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Impact of the Course Health At Every Size: A Non-diet Approach to Wellness on Intuitive Eating, Body Esteem, Dieting Behaviors, and Anti-fat Attitudes of College Students ABSTRACT

Objective: To investigate the effects of a HAES-centric curriculum on intuitive eating (IES), body esteem (BE), cognitive behavioral dieting scores (CBDS) and anti fat attitudes (AFA) of college students. Methods: This quasi-experimental study included surveying students (n = 149) attending classes during the 2012-2013 school year. Analysis of variance and post hoc Tukey adjusted tests were used. Results: Mean scores for total IES (P < 0.001), unconditional permission to eat (P < 0.001), reliance on hunger (P < 0.001), CBDS (P < 0.001), BE appearance (P < 0.002), BE weight (P < 0.001) and AFA (P < 0.001) significantly improved for students in the intervention group. Conclusion and Implications: Students in the HAES class showed improved eating and dieting behaviors, body esteem and anti-fat attitudes. HAES related curriculum may positively impact individuals and their interaction with clients as future health professionals. Abstract Word Count: 150 Key Words: college students, dieting, intuitive eating, HAES

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INTRODUCTION

Dieting and weight loss efforts often result in a repetitive cycle of self-deprivation that can lead to disordered eating including binging, anorexia, bulimia, and a worsening self image (Derenne & Beresin, 2006; Herman and Polivy, 1999, Killen et al., 1993). Dieting rarely results in long-term weight loss, but rather weight gain (Patton, Selzer, Coffey, Carlin, and Wolfe, 1999; Neumark-Sztainer, Wall, Story, Haines, and Eisenberg, 2006, Pietilainen, Saarni, Kaprio and Rissanen, 2012; Nemark-Sztainer, Wall, Story and Standish, 2012; Field et al, 2003; NeumarkSztainer, Wall, Story, Haines, and Eisenberg, 2006). Unintended physical and psychological consequences of dieting include: feelings of worthlessness, self-hatred, depression, loss of muscular strength and endurance, decreased oxygen utilization, loss of coordination, dehydration and heart problems, weight regain, and weight cycling (Goldschmidt 2012, Gillen 2012, Bacon et al., 2002; Bacon, Stern, Van Loan, & Keim, 2005; Dansinger, Gleason, Griffith, Selker, & Schaefer, 2005; Dansinger, Tatsioni, Wong, Chung, & Balk, 2007; Field et al., 2003; Mann et al., 2007; Neumark-Sztainer et al., 2006; Stice, Cameron, Killen, Hayward, & Taylor, 1999, Field, Manson, Taylor, Willett & Colditz, 2004, Pietilainen, Saarni, Kaprio and Rissanen, 2012; Nemark-Sztainer, Wall, Story and Standish, 2012). Furthermore, studies have identified several risk factors for ones eating pathology, including self-reported dietary restraint, perceived pressure for thinness, thin-ideal internalization and body dissatisfaction (Stice, Ng & Shaw, 2010)." College students are particularly vulnerable to the effects of dieting, body image

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dissatisfaction, eating disorders and depression (Ackard 2002, Racette 2005, Kiess 2001). Dieting frequency is positively correlated with the onset of certain psychological issues in college students such as depression, difficulty in mood regulation, obsessive behaviors around eating and exercising, and finally the onset of an eating disorder (Ackard 2002). New research on weight and health has brought into question the efficacy of traditional weight loss methods. The Health At Every Size (HAES) paradigm is a non-diet approach that offers a solution to the dieting epidemic (Bacon & Aphramor, 2011). The HAES approach aims to shift the focus from weight to health, promote body acceptance, attend to internal hunger and fullness cues and to emphasize the intrinsic benefits of physical activity (Bacon & Aphramor, 2011). Instead of promoting calorie control, and restriction of certain food groups or nutrients, the HAES paradigm promotes permission to enjoy a variety of foods and activities. In studies where HAES programming was implemented, participants experienced improvements in diet quality, physical activity and various physiologic and psychosocial factors (Bacon 2005, Bacon 2002, Ciliska 1998, Goodrick 1998, Provencher 2007, Provencher 2009, Rapport 2000, Tanco 1998). Few researchers have examined the effects of disseminating HAES concepts within a college curriculum. Dr. Linda Bacons Eat Well For Your Self, For the World text and curriculum significantly improved the food and nutrition related attitudes and lifestyle habits of college students, including food purchasing and meal preparation habits, Intuitive Eating Scale (IES) scores, and pleasure obtained by the eating experience, compared to control participants (Rios 2011). In another study, nutrition students read and reflected on either The Food and Feelings Workbook (Koenig 2007) or Intuitive Eating (Tribole & Resch 2003). The authors reported that both texts and accompanying assignments significantly improved IES scores from

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pre to posttest (Welden 2009). Finally, another study indicated that the incorporation of Bacons text, Health at Every Size: The Surprising Truth about Your Weight (Bacon 2010) in a community nutrition course, led to significant increases in knowledge of and positive attitudes towards the HAES paradigm (Neyman Morris, 2010). While these three studies demonstrate the benefits of incorporating non-diet approaches into nutrition course curricula, it is unknown how an entire course on the HAES tenets may influence participants, while incorporating a theoretical foundation. The Social Cognitive Theory (SCT) can strengthen an intervention to promote behavior change (Bandura 1986). According to the SCT, an individuals behavior is influenced by personal factors and environmental cues (reciprocal determinism). When applying observational learning, teaching behavioral knowledge and skills (behavioral capability), promoting selfefficacy, identifying the barriers and benefits to a behavior change (expectations), and enhancing the value one places on a behavior change (expectancies), individuals are more likely to change a health behavior and maintain that behavior change over a long period of time. College courses often result in positive health behavior changes (Heker 2010, Emrich 2009), and therefore can be considered health-based interventions. The purpose of this study was to assess changes in intuitive eating, body esteem, changes in dieting behaviors and anti-fat attitudes of students enrolled in a HAES general education course, that utilizes constructs of the SCT, compared to a traditionally-taught basic nutrition course that does not include HAES concepts (control), and a basic nutrition course with some lectures that address HAES concepts (comparison).

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METHODS

Participants and Recruitment

This quasi-experimental research design utilized a convenience sample of college students attending either a four-year university or a nearby community college. Students enrolled in the general education course Health at Every Size: A Non-Diet Approach to Wellness (HAES) during the Fall 2012 and Spring 2013 semesters at a mid-sized west coast state school served as the intervention group. Two different instructors, who used the same curriculum, taught the Fall 2012 and Spring 2013 courses. Students enrolled in a basic nutrition course at the same institution served as the comparison group. The comparison group was utilized in order to determine if the length of the intervention would be a factor in changing the students scores in the measured scales and subscales. Students enrolled in a basic nutrition course at a mid-sized west coast community college served as the control group. Both the comparison and control group courses used a popular introductory nutrition textbook. The control group instructor taught the weight management section in accordance with the textbook which focuses on the reduction of weight through calorie restriction to improve health. The instructor in the comparison group deviated from the textbook when teaching the weight management section, incorporating three lectures on HAES concepts instead.

Study Design and Protocol

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Students completed a self-reported pre and post-survey during the first and second to last week of school that was a compilation of four valid and reliable measures. The Intuitive Eating Scale-2 (IES-2), a 23-item 5-point Likert Scale (strongly disagree-strongly agree) was used to assess perceived use of internal cues to guide meal timing and quantity consumed (Tylka 2012). This measured four subscales, (1) unconditional permission to eat, (2) eating for physical rather than emotional reasons, (3) reliance on internal hunger/satiety cues, and (4) body-food choice congruence. The Cognitive Behavioral Dieting Scale (CBDS) was used to assess current dieting behaviors of the students. The instrument includes a 14-item 5-point scale (never always), with scores ranging from 14 to 70 (Martz 1996). Body esteem was assessed using the 23-item 5-point (never-always) Body-Esteem Scale (BES; Mendelson 2000, Mendelson 2001). The BES measured three components of body esteem including (1) general feelings about appearance, (2) weight satisfaction and (3) attribution, or ones perception of how others evaluate them. Crandalls 13-item 10-point Likert scale (very strongly disagree-very strongly agree) Anti-Fat Attitudes (AFA) Questionnaire was used to assess explicit anti-fat prejudice among the students (Crandall 2007). Demographic information was also collected, including gender, class standing, age, ethnicity, self-reported current height and weight, as well as participants current major(s) and minor, if applicable. BMI was calculated for each student from self-reported height and weights. The Institutional Review Board for research involving human subjects approved all study procedures and informed consent was obtained prior to data collection. Participation (or failure to participate) in the research study did not influence the students course grades. Sample size calculations indicated that 42 participants per group had 80% power to detect an absolute difference of 3.53 between the three groups for total IES-2 scores, assuming a SD of 0.53 points.

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Intervention

The HAES class focused on teaching students about the physical, social, psychological and economic impact of the diet industry on individuals and society. Classroom lectures covered the following topics: critical analysis of weight loss research, bariatric surgeries, eating disorders, intuitive eating, mindful eating, the Satter Eating Competence Model (Satter 2007), culture and body image, social justice, and size discrimination. This class satisfied the US Diversity and Writing Intensive general education requirements with an aim to increase critical thinking and teach students how to analyze research and write effectively and persuasively. Observational learning, reciprocal determinism, behavioral skills, expectations, and expectancies were the primary constructs that guided the intervention. Observational learning was addressed through multiple guest speakers who shared personal histories of negative body image, chronic dieting, disordered eating patterns, and their journey towards becoming intuitive eaters. Through journaling assignments, assigned readings and class discussions, students were encouraged to assess their environment for barriers and motivators (reciprocal determinism) for improving body image, adopting mindful eating strategies and enjoyable physical activity. Students were taught the benefits and barriers (expectations) of taking a weight-neutral approach towards self-care. In addition, students learned strategies for becoming a mindful eater and even practiced eating mindfully during one of the lectures (behavioral capability). Finally, students were asked to develop a video that explains the advantages of the HAES approach with others (expectancies) and obtain feedback from friends and family members on this alternative paradigm.

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Data Analysis

Data were analyzed for participants in the intervention (n=45), control (n=46), and comparison (n=66) groups who completed both the pre and post surveys using SPSS version 19.0. Descriptive statistics and frequencies were used to analyze continuous and categorical demographic data. Differences in baseline characteristics were compared using a Pearsons Chi Square analysis and Kruskal-Wallis H nonparametric test for categorical and continuous variables, respectively. Analysis of Variance (ANOVA) was used to examine differences between pretest scores and subscales among the three groups. Within group differences were assessed using paired t tests. ANOVA was used to study the treatment effect and compare mean scores among the three groups. The Tukey test was used for post hoc analysis of significant factors from the oneway ANOVA. An independent sample t test was used to compare the means within the intervention group and determine if there was any difference in the pre to post test scores, since a different professor taught each semester. For all tests P values less than .05 (two-tailed) were considered significant.

RESULTS

Subject Characteristics

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Of the 241 students enrolled in either the HAES nutrition class or one of the basic nutrition classes taught at either the 4-year university or community college, 157 (65.1%) completed the study. Table 1 reports the demographic details. A significant difference was found between the three groups for age (P < 0.000), as well as reported majors (data not shown). No significant differences were found for all other baseline characteristics, including selfreported BMI. Between the three groups, there were no significant differences at baseline for IES-2 total scores, for the subscale eating for physical not emotional reasons, or for the CBDS, the BES subscales appearance, weight, and attribution, and for AFA scores (Table 2). A significant difference was found in the pretest scores for three of the IES-2 subscales, including unconditional permission to eat (P = 0.049), reliance on hunger (P = 0.008), and body-food choice congruence (P = 0.040).

Impact of HAES Curriculum

There was a significant improvement in the mean IES-2 total scores for the students in the HAES class compared to the traditionally taught nutrition class (P < 0.001) and the class with some HAES content (P < 0.001) from pre to post. On the unconditional permission to eat subscale and reliance on hunger subscale, HAES students scored higher than students in the traditional class and the class with some HAES content from pre to post (P < 0.001) for each comparison. No significant differences were found between the three groups for the eating for physical not emotional reasons and body-food choice congruence subscales.

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Students in the HAES class experienced significant decreases in CBDS scores than students in the traditional class (P < 0.001) and the class with some HAES content (P < 0.001) from pre to post. Students in the class with some HAES content also scored significantly lower on the CBDS scale when compared to the traditionally taught class (P = 0.022). Students in the HAES class experienced significant increases from pre to post on the Body Esteem subscale appearance compared to the control (P = 0.006) and comparison group (P = 0.040), as well as the weight subscale compared to the control (P < 0.000) and comparison group (P = 0.007) from pre to post. No significant differences were found on the Body Esteem attribution subscale. The AFA scores of students in the HAES class decreased significantly compared to the control (P < 0.001) and comparison group (P = 0.007) from pre to post. It is noteworthy that all mean scores that changed between pretest and posttest, changed within the predicted direction based on the instrument used. There were no significant changes in BMI between the three groups from pre to post-test. Furthermore, a within group analysis showed no significant difference between the students scores within the intervention group from the Fall 2012 to Spring 2013 semesters.

DISCUSSION

Students in the HAES course experienced positive improvements on intuitive eating and mindful eating, suggesting that they adopted concepts learned in class. Positive outcomes, in

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regards to attention to hunger and fullness cues to guide eating as a result of a HAES-based intervention, have also been reported by others (Bacon et al., 2002; Bacon et al., 2005; Provencher et al., 2007; Provencher et al., 2009; Robinson, Putnam & McKibbin, 2007; Steinhardt et al., 1999, Bacon & Aphramor, 2011). Students in the HAES general education class experienced significant improvements in intuitive eating as a whole as well as unconditional permission to eat and reliance on hunger. This finding is consistent with previous studies that involved teaching individuals to listen to their bodies and eat when they are hungry, while recognizing what foods they desire to eat and allowing themselves to satisfy this hunger (Neyman 2011, Tylka 2012, Neyman 2010). However, a significant difference was found for the pretest scores between the three groups for these two subscales. Students in the class with some HAES content had significantly higher IES-2 scores on the pretest compared to the HAES and traditionally taught class. The 16-week course curriculum based on the HAES tenets led to greater change on the scales measured than merely incorporating a few concepts into a traditionally taught nutrition course. There was no difference found from pre to post-test for the IES-2 subscale eating for physical rather than emotional reasons between the three groups; however, since this intervention only lasted 16-weeks, further research is needed to determine if these changes are made at a later point in time following the intervention. Furthermore, since an improvement was not seen on all scales and subscales, this type and length of intervention may be effective for individuals whose eating and dieting behaviors and body esteem are not fully entrenched, as suggested in previous research, and a more aggressive or longer intervention may be necessary for those whose food and body esteem issues are more set (Hawks, Madanoat, Smith & Cruz, 2008). The body-food choice congruence subscale addresses the perception of food choices and

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health consciousness. This subscale was also meant to analyze body acceptance, which is another change that may require a longer-term intervention and will require further research. No significant changes were seen in this study between groups, suggesting that accepting ones body is extremely challenging during the young adult years and responds little to group-based interventions. Related to body acceptance, the Body Esteem Scale subscales for appearance and weight did increase as a result of the intervention. However, the attribution subscale, which analyzes how one perceives others evaluations about their own body and appearance did not change. In a study that evaluated the impact of an elective college course on dieting levels, eating styles, and body image among college students the researchers found that students had very little changes in their BES attribution subscale scores from pre to post-test, regardless of their current dieting behaviors (Hawks, Madanoat, Smith & Cruz, 2008). It may be that group settings are not the best intervention setting for college students, reflecting the sensitive nature of this topic that is also highly individualized. Research by OBrien suggests that body dissatisfaction is related to increased anti-fat attitudes (OBrien 2013). Since this study examined body dissatisfaction among college students it was hypothesized that as body satisfaction increased, anti-fat attitudes would decrease. Findings supported this hypothesis and students in the HAES class had a significant decrease in their anti-fat attitude scores compared to the other two groups. Contrary to previous research, BMI was not a factor in improved anti-fat attitudes or body satisfaction in the current study (OBrien 2007, OBrien 2010). Limitations of this study include the small convenience sampling and the quasiexperimental research design. There was a significant difference in the ages of the three groups,

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as the students in the community college course had a mean age of 23 years compared to 19 years for the intervention and comparison groups. More than half of the students were female, though many of the instruments used are primarily validated among female populations (Tylka 2012, Martz 1996, Mendelson 2001). In addition, more than two-thirds of students were Caucasian, decreasing the generalizability of results. All data were self-reported including weight and height values. Finally, this study lacks long-term follow-up data and it is unknown if changes would be maintained following the intervention. Teaching the HAES paradigm to a young population enrolled in a general education course led to significant changes in attitudes surrounding dieting, eating and body image in this sample. This study utilized several validated instruments to examine aspects of attributes promoted by various non-diet approaches and included a comparison and control group. While the CBDS scores did decrease in the comparison group, the decrease in dieting was the only significant finding with the group that received a shorter 3-lesson curriculum on HAES tenets. These results suggest that an entire course on the topic is necessary in order to see improvements in attitudes about eating and body image. Finally, based on these findings, introductory nutrition courses taught using a traditional weight-focused paradigm do not result in improvements in intuitive eating, body esteem, or anti-fat bias, nor reduce the incidence of dieting.

IMPLICATIONS FOR RESEARCH AND PRACTICE

This study demonstrated that an entire academic course on HAES-related topics is a

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viable way to expose students to a weight-neutral paradigm and empower them to critically evaluate the impact of the diet industry on weight attitudes and how it is reflected in their own lives. This study involved an intense 45-class hour (plus homework) intervention lasting 16 weeks and led to significant changes in eating and body image. However, future research could explore the questions: Does a longer intervention focusing on HAES practices have a greater impact on emotional eating behaviors and attribution? What are the long-term effects of a HAES intervention on college students? What are the effects of a HAES intervention on a more diverse population or on a specific college population, such as dietetics students? General education nutrition courses have an opportunity to teach students how to adopt and promote a sustainable approach to healthy eating. Nutrition instructors can teach students to become aware of their own eating behaviors and challenge messages or perceptions that may negatively affect attitudes about body weight and eating. Teaching the HAES paradigm to college students may not only benefit the student, but future patients and clients of those who pursue health professions. Students exposed to HAES concepts gain the tools to promote a healthy, weight-neutral approach to eating, physical accountability and respect for diverse body shapes and sizes. Improving the intuitive eating scores, dieting behaviors, and body esteem of college students may lead to decreased incidence of disordered eating while also decreasing the anti-fat bias often seen among the general public and health practitioners.

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