Fix the mistakes

Youth Identity Formation

As mentioned in the introduction, teens are at the stage where they are creating their own personal identities, and they are doing so while navigating society’s highly obesogenic environment. While health, wellness, and health practices can all be linked to one’s identity, they are not always consciously considered. Many people internalize health behaviors, such as exercise or healthful cooking as parts of their identity, seeing themselves as “the exerciser” or, by contrast, position themselves as opposed to these and instead enjoying seeing themselves as “couch potatoes” or “lazy bums”(Storer, Cychosz, & Anderson, 1997). What people eat and drink have reciprocal effects on identity, where the internalization of one furthers the other, where identity shapes eating habits and what we eat shapes identity (Bisogni, Connors, Devine, & Sobal, 2002). People eat and drink in a social context, and the social influences and pressures of community, and what is communicated through food and drink must be considered (Pollard, Kirk, & Cade, 2002). Cultural factors, traditions, and accepted norms and etiquette, such as how it is unacceptable to serve guests water in many cultures, make statements about health and wealth.

There are also the powerful effects of peer pressure and social norms that affect teens and their food and beverage choices. In a review article, Salvy and colleagues (Salvy, de la Haye, Bowker, & Hermans, 2012) examined adolescent eating patterns and found that when controlling for all other factors, teens tend to eat more with peers than when alone, but that they also tend to eat more with people they know than with people they do not know. They also found that overweight children respond differently to eating with peers than normal weight children. Social modeling also affects food choices, where modeling healthy behaviors by unfamiliar people led teens and youth to eat more of the healthy choices regardless of whether there are unhealthy snacks available, and regardless of their weight status. Finally, Salvy et al. found that image control is often seen to be connected with eating less for both adults and youth, and the authors speculated that this was probably because of the obesity epidemic and intense fat stigma (Salvy et al., 2012). As teens navigate all of these considerations and define themselves, having positive messages and peer encouragement to enact the favored behavior seems like a promising strategy, assuming the communication of water as an identity statement is considered and addressed.

Before beginning to design a campaign to increase water consumption and decrease Sugar Sweetened Beverage (SSB) consumption, or even to change awareness or intent to consume, it was critical to understand how teens viewed health, and particularly healthful versus unhealthful beverage consumption habits. According to recent research examining the NHANES data, 54% of all youth ages 6-19 in the U.S. are chronically inadequately hydrated (Kenney, Long, Cradock, & Gortmaker, 2015). The Youth Risk and Resiliency Survey (YRRS) data from 2013 indicates that 21% of New Mexico teens reported consuming at least one soda per day during the past seven days, and 7.2% reported having at least 3 sodas per day. These numbers differed by gender; 25% of boys reported consuming at least 1 soda per day compared to 17.3% of girls, and 9.1% of boys reported consuming more than 3 sodas per day versus 5.1% of girls (YRRS Risk Behaviors, 2013). However, the YRRS does not ask about any other types of sugary beverages, or water consumption, so these numbers only reflect soda, which the VIVA II focus groups indicated was already a concern for most people in the focus community.

Limited literature exists that specifically focuses on beverage consumption, rather this is usually lumped together with healthful and unhealthful eating practices, where sugary beverages are considered junk food and water is considered part of a healthful diet. Therefore, using diet as a proxy, I explored the literature on youth perceptions of healthful food choices.

Jenkins and Horner (2005) conducted a critical review of the literature and found that adolescent food choices are influenced by hunger, food cravings, food appeal and amount of time to eat, along with media influences, parental influences, cultural and religious factors, the social contexts of eating, convenience, food availability, and a lack of concern about eating healthily. The most frequently cited barriers to making healthful choices were parents not making healthy meals, not eating with the family, and complaints about school food. School food came up in multiple studies, cited as taking too long to get through lunch lines, not liking school food, lack of healthy options at school, or healthy options not tasting good (Goh et al., 2009; Jenkins & Horner, 2005). The Goh study with middle school students found that the barriers exist on several levels. At the environmental level, fast food and convenience store food is readily accessible before and after school. At the family level, parents often model unhealthy eating habits, and also lack sound nutritional knowledge. At the student level, there is a lack of knowledge, awareness, and motivation to eat healthfully (Goh et al., 2009).

A perception study by Block et al. (Block, Gillman, Linakis, & Goldman, 2013) used focus groups with college students in both Louisiana and Massachusetts to understand beverage preferences. They found similar views across states, that taste was the most important factor, followed by price, particularly the one-dollar price point. The students specifically commented on how they bought the large cans of AriZona Iced Tea because it tasted good and only cost one dollar. As with the Croll study, most of the students in this study were unconcerned about health, seeing it as something that was low on their list of priorities, but a concern for the future. For those who were concerned, they also discussed the balance or trade-off effect, of drinking water to have sweets later, or opting for a soda and then not having dessert. Water was seen as important for hydration, but was discussed mostly in terms of a cure for a hangover, or to hydrate before a night out drinking to prevent a hangover, or in terms of price. Students stated that if water costs the same as something with flavor, they would opt for something with flavor, but sometimes chose water if it was free or cheap. Cost was brought up repeatedly as a factor, and students said they would opt for the cheapest option possible as long as it was not too much of a sacrifice in taste. These findings were consistent with what we heard at the VIVA II student focus groups, where teens said they would drink more water if bottled water was available for free, but not if it cost too much.

[there was more content here before this section]

Strategies to Change Youth Health Behavior

[there was more content here before this section]

The Choice Control Change (C3) curriculum was designed for middle school students and used SCT and Self-Determination Theory, with a strong emphasis on self-efficacy and personal agency (Contento, Koch, Lee, & Calabrese-Barton, 2010). C3 is a science and nutrition education curriculum conducted over 24 lessons, taught by science teachers. The study found a decrease in consumption of SSBs, packaged snack quantities, smaller serving sizes on fast foods, increased physical activity, and decreased screen time, but no change on water or fruit and vegetable consumption.

Literature also exists highlighting the perceived inadequacy of palatable water sources at schools, and the perceptions of unsafe tap water in many settings (Bogart et al., 2013; Bogart, Babey, Patel, Wang, & Schuster, 2016; Patel, Shapiro, Wang, & Cabana, 2013). As discussed in the results from the focus groups, we found similar results in Cuba as well, where parents and students were concerned with the taste of the water as well as with water safety. They speculated about the potential of a range of hazards from lead and other minerals to germs. Building on these perceptions, several other studies were conducted with the aim of increasing access to safe, clean, cold, palatable water sources in schools in an effort to increase consumption, although none were in rural communities. A randomized controlled trial using the Theory of Planned Behavior from an under-resourced urban community in Germany found a 1.1 glass of water per day increase in the intervention group as compared to the control (Muckelbauer, Libuda, Clausen, & AM, 2009). For this project, which took place in several elementary schools, fountains were installed, students received water bottles, and teachers were provided with four optional 45 minute lessons to incorporate into their regular lessons over the course of the whole school year.

The lessons focused on water consumption, the body needs and functions for water, and water in the natural cycle. Teachers were also encouraged to organize water bottle filling sessions at the beginning of the school day and at lunchtime. At three months into the year, the teachers introduced a booster session as a motivational unit with goals for the students to try to achieve, and at five months, the students were given new and improved water bottles. In the process evaluation, the researchers found that most teachers only used 1-2 of the lessons. This study also did not find a significant change in SSB consumption, but they did not focus their intervention on SSBs at all, only on the benefits and need for water.

A similar project was done with primary school children in England, but with the focus on decreasing SSB consumption (James, Thomas, Cavan, & Kerr, 2004). It was also conducted over the course of one school year and included nutrition education. The research team delivered several educational sessions and had a song that the students were encouraged to adopt and turn into their own raps, or songs, which were then used in a contest. They also encouraged teachers to continue to use and promote the messages throughout the year. This study resulted in a 0.6 serving decrease in SSBs as well as an increase in water consumption in both the intervention and comparison groups.

References

Bisogni, C. A., Connors, M., Devine, C. M., & Sobal, J. (2002). Who we are and how we eat: A qualitative study of identities in food choice. Journal of Nutrition Education and Behavior, 34, 128–139. https://doi.org/10.1016/S1499-4046(06)60082-1