated BMI, 28.8% female and

39.4% male were overweight or obese respectively (Harring, Montgomery, & Hardin, 2010).

The study showed that college students demonstrate inaccurate weight perception and engage in

unhealthy weight management strategies. The study indicated that college students need

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education regarding appropriate strategies for achieving a healthy weight and appropriate

methods for preventing and managing obesity.

Interventions for Overweight and Obesity Management in College Students

Various approaches have been used to assist patients to lose weight and reduce the risks

of developing chronic diseases with the majority including providing education on healthful

eating and improving physical activity. Appel et al. (2011) conducted a randomized controlled

trial to examine the effects of two behavioral weight-loss interventions in 415 obese patients.

Participants in the study were obese patients with at least one cardiovascular risk factor such as

hypertension, diabetes or hyperlipidemia. There were two intervention groups in the study and

one control group. Participants in one of the intervention groups received weight-loss support

through remote access involving the use of the telephone, email, and website study. The second

intervention group received face-to-face support in addition to remote interventions using the

telephone, email and website similar to the first group. The control group did not receive any

intervention. The mean weight changes at the end of the 24-months study were compared with

mean baseline weight. The result shows mean change in weight in the control group of -0.8 kg, -

4.6 kg in the group that received remote support only (p < 0.001), and -5.1 kg in the group that

received face-to-face support and remote support (p < 0.00.1). The changes in weight were not

significantly different between the two intervention groups. The study shows a significant weight

loss was achieved by providing patients with weight loss support using the remote method and

providing face-to-face intervention with remote support (Appel et al., 2011).

The use of computers, websites and emails have been found effective for providing

healthy eating and physical activity interventions (Hamel & Robbins, 2013; Mackey et al., 2015;

Schwartz & Richardson, 2015). Mackey et al. (2015) conducted a 24-week randomized

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controlled trial with 47 participants to evaluate the acceptability of an e-mail–delivered

intervention program to promote nutrition and physical activity in African American college

students. Forty-six percent of the participants were overweight or obese with poor nutrition

behavior. The intervention group received an email-based intervention to improve diet and

physical activity while the control group received general health information. At baseline, 80.9%

of the participants showed the desire to improve their diet while 76.0% wanted to improve their

physical activity. At 24-week, 70% of the control and 86% of the intervention group showed

satisfaction with the program. The study shows the feasibility and acceptability of an e-mail

delivered program promote positive health behaviors in African American college students.

Also, Gow, Trace, & Mazzeo (2010) conducted a four-arm pre- post-test control group

study with 170 freshmen with the goal of identifying the feasibility of internet intervention for

obesity prevention in college students. The study participants were randomly assigned to one of

the four study groups that consist of internet intervention, feedback intervention, combined

intervention and control group. This study showed a significant change in the BMI of the

intervention group (Gow, Trace, & Mazzeo, 2010). The authors noted the effectiveness and

feasibility of providing intervention through online medium.

Health Coaching Approach

Health coaching is a patient-centered approach that has been effective for the

management of chronic diseases such as obesity, hypertension, fibromyalgia, diabetes, and

obesity (Crittenden, Seibenhener, & Hamilton, 2017; Hackshaw et al., 2016; Munoz Obino,

Aguiar Pereira, & Caron-Lienert, 2016; Olsen & Nesbitt, 2010; Sherman, Crocker, Dill, &

Judge, 2013). Health coaching is an approach that increases patients’ awareness of their health

problems and enables patients to become responsible for changing their health behavior

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(Crittenden et al., 2017; Munoz Obino et al., 2016). In addition, coaching facilitates patient’s

self-management of health problem by engaging and guiding the patient through behavioral

changes (Sherman, Crocker, Dill, & Judge, 2013). The patient is allowed to identify the

objectives and actions needed to accomplish his/her goals. The coach collaborates with the

patient, providing health education, and challenging the patient through motivational

interviewing, questioning and monitoring patient’s actions. This coaching process improves the

patient’s confidence and encourages patient to change. (Munoz Obino et al., 2016). Health

coaching also involves the use of the motivational interviewing technique which allows patients

to resolve perceived barriers.

The use of health coaching and telephone intervention were found to be effective for

weight reduction in obese adults (Sherman, Crocker, Dill, & Judge, 2013). The authors reported

a case study involving the provision of health coaching for obesity management that resulted in a

weight reduction from 216lbs to 165lbs for a total of 51lbs weight loss within 18 months. The

participant received ten health coaching sessions, seven of which were by using the telephone

and three sessions were provided face-to-face. Health coaching technique encourages

participant’s involvement in setting and achieving their goals (Sherman, Crocker, Dill, & Judge,

2013).

Olsen and Nesbitt (2010) conducted an integrative review to examine the effectiveness of

health coaching in helping patient adopt healthy lifestyle behaviors needed to prevent and control

chronic diseases. The result of the study showed significant improvements in participants’

behaviors including nutrition, physical activity, and weight management.

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Munoz Obino, Aguiar Pereira, and Caron-Lienert (2016) conducted a literature review

with the goal of identifying how coaching could assist in weight loss and improve health.

Thirteen articles were reviewed for the study. The study found that combining in-person sessions

with telecoaching was the commonly used approach in majority of the studies. The study showed

that providing telecoaching was effective for reducing anthropometric measurements. In

addition, the study showed that coaching increased motivations and personal satisfaction

compared with traditional health education alone.

Similarly, other research studies have been conducted that showed the effectiveness of

health coaching in the management of chronic health conditions. Crittenden, Seibenhener, and

Hamilton (2017) conducted a pilot study using the health coaching model for the management of

hypertension. The goal of the study was to examine the impact of health coaching on lifestyle

modification in patients with hypertension. There were 21 participants in the study. At baseline,

57.1% of the participants were unaware of their blood pressure goals, 66.7% were non-adhering

to any lifestyle recommendations, and 81% were low in adhering to their antihypertensive

medications. After the health coaching intervention, the result showed significant changes. The

percentage of participants that were aware of their blood pressure goals increased to 90%, and

the percentage of those adhering to lifestyle modifications and antihypertensive medications

increased to 81%. The conclusion of the study was that health coaching was effective for

sustaining patients’ engagement in lifestyle modification and enhancing adherence to

medication. The study demonstrated the impact that coaching could have in empowering patients

to change lifestyles to achieve their health goals.

Moreover, Hackshaw et al. (2016) conducted a pilot study with the purpose of showing

that health and wellness coaching intervention for the treatment of fibromyalgia would result in

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sustained improvements in health and quality of life of patients and reduce patients’ health care

utilization. There were nine participants in the study. The study finds that the addition of health

and wellness coach to pharmacologic management of patients with fibromyalgia produced

clinically significant improvements. The patients’ quality of life was measured using the Revised

Fibromyalgia Impact Questionnaire (FIQR), patients experienced pain reduction as measured by

the Brief Pain Inventory Short Form (BPI), and there was a decrease in health care utilization.

Kivela, Elo, Kyngas, and Kaariainen (2014) conducted a systematic review of 13 studies

with the purpose of describing the effectiveness of health coaching provided by health care

professionals on adults with chronic diseases. The authors reviewed randomized controlled trials

and quasi-experimental designed articles. The result of the study showed that health coaching

improves patient’s physical and mental health conditions and motivated changes in patient’s

lifestyle behaviors and social life (Kivela, Elo, Kyngas, & Kaariainen, 2014). The study

concluded that health coaching improved the management of chronic diseases.

Gaps identified by many authors in their studies indicate areas where further studies are

needed. Desai et al. (2008) recognized the need for longitudinal studies to evaluate BMI and the

determinants of obesity. To further evaluate the sustainability of weight loss post interventions, a

longitudinal study will allow the evaluation of the effectiveness of the interventions provided.

The effectiveness of weight reduction interventions for preventing chronic diseases could also be

evaluated. A gap identified by Mackey et al. (2015) in their study is the need for research studies

to assess the physical activity level of college students using a validated instrument. The

effectiveness of health coaching for weight reduction in overweight or obese college students

needs to be studied.

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Many students lack knowledge associated with effective weight management. Some

overweight/obese students use unsafe methods such as using diet pills, laxatives, self-induced

vomiting, starvation, and excessive exercise to lose weight (Harring, Montgomery, & Hardin,

2010). The stakeholders at the proposed project site, including the Director of Student

Development and Student Success, the insurance company, and faculty members strongly

support efforts to improve students’ knowledge about weight management, disease prevention,

and health promotion. The Advanced Practice Nurse (APRN) is in an ideal position for educating

and motivating students in efforts to achieve a healthy weight (Downes, 2010). This project

proposes to provide students with the education about diet and physical activity needed to

facilitate weight reduction and provide health coaching for motivating overweight/obese students

to actively participate in their weight loss efforts, thereby increasing self-efficacy.

Theoretical Model

Pender’s Health Promotion Model (HPM) provides the framework for this project (Figure

1) (See Appendix A). The HPM was proposed by Nola Pender in 1982 and revised in 1996

based on changing theoretical perspective and empirical findings (Pender, Murdaugh, & Parsons,

2011). The theoretical background of the theory includes Expectancy-Value Theory and Social

Cognitive Theory (Pender et al., 2011). The expectancy-value theory posits that individuals will

engage in actions that they perceive to be possible and will result in a valued outcome. Similarly,

social cognitive theory indicates that thoughts, behaviors, and environment interact, therefore for

an individual to alter their behavior, they must alter their thought. The HPM is a model that is

based on human behaviors. The purpose of the model is to assist nurses in understanding health

behavior determinants as the basis of behavioral counseling to promote health (Pender et al.,

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2011) There are three components to the theory that include individual characteristics and

experiences; behavior-specific cognition and affect; and behavioral outcome-health promotion

behaviors (Appendix A). Individual characteristics and experiences component of the model

include prior related behaviors and personal factors. The second component is personal related

behaviors and personal factors. This component consists of constructs that are frequently studied

in research works. They include perceived benefits of action, perceived barriers to action, self-

efficacy, activity related affect, interpersonal influences, social support, situational influences.

The third component is behavioral outcome-health promotion behaviors. This third component

could be influenced by some immediate competing demands and commitment to action.

This model fits the obesity management and prevention project as a health promotion

model. The project seeks to effect behavioral changes and actively engage overweight and obese

students in weight reduction efforts. Perceived benefits and self-efficacy constructs play major

roles in influencing behavioral change (Pender et al., 2011). Perceived benefits are the benefits

an individual believes they will achieve by performing the action; this belief reinforces the action

while self-efficacy is the belief that one can perform the action or perform the health behavior

successfully. Self-efficacy involves having confidence in one’s ability to achieve a goal.

One of the assumptions of the HPM is that the health professionals is a part of a patient’s

interpersonal environment that could influence the patient throughout their life span. Nurses and

advanced practice nurses could assess patient’s knowledge need as they perceive the benefits of

an action that could impact their health and provide the education needed to increase patients’

knowledge. Additionally, nurses could provide positive motivation to enable patients to

participate in managing their chronic health management. Advanced practice nurses can also

educate patients to enable a change in their perceptions of barriers and develop ways of

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overcoming obstacles to lifestyle changes. Patients’ self-efficacy could be enhanced by

empowering them by collaborating with them in making lifestyle changes.

Project and Study Design

The study was a quantitative 4-week descriptive pre- and post-intervention pilot study

design. Institutional Review Board approvals were obtained prior to the start of the study from

Maryville University and the University where the study was conducted. The University is

located on the eastern part of the United States. Participants were selected from the target

population at the University. Participants were recruited by flyers to be placed in students’

common areas and by inviting overweight or obese students to participate in the study after their

clinic visits. Participation in the study was voluntary. The link to the Youtube PowerPoint

presentation was emailed to volunteers for the study. The PowerPoint presentation discussed the

roles of study participants and the researcher, inclusion and exclusion criteria, and the informed

consent. The researcher’s contact information was included in the presentation for potential

participants to schedule an appointment with the researcher. During the appointment, any further

questions about the study was answered. Volunteer’s height was measured by the researcher

using Accustat Genentech Stadiometer, and weight was measured using Tanita Composition

Analyzer BF-350. Body mass index (BMI) was calculated using height and weight

measurements; the BMI result was used to determine eligibility. A signed informed consent was

obtained from participants. Participants thereafter completed the demographic questionnaire

(Figure 2) (See Appendix B), the Youth Risk Behaviors Survey (YRBS) (Figure 3) (See

Appendix C) and the Motivators and Barriers Survey of Healthy Lifestyle Survey (MABS)

(Downes, 2015) (Figure 4) (See Appendix D). Appointments for the weekly phone calls were

scheduled.

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The health coaching intervention consisted of three weekly calls to participants. Coaching

involves using the motivational interviewing technique to strengthen a person’s commitment to

change. The motivational technique involves asking open-ended questions, validating

information, attentive listening, and encouraging self-efficacy and confidence. Participants were

guided towards identifying positive behaviors and making healthy choices. Weekly calls focused

on dietary and physical activity education. Participants were encouraged to focus on their goals

towards changing any unhealthy habits related to nutrition and physical activity. Eating

recommended five servings of fruits and vegetables daily, limiting sugary drinks, drinking more

water, and portion control were encouraged. In addition, participants were encouraged to get 30

minutes or more of physical activity daily.

Validated instruments were used to collect data from the participants. The Youth Risk

Behavior Survey (YRBS) is a 12-item self-reported instrument that measures dietary habits and

physical activity behaviors. The Motivators and Barriers Survey of Healthy Lifestyle Survey

Scales (MABS) is an 18-item tool that is divided into two subscales, with eight items measuring

motivating factors while ten items measure barriers that were inhibiting healthy lifestyle

behaviors. The scoring of the MABS is on a Likert scale. The MABS questionnaire has a

Cronbach’s alpha internal consistency of .81 for the Motivators and .88 for the barriers (Downes,

2015). Permission to use the MABS was obtained from the author; no permission was needed for

the use of YRBS. Participants’ height and weight were measured at the beginning and the end of

the fourth week and participants also completed the YRBS and MABS. Collected data was

categorized and entered an Excel spreadsheet for statistical analysis.

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Setting and Resources

The setting for the study was a University located on the eastern part of the United States.

Resources needed for the study were a telephone, a laptop computer, copies of questionnaires,

measurement tools for height and weight, pens and pencils. The researcher used a personal

telephone and laptop that were password protected and only accessible to the researcher. The

clinic provided photocopies of the questionnaires. A private office available at the Health Center

was used for completing the questionnaires. Limited financial resource was needed. The

researcher purchased pencils and pens at a minimum cost.

Study Population

Participants in the project included adults, overweight or obese college students at the

University. Participants for the study were recruited using flyers placed in students’ common

areas on campus. All overweight or obese students were asked to participate in the project after

their scheduled clinic appointment. Participation in the study was voluntary and did not impact

the care provided. Inclusion criteria are 1) College students ages 18 to 29, 2) Current enrollment

in the institution, 3) Male and female students, 4) Body mass index (BMI) of 25 kilograms per

meter squared (kg/m2) or greater, and 5 All ethnic groups. Eligibility was determined by

performing actual measurements of height and weight and calculating BMI. The currency of

student’s University status was validated. Exclusion criteria were: 1) Students currently

undergoing weight reduction treatments or pregnant, 2) BMI less than 18 kilograms per meter

squared (kg/m2), 3) Contraindications to exercise, 4) Special diets prescribed by a healthcare

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provider, and 5) Not currently enrolled at the institution. A convenient sample of 20 participants

was selected.

Sources of Data

Research instruments for data collection include the demographic questionnaire, the

Youth Risk Behavior Survey (YRBS), the Motivators and Barriers to Healthy Lifestyle Survey

(MABS) and performing biophysical measurements of height and weight and calculating body

mass index (BMI). The Youth Risk Behavior Survey (YRBS) is a 12-item self-reported

instrument that measures dietary habits and physical activity behaviors (CDC, 2017b; Downes,

2015). The Motivators and Barriers Survey of Healthy Lifestyle Survey Scales (MABS) is an 18-

item tool that is divided into two subscales, with eight items measuring motivating factors while

ten items measure barriers inhibiting healthy lifestyle behaviors (Downes, 2015). The scoring of

the MABS is on a Likert scale. The MABS questionnaire has a Cronbach’s alpha internal

consistency of .81 for the Motivators and .88 for the barriers (Downes, 2010). Participants’

heights were measured by the researcher using Accustat Genentech Stadiometer and weight

measured using Tanita Composition Analyzer BF-350. BMI was calculated using their height

and weight. Permission to use the MABS was obtained from the author; no permission was

needed for the use of YRBS.

The principal investigator collected all data, performed all measurements, and provided

weekly phone calls. Key research variables for the study are weight, height, body mass index,

exercise habits, dietary habits, motivators, and barrier factors. Operational definitions of the

variables are:

Weight: Participant’s body weight in pounds and ounces measured without shoes.

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Height: Participant’s height in feet and inches measured without shoes.

Body mass index: Body weight in kilograms divided by the square of height in meters to assess

overweight and obesity (Centers for Disease Control and Prevention [CDC], 2016)

Exercise habits: Participant’s 7-day exercise habit recall (CDC, 2017b)

Dietary habits: Participant’s 7-day dietary habit recall (CDC, 2017b)

Motivators factors: Personal and environmental factors affecting the participant’s healthy

lifestyle behaviors (Downes, 2015).

Barrier factors: Factors contributing barriers to participant’s healthy lifestyle behaviors

(Downes, 2015).

Data Analysis

Collected data were categorized and entered into an Excel spreadsheet and submitted to

the statistician for data analysis. Descriptive Statistics and paired t-test were calculated (Table 1)

(See Appendix E). Frequencies and percentages were obtained for categorical data such as age,

gender, race/ethnicity, class status, and housing. Means and standard deviations were calculated

for continuous data such as weight and BMI. Paired t-test was calculated to determine the

difference between pre- and post-intervention measurements.

Quality

Data were collected at the intended University in a timely manner; all participants

completed the questionnaires at the beginning and at the end of the study. The research

administered all questionnaires in the same manner in a private environment free of distraction

by the researcher. All biophysical measurements were performed by the researcher using

specialized instruments for consistency. The data collection instruments used were pretested for

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reliability and validity by the creator of the tools. The YRBS has a test-retest reliability of 75%,

and the MABS has Cronbach’s alpha of .81 for the motivator subscale and .88 for the barrier

subscale (Downes, 2015). Principal investigator administered the questionnaires to eliminate

bias and to maintain the validity and reliability of measurement tools. In addition, no changes

were made to the questionnaires by the researcher. The YRBS and the MABS are valid and

reliable measurement tools; both have face and content validity. The questionnaires were specific

and sensitive to the construct of the study. The YRBS measures the dietary habits and exercise

behaviors of participants. This instrument has face validity; sample questions are: In the past

seven days, how many times did you exercise or participate in physical activity for at least 20

minutes that made you sweat? and In the past seven days, how many times did you eat

vegetables?

Collected data were secured in a locked box in the researcher’s private office that only

the researcher has access to. The principal investigator administered all questionnaires to

eliminate bias and maintain the consistency of measurement tools

Results

Of the 15 participants that completed the study, 13% were male, 87% were female; 60%

were African American. The median age of the study participants was between 21-22 years.

Participants’ academic class levels were: 33% freshman, 27% sophomore, 7% junior, 13%

senior, and 20% graduate, the majority were freshman students. The University is a non-

residential institution, 53% of the participants live independently in the community, 20% live in

off-campus university housing, 27% live with family. The mean average pre- and post-

intervention weight was 197.1 and 195.6lbs respectively (Table 1) (See Appendix E), and the

amount of weight loss by participants are shown in Table 2 (Appendix F). Sixty percent (10) of

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the participants lost weight ranging from 0.2 to 8.6 lbs. The pre- and post-intervention body mass

index (BMI) shows a slight difference. Four participants gained weight including the two male

participants in the study.

The difference between mean pre-intervention and post-intervention weight was 1.5 lbs.

and the mean pre-intervention and post-intervention BMI was 0.26 respectively (Figure 5) (See

Appendix G). The paired t-test result shows no significant difference in the scores for pre- and

post-intervention weight (t(14) = 1.37, p = .19) and BMI (t(14) = 1.57, p = .14) ( Table 1), (See

Appendix E).

The pre-intervention results of the YRBS questionnaire show that none of the participants

ate the recommended amount of fruits and vegetables. Sixty percent of the participants drank

fruit juice or ate fruit 1-3 times per day. Similarly, 60% ate 1-3 vegetables per day, and 47% ate

snacks 1-3 times per day. Additionally, the YRBS shows that 40% of the participants performed

20 minutes of vigorous physical activity 1-3 days per week, 33% reported exercising for 30

minutes 1-3 days per week. The three top barriers to healthy lifestyle were: having too many

things to do, stress, and lack of motivation (Figure 6) (See Appendix H), while motivators for

practicing a healthy lifestyle include wanting to be healthy, energetic, and lose weight. All 15

participants received three weekly telephone calls to provide health coaching using structured

scripts for consistency. Participants discussed challenges about their diet and physical activity.

Some participants reported a lack of accessibility to healthy food choices due to limited funds.

Participants were offered support and motivation and encouraged to identify ways to eat healthy

and exercise with their limited resources.

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Discussion

Majority of the study participants were females which is similar findings in research

studies (Moe, Lytle, Nanney, Linde, & Laska, 2016). The low male participation in obesity

reduction study was noted attributed to possible perception of their weight as some male showed

no dissatisfaction with the weight (Moe, Lytle, Nanney, Linde, & Laska, 2016). The weight loss

among participants ranged between 0.2 to 8.6lbs although the overall difference in pre- and post-

intervention BMI was not significant. The range of weight loss suggests that some participants

were more motivated than others. Pre-intervention YRBS data shows none of the participants ate

the recommended amount of fruits and vegetables nor performed the recommended amount of

physical activity. This is consistent with research findings that many college students consume

less than the daily recommended amount of fruits and vegetables and do not perform the

recommended amount of physical activity per week (Nanney et al., 2015). Poor eating habits and

the inadequate amount of physical activity are factors contributing to overweight/obesity.

Barriers to a healthy lifestyle results are consistent with research findings that stress is one of the

factors contributing to weight gain in college students (Nanney et al., 2015). Majority of the

participants were African American, and the rate of obesity is higher in African Americans than

the other ethnic groups. This finding is consistent with findings in other studies that African

American has a higher rate of overweight and obesity than other ethnic groups (Sa, Heimdal,

Sbrocco, Seo, & Nelson, 2016).

Limitations

The sample size for the study was small, and there were few male participants in the

study which limits the generalizability of study findings. Also, a convenience sample was used

that may not be representative of the target population. The duration of the health coaching of

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four weeks may not be long enough to measure a significant change in weight and BMI. Other

studies that used health coaching for weight loss provided the coaching longer periods. The use

of self-report is appropriate for obtaining information about dietary and physical activity recall

but could subject the data to bias. Causality cannot be inferred from the study. Another limitation

is that participants were recruited from one setting which is a non-residential Historically Black

University. The study has only two male participants which further limits the result from being

generalized. The racial diversity in the study is limited with the majority being African America.

Implications for Practice

The inadequate dietary and physical activity behavior among some college students

remains a challenge to health care providers. The implications of the study include the clinical

significance at the individual level as evidenced by ten out the 15 participants losing some

weight. Participants who experienced weight reduction might feel a sense of accomplishment

and improved self-confidence in their ability with the appropriate education and support.

Coaching method can be included in practice to motivate, educate and support overweight or

obese students. Results of the study could increase nurses’ knowledge of the barriers and

motivators for healthy lifestyles in college students. The study shows that 33% of the sample

population were in their freshman year. There is a need to educate and motivate overweight and

obese freshman college students to lose weight to prevent weight gain in subsequent years in

college. Nurses need to assist with finding food resources due to many students lacking adequate

resources to provide appropriate food. Weight loss intervention for male college students

requires further study.

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Ethics and Human Subjects Protection

Institutional Review Board (IRB) approvals from Maryville University and at the

University used for the study were obtained before starting data collection for the study to ensure

human subject protection is maintained. One risk for conducting this study is the potential for

breach of confidentiality, which is minimal. Another risk is that participants may feel coerced to

participate in the study as this researcher is one of the healthcare providers at the Student Health

Center. There is a potential risk for injury due to physical activity as participants were advised to

exercise. Also, there is the potential risk of being identified as overweight or obese based on

BMI calculation.

The potential risk of breach of confidentiality was managed by the use of de-identified

data and limited access to the data by only the researcher performing the study. This risk was

minimized by identifying participants by numeric codes instead of using names on all data

collection sheets. The list linking subjects’ names and numeric codes, as well as the signed

informed consents, were kept separate from the data collection sheets and locked in a file cabinet

in the researcher’s locked private office with access limited to the researcher. The data collection

sheets will be kept in a locked file cabinet, separate from the subjects’ names and numeric codes,

as well as the signed informed consents, in the researcher’s locked private office with access

limited to the researcher. The numeric codes and data collection sheets will be shredded upon

conclusion of the study. Informed consents will be shredded after three years.

The second risk of coercion was mitigated by requesting participation in the study after

the office visit is completed. In addition, the researcher informed participants that choosing not

to participate will not adversely affect the participants’ relationship with the researcher as their

healthcare provider. The participants have the freedom to ask questions and withdraw from the

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study at any time without penalty. The researcher emphasized that the treatment of the

participants was equitable before, during, and after the research study. It was emphasized that

whether the patients who meet the inclusion criteria agreed to participate in the study or not will

in no way affect the care they receive from their provider.

Any type of physical activity can come with a risk of physical injury. To minimize the

potential risk of physical injury, only participants who have no contraindications to exercise were

recruited for the study. The researcher will verify any contraindication to physical activity by

requesting participants to self-report any healthcare provider’s restrictions on physical activity at

the beginning of the project and during the weekly telephone calls. Participants with

contraindications such as advised not to exercise were excluded from the project to prevent

injury. In addition, the researcher could remove individuals from the study if in the researcher’s

judgment mental or physical health could be compromised if they continue to participate.

Participants will be encouraged to increase their activity and refrain from a sedentary lifestyle.

Participants were not coerced to perform any activity that they felt could compromise their health

or is not within their capacity.

The potential negative impact related to being identified as overweight or obese based on

BMI calculation was minimized by not using negative terms to address participants. Instead,

participants were addressed by their names and terms such as elevated BMI will be used in place

of overweight or obese to avoid any stigma.

Timeframes or Timeline

Institutional Review Board (IRB) approvals were obtained from the University used for

the study in December 2017 and from Maryville University in April 2018. The recruitment of

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participants for the study and data collection was started from April 2018 till September 2018.

Data analysis was performed in October 2018, the interpretation of results was conducted in

November 2018. Oral presentation of capstone project and submission of the write-up were done

in December 2018.

Budget

The researcher contributed to the use of personal telephone for making weekly calls and

the use of a personal password laptop computer that was only accessible to the researcher. The

researcher also measured participants’ heights and weights and calculated BMI. A private room

was available at the Health Center at no extra cost for participants to complete the

questionnaires. Other resources available for use for the study include the Stadiometer scale for

measuring height and the Tanita scale for measuring participants’ weight. The researcher

purchased pencils and pens for at a minimum amount. The statistician who analyzed the data is

an instructor at Maryville University who provided the service at no cost to students.

Strengths and Weaknesses of the Study

Strengths

The data for the study was collected in a timely and consistent manner as planned for the

project. The principal investigator used the same measuring tools to measure the height and

weight of participants; and administered the demographic questionnaire, the YRBS and the

MABS to participants in a private environment free of distraction. Nutrition and physical activity

education were provided to each participant via weekly telephone calls in a consistent manner to

increase the rigor of the study. Valid and reliable tools were used for data collection. The study

could be replicated in similar University settings that are non-residential. The intervention could

work in other health conditions due to the use of valid and reliable tools for data collection.

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There was an organizational support for the project by the University used for the study.

The support includes the approval of the project by the Chief of Student Success and Student

Development and granting the IRB approval.

Weaknesses

Findings from the study could not be generalized due to the small sample size. A large

sample size is needed to achieve a statistically significant result. There was limited diversity in

the ethnic composition of study participants which limits the generalizability of results. The use

of convenience sampling and self-report questionnaires limit the generalizability of results. In

addition, having few male participants in the study is a limitation that could impact the results of

the study.

Conclusion

The study shows adherence to recommended diet and physical activities could result in

weight reduction. Though no statistical significance was determined for the intervention, some

participants lost some weight. The study shows some overweight and obese college students

want to lose weight and need education and support and should be provided with such. Further

studies are needed with larger sample size and the study conducted for a longer period to allow

for recruitment of participants and be able to evaluate the significance of the intervention.

Challenges of overweight and obesity in college students warrant comprehensive intervention

with a multi-disciplinary approach. By involving the athletic department, counseling department,

nutrition and dietetic department, and health services in developing health promotion activities,

an effective weight loss, and weight management goal could be achieved.

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Appendix A

Figure 1. Pender’s Health Promotion Model

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Appendix B

Figure 2. Demographic Questionnaire

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Demographic Questionnaire: Administered by Researcher

(Answer the following questions)

Code #:________________

Age:

___ Under 18

___ 18-19

___ 20-21

___ 22-24

___ 25 and above

Sex/Gender:

___ Male

___ Female

Race/Ethnicity:

___ African American

___ Asian/Pacific Islander

___ Hispanic/Latino

___ Multiracial

___ Native American/American Indian

___ White

___ Not listed

___ Prefer not to respond

Class Status:

___ Freshman

___ Sophomore

___ Junior

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___ Senior

Housing:

A. Which of the following is/are applicable to your living situation? (Check all that apply)

___ I live alone

___ I live with other students

___ I live with parent (s), relative (s) or guardian (s)

___ I live with a husband/wife/significant other

___ I live with my child/children

B. Which best describes where you currently live?

___ Off-campus university housing

___ Living at home with family

___ Living independently

Appendix C

Figure 3. Youth Risk Behavior Survey

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Appendix D

Figure 4. Motivators and Barriers of Healthy Lifestyle Survey Scales (MABS)

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Appendix E

Table 1. Descriptive Statistics and Paired t-Test

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Appendix F

Table 2. Pre- and Post-Intervention Weight Differences

POSTWEIGHT

PREWEIGHT Weight Difference

217 225.6 -8.6226 221.4 4.6

183.4 182.4 1.0209 209.8 -0.8

169.6 172.4 -2.8257.6 249.8 7.8180 185 -5.0212 210 2.0

175.6 175.6 0.0154 154.2 -0.2179 183 -4.0177 181.6 -4.6

205.8 210.2 -4.4172.8 176.2 -3.4215 218.8 -3.8

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Appendix G

Figure 5. Pre- and Post-Intervention BMI

1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

5

10

15

20

25

30

35

40

45

Pre- and Post-Intervention BMI Dif -ferences

PRE-BMI POSTBMI

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Appendix H

Figure 6. Barriers to Healthy Lifestyles

9. Am not motivated

10. Do not have

11. Live in an unsafe

12. Have too many

13. Have health

14. Do not know what

15. Am unable to

16. Am not able to

17. Have not been

18. Feel stressed.

0

1

2

3

4

5

6

7

8

9

10

Barriers to Healthy Lifestyles

Strongly Disagree Disagree Agree Strongly Agree

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