1. 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

2. 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

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

4. 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.

5. 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

6. 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

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

8. 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
Surveys of 2,516 high school students and early young adults 5-year longitudinal follow-up (ages 17-23)
EAT-III
10-year follow-up on early and middle young adults (N=2,287; ages 21-27)
EAT-IV
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
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
Follow-up on young adults and their families, friends, school/worksites, and neighborhoods
EAT 2024
Ongoing follow-up to inform multilevel explanatory models and interventions to reduce eating, activity, and weight-related problems

9. 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 Cohort

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

11. 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

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

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

14. 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

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

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

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

18. 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:

19. 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%, %
Hispanic families: 1999=18%, 2010=6%
Larson, Hannan, Fulkerson, Laska, Eisenberg, Neumark-Sztainer. Am J Public Health. 2014;104:e62-e69.

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

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

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

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

24. 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):

25. 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):

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

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

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

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

30. 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.

31. 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.

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

33. 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):

34. 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:

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

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

37. 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):

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

39. Building the evidence:
Recommendations for health care providers and families

40. 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: J. Adolesc. Health. 2009;44(3):

41. 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

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

43. Developments in understanding what is needed to support healthy eating behaviors

44. 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

45. 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.

46. 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.

47. 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.

48. 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:

49. 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.

50. 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):

51. 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):

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

53. 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

54. 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:

55. 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:

56. 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:

57. 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:

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

59. 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?

60. 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.

61. 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.

63. 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.

64. 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):

65. 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:

66. 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):

67. 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):

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

69. 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:

70. 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.

71. 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.

72. 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

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

74. Contact Information
Nicole Larson School of Public Health, University of MN Phone: Website: