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

Funding acknowledgment Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services Grant R40 MC 00125 Grant R40 MC 00319 National Heart, Lung, and Blood Institute, National Institutes of Health Grant R01HL084064 Grant R01HL093247 Grant R01HL116892 Grant R01HL127077 Grant R35HL139853

Research program team Dianne Neumark-Sztainer (PI) Marla Eisenberg Jerica Berge Susan Mason Daheia Barr-Anderson Melanie Wall Katie Loth Laura Klein

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

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

Project EAT Research Aims Promote nutritional and weight-related health Learn more about a broad spectrum of eating, activity, and weight-related problems in diverse young people Identify multilevel predictors of these outcomes to inform more effective interventions Understand trajectories of these outcomes throughout critical periods of the life course

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

What is Project EAT? EAT-I 1998-99 Surveys and measurements of 4,746 diverse middle and high school students in Minnesota (ages 11-18) EAT-II 2003-04 Surveys of 2,516 high school students and early young adults 5-year longitudinal follow-up (ages 17-23) EAT-III 2008-09 10-year follow-up on early and middle young adults (N=2,287; ages 21-27) EAT-IV 2015-16 Follow-up on young adults (N=1,830; ages 27-33), participants’ significant others (N=733), and participants’ preadolescent and adolescent children (N≅260; ages 9-18) EAT 2010 2009-10 Recruitment of 2,793 new middle and high school students (ages 11-17) and surrounding environments F-EAT Assessment of parents of 2,000 adolescents (N=3,709) EAT 2018 2017-18 Follow-up on young adults and their families, friends, school/worksites, and neighborhoods EAT 2024 2018-24 Ongoing follow-up to inform multilevel explanatory models and interventions to reduce eating, activity, and weight-related problems http://www.sphresearch.umn.edu/epi/project-eat/

Project EAT timeline EAT I-IV Cohort EAT 2010-2018 Cohort 1996 1998 Mail & phone surveys with some parents Web & mail surveys with a significant other EAT I-IV Cohort Mail & web surveys with a child Focus groups to inform baseline survey Baseline EAT surveys in 31 MN metro schools EAT-IV follow-up web & mail surveys EAT-III follow-up web & mail surveys EAT-II follow-up mail surveys 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 EAT 2010 surveys in 20 MN metro schools EAT 2018 follow-up web & mail surveys Mail & phone surveys with both parents Follow-up 2018 mail, phone, & web surveys with parents School surveys & neighborhood GIS Neighborhood GIS EAT 2010-2018 Cohort

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

Project EAT population samples for analysis of secular trends % Ethnicity/race White 1029 33.5 525 18.8 Black 723 23.6 808 28.9 Asian 753 24.5 555 19.9 Hispanic 243 7.9 472 16.9 Native American 133 4.3 102 3.7 Mixed/other 191 6.2 331 11.8 Socioeconomic status Low 683 22.2 1072 38.4 Low-middle 601 19.5 595 21.3 Middle 755 24.6 471 High-middle or high 871 28.4 550 19.7 EAT 2010 (2010) 20 schools N=2793 EAT-I (1999) 27 schools N=3072 Full EAT-I Sample 31 schools N=4746

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

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

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

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

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

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

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

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

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

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

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

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

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

Trends in high fast food intake (%) from adolescence (Wave 1) to young adulthood (Wave 4) at 5-year intervals % High defined by 3 or more times per week Wave Neumark-Sztainer, Wall, Chen, Larson, Christoph, Sherwood. Am J Prev Med. 2018;55(2):133-141

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

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

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

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

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

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

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

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

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

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

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

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

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

Building the evidence: Recommendations for health care providers and families

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

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

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

Developments in understanding what is needed to support healthy eating behaviors

Family, home, and neighborhood supports for healthy eating Adolescent eating behavior & dietary intake Home healthful food availability Parent healthy food modeling Parent encouragement of healthy eating Focus on healthy behavior vs weight Frequent family meals Child involvement in food preparation Warm parent-child communication High family functioning Adult eating behavior & parenting practices

Home environment profiles: adolescent fruit & vegetable intake HIGH healthy home food availability LOW healthy home food availability Average # of daily servings Loth, MacLehose, Larson, Berge, Neumark-Sztainer. Appetite. 2016;96:80-86.

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

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

Family meals, parenting practices, & adolescent fruit & vegetable intake (mean servings/day) Infrequent Family Meals (<2 times/wk) n=864 Frequent Family Meals (>5 times/wk) n=1,093 Parent communication Low 3.5 3.7 High 3.3 4.2 Home availability of fruits and vegetables Never/rarely 3.0 Usually/always 3.6 4.1 Home accessibility of fruits and vegetables Never/sometimes 3.2 On a regular basis Parent encouragement for healthy eating Never/somewhat Very much 4.4 Watts, Loth, Berge, Larson, Neumark-Sztainer. J Acad Nutr Diet. 2017;117:707-714.

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

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

Meal preparation and adolescent diet quality Adolescent involvement linked to higher intake: Fruit Vegetables Iron Calcium Folate Vitamins C, D Fiber Fast food Parent involvement not related to intake of food group servings, vitamins, or minerals Berge, MacLehose, Larson, Laska, Neumark-Sztainer. J Adolesc Health. 2016;59(5):530-536.

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

Adolescent Involvement Food Preparation Behaviors in Emerging Adulthood by Involvement in Food Preparation during Adolescence Adolescent Involvement Never (n=420) At least 1-2 times in past week (n=892) P value % report engaging in behavior 1+ times/week as emerging adult Buying fresh vegetables 19.4% 33.9% <0.001 Writing a grocery list 12.0% 21.4% Preparing a green salad 29.1% 28.5% 0.83 Preparing a dinner with chicken, fish or vegetables 44.9% 52.3% 0.01 Preparing an entire dinner for 2+ people 41.0% Laska, Larson, Neumark-Sztainer, Story. Public Health Nutr. 2012.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Experiences of weight teasing in adolescence and weight-related outcomes in adulthood Females: Higher BMI Engaging in binge eating Use of unhealthy weight control practices Eating to cope Poor body image Past year dieting Males: Higher BMI Eating to cope Poor body image The observed linkages took baseline weight status in to account along with ethnicity/race, socioeconomic status and age. Peer and family-based teasing were important for females and peer-based teasing for males. Puhl, Wall, Chen, Austin, Eisenberg, Neumark-Sztainer. Prev Med. 2017;100:173-179.

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

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

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

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

Contact Information Nicole Larson School of Public Health, University of MN Email: larson@umn.edu Phone: 612-625-5881 Website: http://www.sphresearch.umn.edu/epi/project-eat/