T Price Special Problem

Running Head: FOOD INTAKE COMPARED WITH PERCEPTIONS OF HEALTHY
EATING AND NUTRITION KNOWLEDGE

Utilizing the ASA24 in College Students to Compare Food Intake with Perceptions of Healthy
Eating and Nutrition Knowledge
Theresa Price
The University of Southern Mississippi


Introduction
The number of obese and overweight adults in America is alarming, with as many as 3
out of 10 adults, aged 20 or older, being classified as either overweight or obese (Ogden,
Carroll, Kit, & Flegal, 2012; Sparling, 2007). The continued increase in young adults who are
considered overweight and obese is disturbing because being overweight or obese puts these
individuals at a higher risk for many chronic diseases such as heart disease, diabetes, stroke,
hypertension, and cancer (Franko et al., 2008; Kopelman, 2000).
Poor dietary intake such as increased portion sizes of higher-fat, sugar, sodium, and
calorie dense foods, in combination with lower fruit and vegetable intake are all contributing
factors to becoming overweight and obese (Burger, Kern & Coleman, 2007; Frankenfeld,
Poudrier, Waters, Gillevet, & Xu, 2012; Franko et al., 2008; Ha & Caine-Bish, 2009; Kocken et
al., 2012; Kolodinsky, Harvey-Berino, Berlin, Johnson & Reynolds, 2007). Unfortunately,
these risky and life threatening dietary behaviors have become commonplace among many
college-age adults. Many colleges and universities in the US offer general nutrition; however,
many students are not required to take the course as part of a general curriculum (Pearman et al.,
1997). A report by Ha & Caine-Bish (2009) and one by Franko (2008) indicated that college
students who were enrolled in a general nutrition course were more likely to increase fresh
fruits and vegetable intake as well as decrease fried food intake.
Research has indicated that perceptions of healthy eating may determine ones nutrition
beliefs and also influence dietary intake; therefore, assuming that if an individual has a poor
perception and attitude about healthy foods then that individual may have a poor dietary intake
as well (Burger et al., 2007; Ferguson & Bargh, 2004; Lake et al., 2007). Studies have shown
the more nutrition knowledge a person has, the more likely that individual will have healthy

eating patterns and a lower body weight (Byrd-Bredbenner & Finckenor, 2001; Fahlman, Dake,
McCaughtry & Martin, 2008; Franko et al., 2008; Kolodinsky et al., 2007; Marietta, Welshimer,
& Anderson, 1999).
Several researchers have examined college students consumption patterns related to the
students nutrition knowledge (Anderson, Shapira, & Lundgren, 2003; Burger et al., 2007;
Byrd-Bredbenner & Finckenor, 2001; Crawford, Obarzanek, Morrison & Sabry, 1994; Fahlman
et al., 2008; Frankenfeld et al., 2012; Franko et al., 2008; Ha, Caine-Bish, 2009; Kolodinsky et
al., 2007; Marietta et al., 1999). However, these studies utilized traditional methods of dietary
analysis and there have been no studies using a validated web-based 24-hour recall as a measure
of dietary intake. Weight status, perceptions of healthy eating, and nutrition knowledge of
college students are of particular interest.
Prevalence of Obesity in College-age Adults
Body Mass Index (BMI) is a number calculated from a persons weight and height and is
a fairly reliable indicator of body fatness for most people. BMI is used as a screening tool to
identify possible weight problems for adults. Using BMI as an indicator, research has shown
that nearly 150 million Americans were classified as overweight and of those, 75 million were
considered obese (Roger et al., 2012). Higher BMI and waist circumference in younger adults
indicates higher risk of obesity and mortality as they age (Engeland, Biorge, Tverdal, & Sogaard,
2004). Likewise, research has indicated that overweight adolescents have a 70% chance of
becoming over weight adults (Ogden et al., 2012). Poor nutritional habits that are formed in
young adulthood have increasingly shown to be a risk factor for future obesity (Engeland,
Biorge, Tverdal, & Sogaard, 2004; Morrell Lofgren, Burke, & Reilly, 2011; Ogden et al., 2012).

In an effort to decrease obesity, some researchers have hypothesized ways to improve
activity and nutrition knowledge such as, implementing courses about maintaining and achieving
healthy weights with information on nutrition, physical activity, energy balance, and time
management; promotion of public speakers who are highly involved with nutrition and fitness,
improvement of physical education classes, promotion of walking on and around campus, and
promotion of healthy foods on campus (Sparling, 2007).
A college students freshmen year of college is typically a significant period for weight
gain and in a study by Anderson and colleagues (2003), college students weight was evaluated
three separate times during their freshman year of college. Researchers concluded that there was
a significant increase in weight from the first evaluation to the second (p<0.01) and less
significant from the second to the third (p>0.05). Some factors that affect students during the
freshmen year of college include moving away from home, purchasing their own food items,
consuming less home-cooked meals, and more fast food or readily available items from vending
machines or a la carte, late night snacking, alcohol-related eating, eating because of stress or
boredom, financial independence, and decreased activity due to adjustments to a new schedule,
poor weather, lack of time and motivation, less social support for exercise (Greaney et al., 2009;
Nelson, Story, Larson, Neumark-Sztainer, & Lytle, 2008; Nelson, Kocos, Lytle, & Perry, 2009;
Walsh, White, & Greaney, 2009).
At least 300,000 deaths each year in the US are attributed to obesity (Morrell et al.,
2011). A study conducted by Morrell and colleagues (2011) collected data from college age men
and women (n=2,103). The participants in this study filled out a questionnaire and health record
to determine demographics and health status, then went to a testing facility twice to determine
anthropometrics, biochemical and clinical variables, and participants also filled out a 3-day food

record. Nearly half (46.9%) of men and a third of women (27.2%) in the study were considered
obese. Low HDL (30.6% of men and 23.7% of women) and high blood pressure (62.1% of men
and 21.2% of women) were the most common Metabolic Syndrome indicators identified in this
study.
A cross-sectional study conducted by Greene and colleagues (2011) collected data on
college students (n=1,689) aged 18-24, who wanted to lose weight with a three-month nutrition
and exercise intervention. Nearly a third (28.9%) of all students were considered overweight or
obese, and 58.7% of the obese women and 3.0% of overweight men had increased health risks
due to elevated waist circumferences.
Studies have suggested awareness of the weight gain period is critical during a college
adults freshman year of college. Likewise, being aware of college-age adults barriers to healthy
eating may increase the effectiveness of weight related education for this population (Anderson
et al., 2003; Greaney et al., 2009). Research has also suggested that college-age adults do not
consider proper nutrition and exercise as high priorities despite having extra time, desire to
exercise more frequently, and having exercise expectations. Researchers theorized that college-
age adults do not maintain proper eating and regular exercise due to poor time management,
satisfaction with body image, and feelings of laziness (Strong, Parks, Anderson, Winett, & Davy,
2008). Recent research found that eating patterns and physical activity patterns are shaped by
many factors including gender differences, motivation, self-regulatory skills, and social and
physical environments (LaCaille, Nichols Dauner, Krambeer & Pedersen, 2008).


Perceptions of Healthy Eating in College-age Adults
While perceptions of healthy eating by college-age adults have been studied in the past,
this topic remains an important focus for research because perceptions have been shown to
influence behaviors. Researchers have linked perceptions of a healthy diet with attitudes and
beliefs as building blocks for a persons behaviors, which may in turn determine a persons
actions (Lake et al., 2007). Ferguson and Bargh (2004) asserted that perceptions are learned
from a persons experiences and knowledge, which continue to evolve based on conscious
choices, potentially leading to specific actions. Several researchers have suggested that if
healthy food items that are seen as unappetizing can be altered to show the benefits to health and
also appear appetizing, then college-age adults may choose these foods which may in turn lower
obesity and disease risk related to poor intake (Burger et al., 2007; Ferguson & Bargh, 2004;
Lake et al., 2007).
Some research has shown that overweight and obese individuals have inaccurate
perceptions regarding portion sizes resulting in an excess intake of calories, which in turn may
lead to obesity. Burger and colleagues (2007) conducted a quasi-experimental study in order to
determine the relationship between participants perceptions of portion sizes and BMI. There
were 51 participants recruited by email and telephone, that met criteria of 18 years of age, were
currently a student of the University, spoke and read English, and were willing to spend three
hours participating in the research. Instrumentation used in this study included a 24-hour dietary
recall, assessment of disordered eating and dietary restraints, assessment of the familiarity,
hunger, and liking scale, and self-reported health, demographics, and anthropometrics. All
participants chose larger portion sizes for 10 out of 15 food and beverage choices and those with
a BMI greater than 28 had larger portion sizes than those with a BMI less than 28. This research

illustrated the need to educate college age adults about controlling portions and healthy eating
behaviors.
Recent research showed that college students gather most of their nutrition information
from the Internet and are more likely to be affected by food advertisements. Lee, Jin, Fowler,
and Yuan (2011) collected data from college students (n=161) that showed a significantly
different (p=0.05) mean value for participants perception of nutrition value between normal
foods and healthy foods. Researchers also determined that participants generally described
healthy foods using the phrases low-calorie food (o=.869), low greasy food and healthy
drink (o=.764), and low cholesterol (o=.734).
Research conducted by Lake (2007) looked at healthy eating perceptions in relation to
eating practices. There were 197 participants in this study who volunteered as a follow up from
the ASH30 longitudinal study. Respondents completed two three-day food records, an
interview, and a questionnaire. The questionnaire asked respondents to agree, disagree, neither
agree, or neither disagree to the statement My eating patterns are healthy, among five food
categories, including breads, cereals, and potatoes, foods containing sugar and fat, fruits and
vegetables, meat, fish, and other protein, and milk and dairy foods. The participants who agreed
with this statement had the highest intake of fruit and vegetables and the lowest intake of fat,
sugar, and meat. The participants who agreed also had a lower BMI and a higher socio-
economic status. Over half (54%) of the participants stated that a balanced diet was part of
healthy eating, and more than one-third (34%) said, nutrients were important. Participants were
asked to state what healthy foods meant and over half (51%) stated fruits and vegetables ,
nearly half (49%) stated low fat , and very few (16% and 14%, respectively) stated fiber or
fresh food products as terms for healthy foods. On the contrary, over half (55%) of participants

said fat, 19% stated confectionary (8%) stated salt, and 5% stated processed foods were terms for
unhealthy items. These findings indicate that perceptions of healthy intake and measured food
intake are significantly associated and adults with a higher education and economic status
generally have a lower BMI which may indicate healthier eating behaviors.
Various factors determine college students selection of food and these diets rarely meet
dietary recommendations for the consumption of nutrients. Research presented by Davy (2006),
studied the difference in dietary trends, eating habits, and nutrition assessment in college
students at a Midwestern university. Participants (n=286) were recruited from a general nutrition
course. Participants completed a 21 question survey that assessed anthropometric measurements
and specific diets such as Atkins, Weight Watchers, low-fat, low-carbohydrate, and South Beach.
Men were higher in weight, height and BMI; more men had never tried a diet in the past
(p<0.0173). Women were significantly lower in height, weight, and BMI (p=.0001); more
women had tried low-fat (p=0.0285) and low-carbohydrate diets in the past (p=0.0075).
Significantly more women had tried a diet compared to men (p=0.0173), also more women
gained nutrition knowledge from family (p=0.0033) and media (p=0.0345) than men.
Significantly more women reported too much sugar in the diet (p=0.0157), that it is important to
lower carbohydrate consumption (p=0.0077), and important to lower fat consumption (p=0.0194)
in order to lose weight. Nearly all participants (94.4%) stated it is important to eat a variety of
foods for good health, but a significant amount of women stated a desire to lose weight
(p=0.0001). This study shows that college men and women related to some nutrition issues
differently yet specific diet choices showed few significant differences between the genders for
satisfaction with diets and current diet practices. Researchers concluded that when developing
nutrition education, gender differences should be taken into account.

Another study conducted by Byrd-Bredbenner & Finckenor (2001) determined college-
aged womens eating patterns. A total of 91 participants aged 17 to 30, volunteered for the self-
report survey. The six-part survey assessed fat and fiber intake, fat avoidance, and knowledge
concerning diet and disease. Only 26 of the 91 participants reported consuming the
recommended fat intake of 30% or less, and all participants reported consuming less than the
recommended fiber intake of 25 to 35 grams a day. Nearly 60% of the participants reported
avoiding high-fat foods with a higher knowledge score with diet and disease. When researchers
asked if participants would change their current dietary intake if they knew it was high in fat
content nearly all participants (93%) stated they would make dietary intake changes to reduce the
amount of fat. This study concluded that college-age women had diets low in fiber and higher in
fat than what is recommended but would change the current eating habits if more aware of the
high-fat food items.
A recent thesis conducted by Timken (2012) reported that women living in a sorority
house (n=38) enjoyed the unhealthy foods being served such as chicken strips and French fries
but nearly all residents (90%) stated they wish there were healthier options also served. Despite
what the students reported they wanted, there was not a decrease in unhealthy food consumption
when healthier options were offered. Throughout the study, students became more satisfied with
the menu changes and the incorporation of healthy meals from the first survey to the third survey
(p=.002).
Renner, Knoll, and Schawarzer (2000) examined the degree to which nutrition-related
beliefs are based on objective health indicators such as age and body weight. Researchers
reported that age and body type may make a difference in beliefs and nutrition behaviors.
Participants (n=1,583) completed two separate questionnaires; the first survey contained five

questions to help determine health and risk perception and the other consisted of 20 items to
assess outcome expectancies, self-efficacy, behavioral intentions, and nutrition behavior. Out of
the 371 participants under 31 years of age, 43 participants were considered overweight and 35%
reported to have less than excellent health. Unfortunately, the number of those who reported
being interested in adopting a low-fat diet (37.2%) and practicing preventive nutrition (18.9%)
were relatively low. The older adult categories scored higher in preventive nutrition, intention to
adopt low-fat nutrition, perceived self-efficacy, positive outcome expectancies, and overweight
status. This research illustrated that younger adults may have lower rates of overweight and
obesity but do not perceive themselves at risk for becoming overweight or feel there is a need to
eat a lower-fat diet because of functional optimism and lack of perceived vulnerability.
Researchers also stated that health risk perception is a starting point for health behavior change
and it sets the stage for outcome expectancies and increased self-efficacy.
Nutrition Knowledge Among College Students
Many college students are surrounded by foods with high fat, sugar, sodium, and calories.
Fortunately, evidence has shown that college-aged students who have higher levels of nutrition
knowledge will have an increased intake of vegetables and fruits and a decreased intake of less
healthy options (Dooley, Novotny & Britten, 1998; Fahlman et al., 2008; Franko et al., 2008;
Kolodinsky et al., 2007; Marietta et al., 1999). After individuals increased nutrition knowledge,
positive actions were noted and included utilization of food labels, increased consumption of
fruits, vegetables, and other health promoting foods, and increased confidence to make healthier
choices in the future. The Healthy People 2020 objectives (USDA, 2012) stated that knowledge
is a contributing factor in influencing diets, which further emphasizes why knowledge and
perceptions are imperative to study in this population.

Research conducted on college students by Peterson and colleagues (2010), was to
determine if short-term interventions could achieve improved selections of healthful foods.
Researchers recruited 104 students to take pre and post surveys to see if there was an increase in
healthful food choice knowledge. Over 20% of participants stated they were more aware of
healthy food choices since the three-week intervention. This study was helpful in providing
evidence that many students do learn from a short intervention in dining halls that involve
showing them what foods are proper for their nutrition and what foods to avoid.
An article by Marietta (1999), reported research examining knowledge, attitudes, and
behaviors of college students in regards to nutrition labels. Researchers questioned whether
increased education on nutrition labels was useful for students and nutrition labels also
influenced knowledge, attitudes, and behaviors among college students eating habits.
Researchers collected surveys on 208 participants for a descriptive and non-experimental study
design. The survey was created specifically for this research and was designed to measure
knowledge, attitudes, and behaviors. The participants scored nearly half (48%) for the mean
knowledge score. Likewise, the knowledge score positively correlated with attitudes towards
labels (r= .14, p=.04) and the use of labels (r=.87). The students were given both the survey and
a booklet on how to read nutrition labels. The 108 students who had been previously educated
on reading nutrition labels scored higher than the 100 who had not. The students who had
previous education on labels were 80% more likely to read the labels and had higher nutrition
knowledge scores (p=.04) than those who had not. Women were more likely to read the
information label for nearly all aspects of the label more than men. Nearly all participants (95%)
felt nutrition labels were useful and 70% of students reported looking at the nutrition labels when
purchasing the item for the first time. This study concluded that having a positive attitude

toward nutrition labeling was the best indicator to actually using the labels when purchasing food
items. This study provided evidence that students who are educated on nutrition labels are more
likely to read and understand the nutrition facts based on a label.
Research was conducted to determine if adults read and understood the nutrition labels
while grocery shopping (Dooley et al., 1998). A convenience sample of 212 adults, mostly
under 40 years of age (61%) were recruited while grocery shopping. Half (50%) reported
reading the nutrition labels, while only 18% reported sometimes reading the labels and 32%
reported never reading nutrition labels. Participants were asked several questions including
What do grocery shoppers understand or not understand about food labels? What education
materials about labels are needed? and Do the education materials improve shoppers
understanding of the labels? Caucasians reported significantly more use of nutrition labels than
other races (p< .02), while nearly all participants (91%) reported at least one item on the food
label as important. Participants were given a pretest to assess nutrition label knowledge and the
intervention group was given a brochure that provided information about nutrition labels,
grocery list that highlighted key information, and a folder than encouraged participants to use the
nutrition label. All respondents were asked to schedule a follow-up phone interview 10 days
later to assess any increase in nutrition label knowledge. Overall there was an increase in the
amount of adults who reported using labels from pretest to post-test (p=.0001). The control
group (n=110) had 21% of participants answer questions correctly during the pretest and
increased to 25% for the post-test, the intervention group (n=102) had 30% of participants
answer questions correctly during the pretest and increased to 49% during the post-test. This
study suggests that when given nutrition education, adults may increase dietary knowledge and
have a better understanding of nutrition labels.

Another study to determine if nutrition labels were valuable for college-age adults was
conducted by Graham and Laska (2012). Researchers used a cross-sectional online survey to
collect data from participants (n=1201). This study indicates that college-adults who have higher
reported tendencies of reading nutrition labels were more likely to have healthier dietary intakes
compared to college-adults who read labels sometimes or rarely (p<0.001). This study further
supports that higher nutrition knowledge increases healthy eating patterns in college-age adults.
A controlled research study was conducted to determine whether an online nutrition
education program could enhance dietary intake among college students (Franko et al., 2008).
Researchers recruited 476 students from six different universities and then participants were
randomly selected to join an experimental group or a control group. Experimental I participants
(n=165) had two nutrition education sessions, experimental II participants (n=164) had three, and
the control group (n=147) had two anatomy education sessions. Researchers gathered
assessment information at baseline, after the second education sessions, at a three month and six
month follow up. Experimental I group increased servings of fruits and vegetables by .33
servings and experimental II group increased by .23 servings compared to the control group.
Both experimental groups increased nutrition knowledge, had higher motivation to eat healthy
(p<.05), and were more likely to change current dietary habits (p<.05). There were no
significant differences between the experimental groups but the experimental groups were
significantly higher than the control group in reported fruit and vegetable intake, self-efficacy,
encouragement for dietary change, and readiness to change in regards to healthy eating habits.
This study emphasizes that increased nutrition knowledge relates to better eating patterns and
concerns for ones dietary intake.

A review completed by Ferrara (2009) looked over several studies and how researchers
implemented weight loss programs for college-students. According to this review three out of
six research studies had a semester-long nutrition course, one 12-week program, and one weekly
feedback on changes. Each of the studies looked at had weight loss success. Four out of seven
research studies reviewed had participation in class to engage students in physical activity; one
was a 16-week program, one an eight-week program, and one a 24-month program. Each
intervention resulted in participants increasing physical activity, improving attitudes about
exercise, or increased the likelihood to choose an active lifestyle. Ferrara (2009) suggested that
further research be conducted to provide health-related information on campus to encourage
individuals to live a healthy lifestyle.
A cross-sectional study was done in college-age adults to determine if knowledge of the
current dietary guidelines provided better food choices in students (Kolodinsky et al., 2007). A
convenience sample of 193 students, aged 18 to 20 years old, utilized a web-based questionnaire
to determine relationships between self-reported eating habits and nutrition knowledge.
Participation in this study was voluntary and eligibility criteria included first-year students who
would be on a campus meal plan for two years. The web-based survey consisted of self-reported
activity level, intake for the five major food categories (i.e. fruits, vegetables, grains, dairy, and
protein), and perceived importance of dietary guidance. Individuals who consumed more fruit
had a significant difference (F=3.72, p<0.05) and higher amount of food knowledge. Moderate
amounts (37%) of participants were classified as overweight and only one-third of students
reported eating the recommended amounts of daily food intake. Students who reported eating
lower amounts of protein had greater nutrition knowledge compared to those who had lower
knowledge (p<0.001). Those who reported consuming the recommended amount of dairy had

higher nutrition knowledge (p<0.001). Students who reported consuming more than the
recommended amount of fruit scored higher nutrition knowledge than those who reported
consuming less than the recommended amount. Researchers concluded that increased dietary
knowledge positively influences dietary eating patterns.
College students barriers for eating healthy.
Students have reported lack of time, lack of self-discipline, social engagements, social
pressure, and temptation as barriers to eating healthy (Greany et al., 2009; Silliman, Rodas-
Fortier & Neyman, 2004; Stevenson, Doherty, Barnett, Muldoon, & Trew, 2006). College-age
adults have a difficult time foreseeing how these barriers can affect long-term health, but when
nutrition education is provided repetitively, nutrition knowledge may increase and help prioritize
healthy eating.
Research conducted by Stevenson (2006), used focus groups for data collection to
determine main barriers to healthy eating. This study used 12 focus group discussions with five
to eight young adults per group, for a total of 73 total participants. The four main barriers found
in this study were physical and psychological rewards, perceptions of food and eating,
contradictory messages, and issues with the concepts of healthy eating and dieting. Researchers
suggested that the way to approach these barriers is to understand where the issues are derived.
Some of the barriers arise from taste preferences and emotions, self perceptions, and social
pressures. This research supplies data that explains barriers as to why some college-age students
would claim to not eat healthy and also gives insight as to where the barrier derived. This study
concluded that the data collected should provide insight for food-related education in the future.
With this knowledge, nutrition educators can create ways to overcome these barriers and help
this population succeed in making healthier food choices.

Another article by Greeney (2009) also identified barriers for why college students do not
eat healthily or maintain a healthy weight in college years. This study evaluated 16 online focus
groups, in eight states, between eight universities, with 115 participants. All participants were
recruited through email, flyers, and face-to-face meetings. Over half (55%) of participants were
women and 45% were men, 18-24 years of age, and no participants were majoring in nutrition or
exercise science. Respondents filled out a self-report survey on food intake and physical activity
levels as well as demographics, height, and weight. Despite a quarter of the participants (n=29,
25.2%) being classified as overweight or obese, many of the participants reported eating a high
amount of fruits (M=4.2, SD= 2.4) and vegetables (M=3.6, SD=2.1) daily. Both men and
women stated the same barriers to weight management including temptation, lack of discipline,
readily accessible foods, time constraints, and social events. Participants reported semester goals
including improving or maintaining academic standing, being healthy by increasing physical
activity or improving diet, maintaining a social life, and gaining, losing, or maintaining weight;
therefore, half of the semester goals provided by the students dealt with improving health. This
research suggests that students desire to be healthy by improving nutritional intake and
increasing physical activity, but are sensitive to barriers to achieve nutrition goals. This study
concluded that in order to see a behavior change, there needs to be individualized interventions
provided to students.
Research conducted by Silliman (2004) assessed diet and exercise habits and the barriers
to living a healthy lifestyle in college adults. This research gathered 471 participants with a
stratified random sample of upper and lower general education classes. The participants selected
were 18 years of age and older, mostly 18-21 (60%), and over half were women (n=264, 57%).
Students were asked to complete a three-section survey that collected anthropometric and

demographic data, current dietary habits and barriers to eating a healthy diet, and current
physical activity patterns. Thirty-one percent of the sample had a BMI of 25, with 46% of
participants claiming a weight gain (2 to 100 pounds, M=12, SD= 10) had occurred in the last
few years. Breakfast was the most common meal skipped by students, with 8% who never eat
breakfast and 23% of participants who always eat breakfast. Many students (63%) reported
snacking as part of daily usual intake, and stated that boredom, partying, while studying, and
being in an emotional state were the main reasons for snacking. Chips, crackers, nuts, ice cream,
cookies, and candy were the most highly snacked on food items, while most participants reported
lean protein was consumed once a week or less (p<0.041), vegetable (58%) and fruit (64%)
intakes less than once per day, and over half of the students (51%) rated current health as poor or
fair. This study concluded from participant responses that, lack of time lack of money, taste
preferences, convenience, student meal plans on campus, and not caring about healthy eating
were barriers among a college population. Research concluded that students have many reasons
for not eating healthy due to time restraints, money, and food preferences. This study indicates
that interventions should teach students how to build a lifelong healthy diet and exercise habits to
prevent future diseases.
In order to improve nutrition knowledge in college-age adults several factors should be
implemented. Evaluating college students perceptions of healthy foods and knowledge of
healthy foods is a start to improve nutrition knowledge. Once knowledge and perceptions have
been determined, educators may be able to influence students knowledge and therefore
influence nutrition perceptions, attitudes, and actions with continued nutrition education. Lastly,
identifying which barriers students feel are a major conflict to eating healthy may be helpful in

determining how to individualize an intervention so that each person can achieve a healthier
lifestyle, weight, and eating pattern.
Measurement of College Students Food Intake
Three common ways to measure dietary intake include food frequency questionnaires,
(FFQ), food diaries, surveys, and 24-hour recalls. Out of all three dietary intake measures, there
are positive and negative qualities and no one method alone is more accurate than another
(Woteki, 1992). A FFQ is a survey that provides questions asking how frequently a particular
food item has been consumed in recent months. Due to the amount of questions on a FFQ it is
able to cover a wide variety of foods; because there are typically many questions on the
questionnaire, participants may feel this is inconvenient and quit before it is fully completed.
The questionnaire asks how frequently foods were eaten in recent months and it may be difficult
for participants to estimate if they are unsure how to measure portion sizes. FFQs have been
shown to be less accurate in determining exact energy and protein intake in relation to disease
risks (Schatzkin et al., 2003). FFQs are beneficial when researchers are interested in what
participants actually consumed instead of nutrient consumption (Woteki, 1992).
Three-day food records have been shown to provide accuracy when compared to FFQs
and 24-hour recalls. Research indicated that the three-day food record showed lower percentage
of absolute errors compared to a 24-hour recall and a FFQ, and had a lower proportion of
missing foods and phantom foods for the three-day food record, compared to the 24-hour recall ,
and FFQ. If done properly, three-day food records collect an individuals entire intake for three
days. Ideally, a brief overview with a dietitian about the procedures for recording dietary intake
would occur. Then, another session accounting for missing foods and additional items should be
factored in to the cost and time needed to complete these records. Food records are time

consuming and require skill and participation from research subjects. While food records are
good for intervention purposes to show individuals what is eaten and how certain foods and
snacks affect health, they could also have a low participation or high dropout rate due to the
amount of work that is involved from the participant (Crawford et al., 1994). Three-day food
records are more appropriate for assessing a participants usual food intake due to the multiple
days of intake that are collected (Worteki, 1992).
A study conducted by Nelson and colleagues (2009) used the EAT-II survey and the
Youth-Adolescent Food-Frequency Questionnaire to determine college-age adults food intakes.
The survey and questionnaire provided crude and adjusted estimates of food intake. The crude
intake allowed researchers to determine which subgroups were at the most risk and adjusted
estimates allowed them to explore the existence of dietary differences among subgroups. Many
researchers use FFQs or surveys created based off of FFQ questions. Surveys can typically be
modified to ask questions that are more relevant to the population being studied. Several
research studies used FFQs or surveys as a data collection tool to measure college students
dietary intake (Davy et al., 2006; Greene et al., 2011; Kolodinsky et al., 2007; Nelson et al.,
2008; Peterson et al., 2010). Other researchers such as Ha and Caine-Bish (2009) and Lake and
colleagues (2007) used three-day food records to collect dietary intake.
Research indicated that 24-hour recalls yield better quality dietary intakes with less bias
and they are relatively simple for participants, which results in higher preference for use in both
researchers and participants (Subar et al., 2012). The main risk of using a 24-hour recall is that it
relies on the participants memory; respondents may forget certain foods or beverages that were
consumed the day before. In the past, 24-hour recalls were expensive and relied on trained
interviewers, which made them a less preferred tool for dietary intake collection. Today, there

are more researcher and respondent friendly 24-hour recalls, such as the ASA24 (Subar et al.,
2012). The 24-hour recall method has shown accuracy when estimating the intakes of
participants and population groups (Woteki, 1992).
The National Cancer Institute created the ASA24 which is a web-based automated 24-
hour recall that guides participants step by step while entering dietary intake. This 24-hour recall
is public and has free access for researchers, clinicians, and educators. The ASA24 does not rely
on trained interviewers and can be used one time or multiple times; these factors make this
instrument practical and inexpensive for researchers to use (Subar et al., 2012). Data is collected
online from participants and registered into a nutrient database, then can be easily downloaded
after completion, which is convenient for both the researcher and the subjects (Frankenfeld et al.,
2012). The ASA24 is not a typical 24-hour recall and differs in the following ways: automated,
web-based, free access, guides participants through the entire process, collects portion sizes with
food models, automatically uploads data into a nutrient database, asks participants to double
check intake, asks for forgotten foods, asks if intake is typical or atypical, and does not need a
trained interviewer (Frankenfeld et al., 2012). All of these qualities make this a highly desirable
tool to use in a research study.
A recent article written by Subar (2012), explored the ASA24 as a valid and reliable 24-
hour recall when it was first introduced to researchers, clinicians, and educators. Researchers
first collected evidence of the accuracy of a 24-hour recall such as providing high-quality dietary
intake data, minimal bias, and being great for studying disease and diet associations. This
particular 24-hour recall has both a respondent and researcher website that link together. The
respondent website guides the individual through the complete recall. The ASA24 hour dietary
recall is very thorough and asks for complete meals, snacks, and beverages. Not only does it ask

about food and beverage intake, it asks if anything additional was added to the food or drink, the
serving size, how it was prepared, and what additives or condiments were used. This site also
has the participant review intake several times and allows for modifications to the recall for
accuracy. This instrument will also ask the individual if this is a usual intake or an unusually
low or high intake for them. Researchers may also allow for additional questions on
supplements. The researcher website allows the researcher to register, monitor, and manage the
study. After a researcher registers for a study, it must be approved to continue with the study in
the public. Once approval from the ASA24 has been granted, the researcher can upload the
amount of participants expected for the study to generate usernames and passwords for the
respondents login. From the researcher website, the researcher may also download data files for
nutrient information on participants individually or may export the data from all participants.
Subar concluded that the ASA24 has been shown to be accurate in estimating energy, protein,
and nutrient intakes of several samples.
Recent research completed by Frankenfeld (2012) compared nutrient intake data from the
ASA24 to a four-day diet record. This study used a convenience sample targeted at 125 students
that were 18 and older and non-pregnant women. Researchers recruited 123 participants, who
completed both the four-day food record and at least one of the two 24-hour recalls. Personal
and demographic information, as well as health characteristics such as age, race, weight, and
marital status, were gathered from an additional self-report survey. Participants were instructed
to log into the ASA24 respondent website at a scheduled time to complete two 24-hour recalls,
though many participants did not complete both dietary recalls. This study also used the Healthy
Eating Index 2005 (HEI 2005) to estimate diet quality by measuring the following: total fruit,
whole fruit, total vegetables, dark green and orange vegetables and legumes, total grains, whole

grains, milk, meat and beans, oils, saturated fat, sodium and calories from solid fats, alcoholic
beverages, and added sugars. The mean BMI for the population was 24.3 + 4.3 and mean age
was 27 + 11. The researchers concluded that the mean intakes from recalls and records did not
differ significantly for nutrient or dietary measures. The two methods may both be accurate but
the 24-hour recall is less participant-involved and more convenient for the researcher and the
participants. It is sometimes difficult to compare a 24-hour recall with a food diary because both
can measure food intake but some individuals prefer to write down intake for the day versus
recall the previous day, and other participants may like the online version of dietary reporting
instead of tediously writing everything down. This study indicated that ASA24 dietary recall
provides a valid and accurate measure of the nutrient intakes of adult populations.
Further research should be performed to compare college-age adults perceptions of
healthy eating, nutrition knowledge, and dietary actions in order to develop better nutrition
education and interventions for this population. Utilizing the ASA24 is a convenient way to
gather dietary intake from participants and has been shown to provide accurate intakes among
participants. Further data collection and more insight into the dietary attitudes and beliefs of
students may bring more useful education strategies, which may contribute to a healthier campus
and population. This step may assist in reaching the Healthy People 2020 goal of promoting
health and reducing chronic diseases by healthy eating (USDA, 2012).
Research Purpose
The purpose of this research is to compare college-age adults perceptions of healthy eating
and knowledge of nutrition with actual dietary intake from a 24-hour recall in order to test the
feasibility of an automated 24-hour recall and better inform the development of effective
nutrition interventions in this population. The objectives for meeting the goal of this research are

to determine college-age adults nutrition knowledge, determine college-age adults perceptions
of healthy foods, and obtain a usual self-reported food intake with an automated and web-based
24 hour recall. This research will also compare college students dietary intake with perceptions
of healthy eating and nutrition knowledge.
Study objectives will be met by recruiting participants to fill out a survey to determine
perceptions and knowledge of the dietary guidelines as well as demographic information, and by
utilizing ASA24s reliable and validated system to determine participants dietary intakes. The
survey used to determine dietary perceptions, knowledge, and personal demographic information
was created specifically for this research but used perception questions from the study conducted
by Lake (2007), adapted knowledge questions from the Food Knowledge Survey produced by
the Centre for Physical Activity and Nutrition Research at Deakin University, and utilized thesis
survey questions by Paugh (2005).
Literature has stated that college-age adults have reported many barriers to eating healthy
and maintaining a normal weight; however, literature has also indicated that adults who have
more nutrition knowledge are likely to choose healthy food items and less likely to choose
unhealthy foods. Evidence also indicated that adults with increased nutrition knowledge are
more likely to read nutrition labels, have lower BMI, and have higher self-efficacy to choose
healthy food items in the future (Burger et al., 2007; Byrd-Bredbenner & Finckenor, 2001; Ha &
Caine-Bish, 2009; Kolodinsky et al., 2007; Marietta et al., 1999). Research studies show that
perceptions and more importantly knowledge of health risks, overall health status, and health
outcomes relate to how a person selects food (Byrd-Bredbenner & Finckenor, 2001; Gustafsson
& Sidenvall, 2002; Franco et al., 2008; Graham & Laska, 2012; Ha & Caine-Bish, 2009;
Kolodinsky et al., 2007; Marietta et al., 1999; Nelson et al., 2008; Nelson et al., 2009; Peterson

et al., 2010; Renner et al., 2000). Research points toward perceptions of healthy food leading to
a persons nutrition beliefs, which could potentially lead to overall dietary actions; therefore, the
main goal for a nutrition intervention is to change college-age students perceptions to healthy
and positive values on nutrient-dense and higher quality food items in order to reduce obesity
and increase the number of healthy individuals (Ferguson & Bargh, 2004; Filipkowski et al.,
2010; Ha & Cain-Bish, 2009; Lake et al., 2007; Marietta et al., 1999). Skewed perceptions of
portion size and taste quality of healthier food items may negatively impact an adults weight
status with increased portion sizes of high-fat, high-sugar, and high-calorie food items, while
decreasing intake of healthier foods like fruits, vegetables, whole grains, and low-fat dairy
products (Anderson et al., 2003; Burger et al., 2007; Davy et al., 2006; Greaney et al., 2009).
Ultimately, college-age adults are an ideal target population for education about healthy eating.


Methodology
Study Design
In order to assess college-age adults nutrition knowledge, dietary intake, and perceptions of
healthy eating, a survey was designed to utilize the newest methods in collection of dietary intake data
and compare these results to perceptions and knowledge of nutrition. Nearly 60 college-aged adults at a
mid-sized, Southern university were recruited to participate in this descriptive and correlational research.
The University of Southern Mississippis Institutional Review Board approved this project (Appendix A).
Participants and Recruitment
The current research project used a non-probability convenience sample and targeted at nearly 60
adults, aged 18-25, attending The University of Southern Mississippi. Inclusion criteria for participants
included being a current student of the University, aged 18 and older, both genders and any race. People
who are under 18 years of age, University faculty, and people on campus that are not registered students
were excluded from the study. Recruitment occurred on campus and students willing to participate were
given a verbal consent.
Instrument
Two electronic data collection tools were utilized for this research (Appendix B). The first, a
Nutrition Knowledge and Perception Questionnaire (NKPQ) administered on Survey Monkey and
consisting of 35 questions took approximately 7-10 minutes to complete. Next, the Automated Self-
Administered 24-hour Recall (ASA24) to collect dietary intake data took approximately 20-30 minutes to
complete. The NKPQ was created for this project but used perception questions from a study conducted
by Lake (2007), adapted knowledge questions from the Food Knowledge Survey produced by the Centre
for Physical Activity and Nutrition Research at Deakin University, and a thesis study by Paugh (2005).
The ASA24 is a validated, electronic and automated dietary recall created by The National Cancer
Institute (Subar et al., 2012) that uses the multiple pass method and asks for all meals, drinks, and snacks

from midnight to midnight the previous day. The ASA24 also asks for portion sizes, amount eaten, what
was added to the foods, and whether or not this was a typical intake for that day.
The original survey was entered on to Survey Monkeys website. The format goes in order from
12 questions in the nutrition perception section, to 16 questions in the nutrition knowledge section, and
finishes with 8 demographic questions. The perception questions were asked on a 4 point likert-type
scales with answers being: not important, somewhat important, important, and very important. The
nutrition perception questions asked the participant how important is it to them personally to eat each of
the recommended dietary guidelines as well as how they perceive their own health. The knowledge
questions were asked in true or false format with statements such as According to the Dietary Guidelines
for Americans, one should consume 2-3 servings from the dairy group a day. The demographic
questions ask participants for information such as height, weight, age, race, and whether they live on
campus with a meal plan or not.
Procedure
Participants were recruited for the study by the researcher on the Universitys campus. The
participants were able to enter their name to win a $50 gift card to Wal-Mart as an incentive for
participating in the completion of both surveys. Once participants consented to be part of the study the
researcher had two separate tabs pulled up on a notebook computer and logged in with the corresponding
username and password. The participant was handed the notebook computer to respond to the
instruments and began with the Survey Monkey website to complete the NKPQ. Once participants
completed this survey the researcher will direct them to the ASA24. The researcher will be nearby to
monitor the participant and be available for any questions or concerns that the participant may have.
Data Analyses
The variables used in the analyses were drawn from the demographics, NPKQ, and the ASA24.
Each question was entered into a secure database and analyses were conducted using SPSS version 20.

Frequency and descriptive information was used to assess participants demographic information, BMI,
food intake, nutrition perceptions, nutrition knowledge, and dietary intake. The first two objectives for
this study were to determine college students nutrition perceptions and nutrition knowledge, utilizing the
measures of central tendency (mean, median and mode) determined which answer choices had the highest
frequency. The third objective was to obtain usual self-reported food intake estimates of college
students, which was done with an automated 24-hour recall. Dietary intake was reported using measures
of central tendency describing calories, fat, and food groups. The final objective for this study was to
compare college students food intake with perceptions of healthy eating and nutrition knowledge to
determine whether a relationship exists between these variables; therefore, a correlational analysis was
performed between perception questions such as, fruit intake being important to them and their nutrition
knowledge with questions such as, the recommended fruit intake being two to three cups a day, to predict
the intake of fruits from the ASA24.


Results
A total of 53 students completed at least one of the two surveys. A total of 20 participants data
were eliminated because of incorrect participant identification numbers from the NPKQ that did not
match the ASA24 or had incomplete ASA24 recalls. The sample consisted of 33 participants, a majority
of whom were 20 to 23 years of age (64.4%), live off campus (66.7%), do not have a meal plan on
campus (42.2%), were white (73.3%), and female (80%). See table 1 for more demographic information.
Over half (64.4%) of participants stated they were familiar with the current American Dietary
Guidelines, while 20% of participants reported the Dietary Guidelines were personally very important to
follow, 31.1% reported somewhat important and most (44%) of participants reported the Dietary
Guidelines important to follow. Out of all the barriers asked for what could be a reason to not choose
healthy food items, healthy food is not as convenient as other food options was considered the most
common barrier (66.7%), being too expensive was considered the second most common barrier (55.6%),
lack of time to cook was the third most common barrier (53.3%). Nearly half of participants ranked their
eating patterns as healthy (40%), and rated their health as good (42.2%). Over half of participants had a
college course in nutrition (68.9%), while 44.4% had received nutrition education from a dietitian or
nutritionist.
Knowledge Results
Most participants answered correctly to all of the knowledge questions asked in the NPKQ.
Over half (53.3) of the participants answered correctly to the statement that one should consume 6-8
ounces from bread, cereal, rice, and pasta, 80% answered that one should consume 2-3 cups from the
fruit group a day, 62.2% responded that one should consume 3 cups from the dairy group a day, 71%
answered that one should consume 5-6 ounces from the meat group a day, 60% stated that 60% of
calories should come from carbohydrates, 95.6% stated that tofu, nuts, and beans are good sources of
protein, 84.4% stated the recommended amount of fiber is 25g per day, 71.1% answered correctly what
fat was most important to limit in your daily diet, 80% answered correctly which dairy food was

recommended for adults to consume in a healthy diet, 86.7% answered correctly which was the least
healthy method of cooking protein, 95.6% answered correctly which was the least healthiest way to cook
vegetables, and 91.1% answered correctly which bread contains the most fiber.
Actual Intake
The 33 participants calorie intake ranged from 313 calories to 3949 calories in a single 24-hour
period. Their protein ranged from 4 grams to 255 grams, total fat ranged from 8.3 grams to 175.2 grams,
and carbohydrates ranged from 0 grams to 380.6 grams. See table 1 for more means and standard
deviations on actual intake data.
Correlational Data
A significant positive relationship was found between participants who reported being familiar
with the Dietary Guidelines and those who stated it is important to follow the Dietary Guidelines (r=.334,
p=.025). Reported healthy eating patterns were significantly positively associated with self-rated health
status (r=.422, p=.004) and familiarity with the Dietary Guidelines was significantly related to previous
nutrition education (r=.402, p=.006). Participants who stated it was important to control portion sizes
there was a significant relationship or correlation----difference has to be tested with a t-test---- in
calories(r=.460, p=.007), protein (r=.489, p=.004), and carbohydrates (r=.482, p=.004; table 2).
Participants who reported healthy eating patterns had a significant with added sugar intake (r=.361,
p=.039). Weight had a significant with the knowledge question regarding the healthiest way to cook
vegetables (r=.364, p=.015) as well as gender (r=.323, p=.032).

Table 1

Demographic characteristics of sample

Age
Frequency Percent
18 4 8.9
19 3 6.7
20 11 24.4
21 6 13.3
22 7 15.6
23 5 11.1
24 3 6.7

Living on Campus

Yes 15 33.3
No 30 66.7

Meal Plan

Yes 19 42.2
No 26 57.8

Gender

Male 9 20.0
Female 30 80.0

Race

White 33 73.3
Black 10 22.2

Mean SD
Height
Feet 5 .6
Inches 5 2.9
Weight 146.9 36.2
Calories 1673.4 881.9
Protein 68.2 44.7
Total Fat 66.1 40.6
Carbohydrate 201.9 109.7


Note. = p<.10,
*
= p<.05,
**
=p<.01,
***
=p<.001. N=96 for all analyses.

Table 2

Correlations between Students intake, knowledge, and perceptions

Kcal Total Fat Carbohydr
ate
Protein

Students Knowledge

Previous nutrition education -.456
**
-.468
**
-.342 -.359
*

Students Perceptions

Important to control portion
sizes
-.460
**
-.230 .468
**
-.489
**


Discussion/Conclusion
Participants who reported they were familiar with the Dietary Guidelines reported that the
guidelines were either somewhat important, important, or very important to follow. Individuals
who reported familiarity with the DGAs also more frequently reported having nutrition
education and reported lower total calorie intakes. These findings can be compared to
conclusions by Lake et al. (2007) where participants who perceived the DGA's were important to
follow actually reported lower overall nutrient intakes. Interestingly, students who reported that
controlling portion sizes was important had lower reported intakes for calories, protein, and
carbohydrates and those who reported having previous nutrition education had lower calories,
protein, and fat intakes. Likewise, conclusions of this study are similar to those of Burger et al.
(2007), Ferguson and Barch (2004), and Lake et al. (2007) which all point to the fact that
perceptions of healthy eating may determine ones nutrition beliefs and influence dietary intake.
Studies such as Byrd-Bredbenner and Finckenor (2001), Fahlman, Dake, McCaughtry and
Martin (2008), Franko et al. (2008), Kolodinsky et al. (2007), and Marietta et al. (1999) have
also reported that increased nutrition knowledge will make them more likely to follow healthier
eating patterns. In the current study, students who agreed with the statement about having a
healthy eating pattern also rated their health status as good; therefore, suggesting that students
who believe they eat healthy also believe their overall health is good. Similar to Lake et al.
(2007) who reported that participants who stated they had healthy eating patterns also had lower
intakes of sugar and fat and higher intakes of fruits and vegetables, the current study showed
those who reported having a healthy eating pattern had lower intakes of added sugar and those
who knew the recommended amount of fiber had higher intakes of vegetables.

Differences in gender and weight status were significant with regards to the knowledge
question about the healthiest way to cook vegetables. This statistic is similar to Davy (2006) and
Byrd-Bredbenner and Finckenor (2001) that stated women were generally more health conscious
then men, and also similar to Byrd-Bredbenner and Finckenor (2001), Fahlman, Dake,
McCaughtry and Martin (2008), Franko et al. (2008), Kolodinsky et al. (2007), and Marietta et
al. (1999), who stated that those who have more nutrition knowledge are more likely to have
healthier eating patterns and a lower body weight. In this study, over half of participants
answered the questions correctly to every knowledge question asked in the NPKQ and over half
of participants had a previous nutrition course. These statistics show similarities in previous
research conducted by Dooley, Novotny and Britten (1998), Fahlman et al. (2008), Franko et al.
(2008), Kolodinsky et al. (2007), and Marietta et al. (1999) by indicating that higher levels of
nutrition knowledge positively affects their healthy eating perceptions to follow the Dietary
Guidelines while lowering their overall intake of calories, fat, protein, and carbohydrates
Similarly to Greany et al. (2009), the major barriers to healthy eating identified from this
study included things such as healthy food is not as convenient as other food options, healthy
food is too expensive, and lack of time to cook.
Implications for Dietetic Professionals
The current study provides statistically and clinically significant results regarding
college-age adults perceptions of healthy eating and knowledge of nutrition with actual dietary
intake from an automated dietary recall. This research also tested the feasibility of using the
ASA24 in this population. This study is unique from other research conducted on college age
adults because it uses an original survey and the ASA24 to determine college students
knowledge, perceptions, and usual dietary intake.

Strengths and Limitations
The current study has several strengths. First, utilizing a 24-hour recall that has not been
previously used in college adults is innovative. Secondly, merging the ASA24 dietary recall and
the NPKQ is an important consideration as two separate databases were used to gather the
information. For future studies it would help to quickly and effectively download, analyze, and
evaluate participant dietary recalls and NPKQ survey data. Limitations of the study included a
small sample size and a convenience sample from only one mid-sized University. These limit the
generalizability of the study significantly. Additionally, some questions were not validated prior
to use which may have been a weakness to the study since they were not previously tested within
this population.
Suggestions for Future Research and Conclusion
Future research is needed to determine which foods play the biggest role in affecting
health in this population and also which intervention strategies are most effective in increasing
fruit and vegetable intake while decreasing foods that adversely affect students health. Studies
like this would require more information from students than simple surveys by obtaining focus
groups to actively engage students and gather insight from their perspective. Gathering a
broader sample and increasing the sample size would also be favorable to future research.
Overall the study suggested that college age adults who reported previous nutrition
education and nutrition courses scored higher on nutrition knowledge. Participants reported
being familiar with the DGAs and the higher nutrition knowledge score the participant had, was
related to reported importance of personally following the DGAs. Those with higher nutrition
knowledge reported fewer overall calories, protein, and total fat. In conclusion, if students

reported that they perceived that it was important to control portion sizes they were more likely
to have lower intakes of overall calories, protein, and carbohydrate intake. Dietetic professionals
should take the evidence provided from this study into account when creating nutrition education
and intervention materials for this population.


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Running Head: FOOD INTAKE COMPARED WITH PERCEPTIONS OF HEALTHY

EATING AND NUTRITION KNOWLEDGE

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