1 WEIGHT CONCERNS AND WEIGHT LOSS PRACTICES OF BABY BOOMER MEN By CHRISTOPHER KEVIN WIRTH A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGR EE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2010
2 2010 Christopher Kevin Wirth
3 To my Grandma Neeley, who told me I was a star, just like Granddad
4 ACKNOWLEDGMENTS First and foremost, I wish to thank my subjects. Without their time a nd effort none of this would have been possible. I want to thank Kathryn Parker and Amanda Andrade for providing multiple venues for me to collect data. I thank Debbie Lee and Gainesville Health and Fitness for allowing me the time and space to recruit at their facility. I wish to thank Dr. Steven Anton for constantly making contacts for me and constantly brainstorming collection sites. I thank Cassie Howard for being the first to offer subjects and for getting the ball rolling. I also would like to say th ank you to the city of Palatka, Florida for allowing me to collect data at the Blue Crab Festival, needless to say it was a huge success. I want to thank my parents, Patsy and Larry Wirth for always being su pportive of every crazy thing I ha ve ever wanted to take on and for teaching me to never quit anything you start. Because of you, I persevered. I want to thank my brother, Joshua Wirth for moving down to Florida and making this place home. Good times bro. I want to thank Grandma Wirth and Grandma Neeley for their encouragement and support in all shapes, sizes, and denominations, making this process easier along the way. I thank my entire fami ly for their patience while I have been gone. I thank them for always keeping me in their thoughts. It was nice to be missed and I missed them all so much as well. I wish to express my extreme gratitude to the entire Tillman family for being my Florida family, for the home cooked meals, the themed tailgates, and always being a place where I felt welcome. In addition, I thank Mark Tillman, for being someone to look up to. I would also like to thank Dr. Keith Naugle for being someone I could always count on for a place to stay or some much needed advice. Thank you for all the pep
5 no rainbows. A huge thank you goes to Methodist University for employing me the past two years despite being ABD, but having faith that I would finish. Methodist is an amazing place to work, I am very fortunate to b e at such a caring and wonderful university. I wish to thank Kirbie Britt for always having an open couch and for competing with me to leave last. Just having another person in the building kept me going sometimes, thank you Kirb. I thank my buddy, mentor, and department chair, John Herring who encouraged Methodist to hire me. Thank you for easing my schedule so I could write every semester and for redirecting students and committee work away from my office. I appreciate all of the long hours of revisions a nd for constantly encouragi s your turn my friend. I also would like to thank all the wonderful You never let things get too far out of m y mind and appreciate all of your support. And yes, Jasmine, you wi ll be the first invite to the celebratory party. I want to thank my dear friend Nichole Ho uy for helping me more than she wi ll ever know. Your constant comic relief kept the stress at a m inimum. You bring so much good to this world, I want to be like you when I grow up. Love you Phlippy. Thank you to a ll of my amazing friends that I ha ve made along the way, Jared Fries, Jacob Pack, Mike off Dover, Kelley Palmer, Kelley c k for all the daily encouragement, Ultimate Frisbee, and tailgates. I want to thank Kim Hand in particular for always telling me I could be anything I wanted and actually believing it. All
6 of you made an impact on my life and I cherish all the time we spent together. It i s GREAT, to be, a Flo ri da Gator. I would like to thank my friend and officemate, Dr Mike Mann for advice I did not always want but generally always needed. Thanks Mike for teaching me to think outside of the box and to never be afraid to go for it. I would also g me over weekly for dinner. I am lucky to have friends like you and I look forward to another Broncos football season! I wish to thank my friends back home for being patient while I ha ve gone missing for long periods of time and for understanding that while I a m busy they we re never far from my mind. I want to give a huge, but hesitant, thank you to my wolf pack, Ian Walls, Michael McGuire, and Wil l want to encourage your behavior, as you really did more to distract me than anything, you fellas kept me living during this process. You a re my boys, you are I want to thank the University of Florida for being such a wonderful experience over the pa st eight years. I love this campus, and I love being part of The Gator Nation. I wish to thank John Todorovich, who got me started on this path way back in Wyoming and suggested I go into health. I see the connection now Dr. T. I thank Gary Nave for always having something available for me to teach. Those classes helped keep me stay sane my friend. I thank my close friend, classmate, teaching partner, and adopted sister, Dr. Abbie Batia for pushing me the entire way, keeping me organized, and finishing befo re me to motivate me to join her. You and Mark are two of the most amazing people I know, thank you for welcoming me into your lives and making me feel
7 like family. I wish to thank Dr. Barbara Rienzo for her support and for providing me with office space o ver the past two summers. I want to thank Dr. Morgan Pigg for always having an encouraging word and helping me keep things in perspective. I want to thank Dr. Christine Stopka for always being so passionate about your profession. I model my teaching after you Dr. Stopka, thanks for helping me see that if I can do this, I can do anything. Nice shirt by the way. I wish to extend a huge thank you to the unsung heroes of the department, JoAnne McLeary and James Milford. James you made things easy for me, even f rom a long distance. Thanks for caring so much about your students. You got me through two degrees! I want to thank my committee, Dr. William Chen, Dr. Jiunn Jye Sheu, and Dr. Thomasenia Adams for all of their incredible patience and support over the past three years. Thank you for sticking with me and for always being understanding. I could not have picked a better group of people to guide me through this process. Most of all, none of this could have been done without the guidance of Dr. Delores James. Sh e has stuck by me when many doubted that I would finish, kicked me in the rear when I needed kicked, and hugged me when I needed hugged. Thank you for all of the hours of transcribing, for involving me for all of your projects, and for helping me understan d what it is to be a faculty member. More importantly, thank you for teaching me to be a better human being, one who is more accepting and understanding of other cultures. I am grateful to have you as my chair, but I am honored to have you as my friend.
8 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ .......... 11 LIST OF FIGURES ................................ ................................ ................................ ........ 13 ABSTRACT ................................ ................................ ................................ ................... 14 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 16 Research Aims ................................ ................................ ................................ ....... 21 Limitations ................................ ................................ ................................ ............... 22 Assumptions ................................ ................................ ................................ ........... 22 Definition of Terms ................................ ................................ ................................ .. 23 Summary ................................ ................................ ................................ ................ 24 2 REVIEW OF THE LITERATURE ................................ ................................ ............ 26 The Economic Burden of Obesity ................................ ................................ ........... 26 U.S. Overweight and Obesity Prevalence ................................ ............................... 27 The Baby Boomer Generation ................................ ................................ ................ 30 Men and Weight ................................ ................................ ................................ ...... 32 Weight Loss Recommendations ................................ ................................ ............. 35 Strategies Men Use to Lose Weight ................................ ................................ ....... 36 Barriers to Weight Loss ................................ ................................ ........................... 37 Eating Habits of Men ................................ ................................ ............................... 38 Physical Activity Recommendations ................................ ................................ ....... 41 Physical Activity and Men ................................ ................................ ....................... 42 Determinates of Physical Activity in Men ................................ ................................ 44 Health Behavior Theory ................................ ................................ .......................... 47 Transtheoretical Model and Stages of Change ................................ ....................... 48 Precontemplation ................................ ................................ ............................. 49 Contemplation ................................ ................................ ................................ .. 49 Preparation ................................ ................................ ................................ ....... 49 Action ................................ ................................ ................................ ............... 50 Maintenance ................................ ................................ ................................ ..... 50 Termination ................................ ................................ ................................ ...... 50 Stages of Change and Healthy Eating ................................ ................................ .... 51 Stages of Ch ange and Physical Activity ................................ ................................ .. 53 Summary ................................ ................................ ................................ ................ 56 3 METHODOLOGY ................................ ................................ ................................ ... 58
9 Resear ch Design ................................ ................................ ................................ .... 58 Sample Population ................................ ................................ ........................... 59 Instruments ................................ ................................ ................................ ....... 60 Data Collection Procedures ................................ ................................ .............. 64 Data Analysis ................................ ................................ ................................ ... 65 Summary ................................ ................................ ................................ ................ 66 Ethical Issues ................................ ................................ ................................ .......... 66 4 RESULTS ................................ ................................ ................................ ............... 69 Participant Characteristics ................................ ................................ ...................... 69 Research Aims ................................ ................................ ................................ ....... 71 Research Aim # 1 ................................ ................................ ............................. 71 Assess the weight status of Baby Boomer men ................................ ......... 71 Wei ght preference ................................ ................................ ...................... 73 Medical weight loss history ................................ ................................ ........ 74 Weight satisfaction ................................ ................................ ..................... 75 Weight loss status ................................ ................................ ...................... 76 Research Aim # 2 ................................ ................................ ............................. 78 Identify weight loss strategies used by Baby Boomer men ........................ 78 Information needed to lose weight ................................ ............................. 78 Stage of change for weight loss ................................ ................................ 79 Weight loss strategies currently being used or attempted in the past ........ 79 Research Aim # 3 ................................ ................................ ............................. 81 Identify barriers and motivators to weight loss among Baby Boomer men ................................ ................................ ................................ ......... 81 Barriers to weight loss ................................ ................................ ................ 81 Motivators to weight loss ................................ ................................ ............ 82 Research Aim # 4 ................................ ................................ ............................. 83 Assess current physical activity levels of Baby Boomer men ..................... 83 Amount, type, frequency, and duration of physical activity ........................ 84 Stage of change for physical activity ................................ .......................... 87 Barriers to physical activity ................................ ................................ ......... 87 Motivators to physical activity ................................ ................................ ..... 89 Research Aim 5 ................................ ................................ ................................ 90 Assess areas of improvement tha t are needed eating habits of Baby Boomer men ................................ ................................ ........................... 90 Eating habits ................................ ................................ .............................. 90 Sources of dieting information ................................ ................................ .... 92 Eating habits that need to be improved ................................ ...................... 93 Eating habits that need to be decreased ................................ .................... 94 Stage o f change for healthy eating ................................ ............................ 94 Barriers to eating healthy ................................ ................................ ........... 95 Motivators to eating healthy. ................................ ................................ ...... 96 Summary ................................ ................................ ................................ ................ 97 5 SUMMARY, DISCUSSION, AND RECOMMENDATIONS ................................ .... 112
10 Summary ................................ ................................ ................................ .............. 112 Discussion ................................ ................................ ................................ ............ 113 Study Findings ................................ ................................ ................................ 113 Weight status ................................ ................................ ........................... 113 Motivators for weight loss ................................ ................................ ........ 116 Barriers to weight loss ................................ ................................ .............. 119 Weight loss strategies ................................ ................................ .............. 120 Physical activity participation ................................ ................................ ... 121 Barriers and motivators to physical activity ................................ .............. 125 Eating habits ................................ ................................ ............................ 128 Barriers and motivators to healthy eating ................................ ................. 133 Stage of change for weight loss ................................ ............................... 136 Stage of change for physical activity ................................ ........................ 137 Stage of change for healthy eating ................................ .......................... 137 Limitati ons ................................ ................................ ................................ ...... 138 Recommendations ................................ ................................ ................................ 138 Implications for Practitioners ................................ ................................ .......... 139 I mplications for Clinicians ................................ ................................ ............... 140 Implications for Health Educators ................................ ................................ ... 141 Implications for Worksite Health Promotion ................................ .................... 141 ................................ .............. 142 Recommendations for Future Research ................................ ......................... 142 Conclusion ................................ ................................ ................................ ............ 143 PARTICIPANT SURVEY ................................ ................................ ............................. 145 INSTITUTIONAL REVIEW BOARD ................................ ................................ ............. 160 INFORMED CONSENT SCRIPT FOR SURVEY ................................ ........................ 163 LIST OF REFERENCES ................................ ................................ ............................. 164 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 177
11 LIST OF TABLES Table page 2 1 Description of Stages of Change ................................ ................................ ........ 57 3 1 Sample sizes computed from a priori po wer analyses ................................ ........ 67 4 1 Demographical distribution by age cohort, income, race/ethnicity, education, and marital status ................................ ................................ ............................. 100 4 2 Clas sification according to Body Mass Index (BMI) ................................ .......... 100 4 3 Information needed for weight loss identified by Baby Boomers ...................... 101 4 4 Info rmation needed for weight loss by race/ethnicity ................................ ........ 101 4 5 Stage of change for currently trying to lose weight and BMI ............................. 101 4 6 Wei ght loss strategies currently being used or used in the past ....................... 101 4 7 Reported weight loss strategies by BMI ................................ ........................... 102 4 8 Cross tabula tion table for demographics and weight loss strategies ................ 102 4 9 Reported barriers preventing Baby Boomers from losing weight ...................... 102 4 10 Reported barriers to losing weight and BMI ................................ ...................... 103 4 11 Reported motivators for Baby Boomers to lose weight ................................ ..... 103 4 12 Reported m otivators for Baby Boomers to lose weight and BMI ...................... 103 4 13 Current level of physical activity ................................ ................................ ....... 104 4 14 Planned moderate cardiova scular activity ................................ ........................ 104 4 15 Primary cardiovascular activity ................................ ................................ ......... 104 4 16 Preferred venue(s) typically used for exercise ................................ .................. 104 4 17 Stage of change for trying to increase physical activity and BMI ...................... 104 4 19 Reported barriers to physical activity and BMI ................................ ................. 105 4 20 Reported motivators to increase physical activity ................................ ............. 105 4 21 Reported motivators to be more physically active and BMI .............................. 106
12 4 22 Eating habit frequency ................................ ................................ ...................... 106 4 23 Cause of overeating ................................ ................................ ......................... 106 4 24 Sources of information about nutrition and dieting ................................ ............ 107 4 25 Information looked for on food labels ................................ ................................ 107 4 26 Items Baby Boomers need to cons ume more of to improve their diet .............. 107 4 27 Items Baby Boomers need to consume more to improve their diet and BMI .... 108 4 28 Items Baby Boomers need to consume less of to improve their diet ................ 108 4 29 Items Baby Boomers need to consume less and BMI ................................ ...... 108 4 30 Sta ge of change for currently trying to eat healthier and BMI ........................... 108 4 31 Reported barriers to consistently eating healthy ................................ ............... 109 4 32 Re ported barriers to consistently eating healthy and BMI ................................ 109 4 33 Motivators for Baby Boomers to consistently eat healthy ................................ 109 4 34 Motivators to consistently eat healthy and BMI classification ........................... 110
13 LIST OF FIGURES Figure page 4 1 Boxplot distribution of calculated BMI ................................ ............................... 111
14 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy WEIGHT CONCERNS AND WEIGHT LOSS PRACTIC ES OF BABY BOOMER MEN By Christopher K. Wirth August 2010 Chair: Delores C.S. James Major: Health and Human Performance The Baby Boomer generation is the largest generation in the history of the United States (U.S.). Currently, this population is becomi ng obese earlier in life than in previous generations. T his is concerning as the earliest members of this generation became eligible for social security in 2008 and will be eligible for Medicare by 2011. Prevention and treatment programs for obesity are ne eded to decrease the potential health risks that will lead to an increase in morbidity and mortality rates among this group. The purpose of this study was to determine how male Baby Boomers view their weight, what weight loss or weight management strategie s they were using, and what barriers and motivators they had to losing weight, increasing physical activity, and eating healthy. An 84 item survey was adapted from similar studies and modified to address the behaviors of men that were identified in the li terature. Men born between 1946 and 1964 were recruited to participate in the study from various sites within the community using purposive and snowball sampling. Surveys were completed by a total of 211 participants. The mean BMI for participants was 29.3 55.07 and 82.3% of participants were overweight or obese. None of the participants were underweight. Weight was inaccurately described by 53% of obese men who had a significantly higher preferred
15 weight than normal and overweight men, F (2, 198) = 19.861, p = 0.000. Seventy seven percent of overweight men preferred a weight in an overweight range. Obese men were significantly more likely to be trying to lose weight than overweight or normal weight men (19%) 2 (6, = 202) = 53.896, p = 0.000). Men most f requently listed needing information on portion control, recommended amounts of physical activity, and how to prepare healthy meals. The predominate weight loss strategies were eating less food, exercising more often, and cutting back on unhealthy foods su ch as fried food and desserts. BMI was significantly higher among those who were not physically active, F (3, 181) = 6.232, p = 0.000. The most frequently reported barriers to physical activity were time and getting home too late, while the motivators to p hysical activity were to lose weight, disease diagnosis, and being told by a doctor to be more active. To eat healthier men reported needing to eat more fruits and vegetabl es and consume less The barriers to eating health y inc luded being unable to give up certain foods, having a busy life, and heal thy eating not being a priority and the motivators were to lose weight, disease diagnosis and disease prevention. The findings suggest that overweight men may not have the same conc erns about their weight as obese men. In addition the low rates of physical activity suggest that men are not physical ly active enough to lose or control their weight. The reported motivators of disease prevention and diagnosis that were present for all t hree behaviors suggest that men may take a more reactive stance towards weight loss. The findings may be used to help develop weight loss programs for Baby Boomer men that provide education as to what a healthy weight is, appropriate portion and serving si zes, and the amount of physical activity needed to lose weight.
16 CHAPTER 1 INTRODUCTION A major concern facing our nation is the potential burden that an obese society will place on health care spending. In 2008 obese Americans cost the United States $147 billion in medical bills, paling in comparison to the $1.8 trillion spent in medical costs for treatment of chronic diseases associated with obesity (Hellmich, 2009). With medical expenses for obese individuals estimated to reach $344 billion by 2018, pre vention is imperative. Obesity is an associated risk factor for hypertension, high blood cholesterol, type 2 diabetes, coronary heart disease, respiratory problems, stroke, gallbladder disease, osteoarthritis, sleep apnea, and some forms of cancer (Departm ent of Health and Human Services [DHHS], 2010). As obesity prevalence continues to expand, deaths from heart disease are estimated to increase by 130 % from 2000 2050 (American Heart Association, 2006). In population studies, overweight and obesity in adul ts is generally calculated using body max index (BMI) (Flegal, 2005). Overweight is classified is having a BMI from 25 up to 29.9, and a BMI over 30 is defined as obese (U.S. Department of Health and Human Services [DHHS], 1998; World Health Organization [ WHO], 1995). Results from the 2007 2008 National Health and Nutrition Examination Survey (NHANES) data indicated that 68.3% of U.S. adults aged 20 and older are overweight or obese (Flegal, Carrol l, Ogden, & Curtin, 2010), an increase from 64.5% in 1999 20 00 (Flegal, Carroll Ogden & Johnson, 2002 ). These findings are not surprising as overweight and obesity prevalence has increased over the past five decades (Parikh et al., 2007). While overweight and obesity prevalence is increasing among all age groups (Flegal et al., 2010), trend data indicates that the percentage of overweight and obesity is highest
17 among older individuals. Among three age groups (20 39 year olds, 40 59 year olds, and persons 60 and older) prevalence was highest among men and women in the two older cohorts (Flegal et al., 2010). Moreover, within these age groups, men have a higher prevalence at in both the 40 59 year old group (77.8%) and 60 and older age group (78.4%) compared to women in both age groups (66.3% and 68.6% respectively). These findings are further concerning for men as in the last decade men have seen significant increases in obesity prevalence, while women have remained relatively stable (Flegal et al., 2010). Currently, men in these age brackets are part of a generation Baby Boomer population is becoming obese at an earlier age than the previous generation (Leveille, Wee, & Iezzoni, 2005) and are already seeing an increase in coronary heart disease and stroke hospi talizations (Shoob Croft, & Labarthe, 2007). An in depth analysis of the characteristics of men within these particular cohorts may reveal insight as to why this is so. generation includes individuals born between 1946 and 1964 (Wasserstein, 2004). B aby Boomers were the first post war children and were born in to a recovering economy Men returned home from the Second World War, marriage rates increased (Wister, 2005), and families increased dramatically in size (compared to previous generations) simply due to people being able to afford to raise more children (Bouvier & De Vita, 1991). As Baby Boomers became parents, they opted to have fewer children or prolonged having children until they were older (Blanchette & Valcour, 19 98) and thus the succeeding generation did not exceed the Baby Boomers in number.
18 As of July 1, 2006, there were an estimated 77.9 million Baby Boomers, approximately one fourth of the U.S. population ( U.S. Census Bureau, 2006). In 2008 the oldest of the Baby Boomer generation turned 62 and were eligible for early retirement and social security. As of 2005, social security expenditure in the U.S. was $523 billion (Browning, 2008). In addition, b y 2011 the oldest will be eligible for Medicare (the governmen t health care plan for the elderly) Medicare, however, was not intended to be used to pay for chronic health conditions (Ed lund, Lufkin, & Franklin, 2003) and thus Baby Boomers are expected to significantly impact insurance resources, such as Medicare, to pay for long term health care (Shoob et al. 2007 ). Current estimations indicate by 2030 there will be 61 million Baby Boomers over the age of 66 (Knickman & Snell, 2002) of which six out of seven will have one or more chronic conditions, one in four will be living with diabetes, half will live with arthritis, and one in three will be obese (Ameri can Hospital Association, 2007). I n addition, to the direct costs of health care prevention and treatment services, Baby Boomers may experience lost income from d ecreased productivity as well as the need to utilize multiple sick days (InsuranceNewsNet, Inc., 2007 ). If these obesity trends continue Baby Boomers may be forced to retire earlier due to poor health status, increasing social security payments for early r etirees, and potential increase the amount of years of needing Medicare for long term care and ADLs ( activities of daily living ) As Baby Boomers retire they could also likely face costs from uncovered prescription drugs, uncovered medical care, uncovered long term care, and the costs of private insurance (Knickman & Snell, 2002). Guidelines for the treatment of overweight and obesity include weight loss, which may also help to decrease the likelihood of developing diseases (DHHS, 1998). Data
19 from th e Beha vioral Risk Factor Surveillance System (BRFSS) indicated that in 2003, 36.0% of overweight men and 63.6% of obese men were trying to lose weight (Baradel et al. 2009). Reasons that men give for losing weight include: to feel stronger, to look better, to b e happier with their al., 2007; Wolfe & Smith, 2002; Yates, Edman, & Aruguete, 2004) and be healthier Raben, & Holm, 20 07) yet little is known about successful weight loss programs designed specifically for men. To date, research has shown that males typically do not participate in commercial weight loss programs (Wolfe & Smith, 2002) and are more likely than females to do nothing about losing weight (Kruger Galuska, Serdula, & Jones, 2004). According to Healthy People 2010 physical activity is a leading health indicator and helps decrease the risk of death from heart disease, lowers the risk for developing diabetes and c olon cancer, and is a key component to weight loss (DHHS, 2000). Despite these known benefits, over 60% of American adults do not regularly participate in physical activity (Adams, Ananian, Kirtland, & Ainsworth, 2003; Lee, Sesso, & Paffenbarger, 2000; Ses so, Paffenbarger, & Lee, 2000; Towers, Flett, & Seebeck, 2005). Some of the barriers to increasing physical activity that have been previously reported include a lack of time (Brown, 2005; Brownson, Baker, Housemann, Brennan, & Bacak, 2001; Buman, Yasova, & Giacobbi, 2010; De Bourdeaudhuij & Sallis, 2002; Sherwood & Jeffery, 2000) and a lack of motivation (Brown, 2005; Brownson et al., 2001). However, research has shown that men may also achieve cardiorespiratory
20 benefits through participation in longer bou ts of exercise fewer days per week This may be a more realistic way to in fuse physical activity into their busy weekly schedules. In addition, the 2005 Dietary Guidelines for Americans recommended reducing caloric intake to lose weight (DHHS, 2005). Unfo rtunately, men have difficulty with making the dietary changes necessary to lose weight (Sabinsky et al., 2007). Previous research indicates that from 1971 to 1999 daily caloric intake has increased from 2,300 kcal to 2,590 kcal (Briefel & Johnson, 2004). Over the past 20 years the quality of foods consumed have also decreased as data from NHANES 2001 2006 indicates that the consumption of fruits and vegetables has gone down while alcohol has increased when compared to NHANES III (1984 1994) data (King, Maa inous, Carnemolla, & Everrett, 2009). It is apparent that controlling caloric intake may have the potential to assist in weight loss. A theoretical model that has been used as a framework for understanding health behavior is the Transtheoretical Model (TT M). The theory uses stages of change as a method for changing behavior over six stages: precontemplation, contemplation, preparation, action maintenance, and termination (Prochaska & Di Clemente, 1983) By using the TTM and stages of change, weight loss pr ograms can be developed in accordance with the given stage of behavior change of an individual and thus can be personalized to help move them toward successful weight management. Research has been limited in determining what knowledge and skills men have and/or need to achieve and maintain a healthy weight. Even less is known about what would motivate them to join a weight loss program. By applying the stages of change, it
21 loss, physical activity, and healthy eating. Understanding current stages of change will enable researchers to design interventions that best meet the behavior change needs of this aging population. Research Aims Aim 1: To assess the weight status of Baby Boomer men (as defined by BMI). 1. Identify demographic differences by age cohort, income, race/ethnicity, education, and marital status. Aim 2: Identify weight loss strategies used by Baby Boomer men. 1. Identify knowledge and skills needed to lose weight. 2. Id entify the current stage of change for weight loss. 3. I dentify demographic differences by age cohort, income, race/ethnicity, education, and marital status. Aim 3: Identify barriers and motivators to weight loss among Baby Boomer men. 1. Identify demographic di fferences by age cohort, income, race/ethnicity, education, and marital status. Aim 4 : Assess current physical activity levels of Baby Boomer men. 1. Assess the amount and type of physical activity among Baby Boomer men. 2. Identify the barriers and motivators to physical activity among Baby Boomer men. 3. Identify the current stage of change for physical activity. 4. I dentify demographic differences by age cohort, income, race/ethnicity, education, and marital status. Aim 5: Assess areas for improvement needed in th e eating habits of Baby Boomer men. 1. Identify the barriers and motivators to healthy eating among Baby Boomer men. 2. Assess eating habits that need to be either increased or decreased.
22 3. Identify the current stage of change for healthy eating. 4. Identify demogr aphic differences by age cohort, income, race/ethnicity, education, and marital status. Aim 6: To make programmatic recommendations for developing weight maintenance programs for Baby Boomer men. Limitations The following limitations should be considered when interpreting the results from this study : 1. The use of self report surveys may have lead participants to provide responses that they believed were socially desirable. 2. Findings from this study cannot be generalized to other populations of male Baby Boome rs. 3. Volunteers who participated in the study may not have represented all male Baby Boomers in a typical community in north central Florida. 4. Data collected between spring of 2008 and summer of 2009 may differ from data collected during other time periods 5. Demographic information obtained by the survey may not capture all pertinent information about participants. Assumptions For the purposes of this study, the following assumptions were made: 1. Volunteers who agreed to participate in the study were consider ed adequate to represent male Baby Boomers in a community in north central Florida. 2. Data collected during the calendar year of 2008 and 2009 was considered adequate for the purpose of the study. 3. The survey instrument was considered adequate to determine ph ysical activity and weight loss practices among participants. 4. Demographic information obtained in the survey was considered adequate to describe study participants.
23 5. The research design was considered appropriate for the purpose of the study. Definition o f Terms For the purposes of this study selected terms were defined as the following: A CTION S TAGE : Individuals who are in the action stage have changed their behavior but have done so for less than six months (National Cancer Institute, 2005). A CTIVITIES OF D AILY L IVING (ADL S ) : Activities of daily living involve behaviors that we normally do daily for self & Franklin, 2003, p. 89). B ABY B OOMER : The name given to the large group of children born between 1946 and 1964 (Wasserstein, 2004, p. 8). B ARIATRIC S URGERY : Surgical means for restricting food intake to the stomach that include stapling, adjustable bands, stapling, bypass, or removal of part of th e stomach (ADA, 2009). Patients qualify for bariatric surgery if they meet the following conditions: morbid obesity, BMI 35.0 39.9 plus at least one severe obesity related medical complication, or a BMI Conference, 1991). B ODY M ASS I NDEX (BMI) : BMI is a measure of weight that is adjusted for height and is calculated as weight in kg divided by height in meters squared (kg/m2). C ONTEMPLATI ON S TAGE : Individuals who are in the contemplation stage intend to take action to change their behavior in the next six months (National Cancer Institute, 2005). D ETERMINANT : an element that identifies or determines the nature of something or that fixes or conditions an outcome (Merriam Webster). M AINTENANCE S TAGE : Individuals who are in the maintenance stage have successfully changed their behavior for more than six months (National Cancer Institute, 2005). M ODERATE P HYSICAL A CTIVITY (MPA) : at use large muscle groups and are at least equivalent to brisk walking. In addition to walking, activities may include swimming, cycling, dancing, gardening, and yard 2010, 2000, p. 2 2 36).
24 O VERWEIGHT : Having a BMI 25 to 29.9 kg/m2 (DHHS, 1998; WHO, 1995). O BESITY : Having a BMI P HYSICAL A CTIVITY : ( U.S. Department of Health and Human Services, 1996, p. 21 ). P RECONTEMPLATI O N : Individuals who are in the precontemplation stage have no intention of taking action to change their behavior within the next six months (National Cancer Institute, 2005). P REPARATION S TAGE : Individuals who are in the preparation stage intend to take ac tion within the next thirty days and/or have taken some behavioral steps toward change (National Cancer Institute, 2005). T ERMINATIO N S TAGE : Individuals who are in the termination stage no longer have the temptation to engage in the old behavior and have 1 00% self 1994, p. 162). V IGOROUS P HYSICAL A CTIVITY (VPA) : activities that use large muscle groups including jogging/running, lap swimming, cycling, aerobi c dancing, skating, rowing, jumping rope, cross country skiing, hiking/backpacking, racquet sports, and competitive 2000, p. 22 36). Summary Since 1950, the prevalence of obesity has increased in men by 29% each decade (Parikh et al., 2007). Moreover, each generation is becoming obese at earlier ages than the previous generation (Leveille et al., 2005). These findings are problematic in particular for the Baby Boomer generation, which currently makes up 26% of the U.S. population (U.S. Census Bureau, 2006). Baby Boomers are already reaching retirement age and will soon be eligible for Medicare treatment for chronic conditions associated with obesity such as type 2 diabetes, hypertension arthritis, and cancer (DHHS, 2010). This will no doubt put a strain on available resources to treat these increasing conditions. Thus, there is a critical need to provide resources and training to help Baby
25 Boomers successfully age. Vaillant and Mukamal (2001) found that successful aging could be predicted by seven variables that individuals participate in prior to the age of 50, which included maintaining a healthy weight and engaging in some exercise. Effective weight management programs need to be deve loped to prevent these individuals from developing chronic conditions that may reduce both the quality and quantity of their remaining years of life. Understanding the barriers and motivators to weight management, physical activity, and healthy eating will assist health educators, practitioners, and clinicians gain a greater understanding of Baby Boomer men. Furthermore, differences that may exist due to age, race, income, education, and marital status can help individualize programs to better suit the give n target group. Thus, the objectives of this study were to assist in the development of theory based weight loss programs by indentifying how male Baby Boomers view their weight, what weight loss strategies they are using, and what their barriers and moti vators are to losing weight.
26 CHAPTER 2 REVIEW OF THE LITERA TURE This chapter provides a review of literature related to topics including: 1) the health care costs associated with obesity, 2) the prevalence of overweight and obesity in the United St ates; 3) the prevalence of overweight and obesity among the Baby Boomer generation; 4) the Baby Boomer generation; 5) weight loss practices of men; 6) physical activity practices of men; 7) the eating behaviors; and 8) the stages of change of the Transtheo retical Model as related to healthy eating and physical activity. The Economic Burden of Obesity Yearly spending on weight loss products and programs, which include: books, videos, low calorie foods and drinks, medical treatments, dietary supplements, and commercial weight loss programs (Cleland, Gross, Koss, Daynard, & Muoio, 2002) has increased on a yearly basis since 1997 (Marketdata Enterprises, 2009). In 2000, revenue for the U.S. weight loss market was $34.7 billion (Cleland, et al., 2002) and by 20 04 revenue was up to $46.3 billion (Adams, 2005) with Americans spending nearly $42 billion on diet and health books alone (Burros & Severson, 2005). The most recent data from 2008 listed revenue for the U.S. weight loss market at $58.6 billion slightly up from $58.5 billion, spent in 2007 (Marketdata Enterprises, 2009). While spending has not increased significantly over the past year, these numbers may be in part due to the current recession (Marketdata Enterprises, 2009). Weight loss spending, however, pale in comparison to the health care costs attributable to obesity. In 2008, obese Americans cost the country an estimated $147 billion in weight related medical bills and accounted for about 9.1% of medical spending (Hellmich, 2009). If current obesity t rends continue, by 2018 the U.S. spending is
27 care spending (Thorpe, 2009). However, if obesity rates are held at their current rates, the U.S. could save a total of $19 8 billion in health care costs by 2018 (Thorpe, 2009). In 2008 $1.8 trillion was spent in medical costs for the treatment of chronic diseases associated with obesity (Hellmich, 2009). These diseases and conditions include: high blood pressure, high bloo d cholesterol, type 2 diabetes, coronary heart disease, respiratory problem, stroke, gallbladder disease, sleep apnea, some forms of cancer (DHHS, 2010), and increases the risk of cognitive disability (Houston, Nicklas, & Zizza, 2009). U.S. Overweight and Obesity Prevalence A measure to define overweight and obesity that is generally used in population studies is body mass index (BMI) (Flegal, 2005). BMI is a measure of weight that is adjusted for height and is calculated as weight in kg divided by height i n meters squared (Flegal, 2005). The calculated BMI is then categorized into weight classifications based on the criteria established by the World Health Organization and the U.S. Department of Health and Human Services, National Institutes of Health, and National Heart, Lung and Blood Institute. For adults, overweight is defined as a BMI from 25 up to 29.9 and obesity is defined as a BMI over 30 (DHHS, 1998; WHO, 1995). Data on the overweight and obesity prevalence in the United States come from a cross s ectional, nationally representative survey called the National Health and Nutrition Examination Survey (NHANES) a program of the National Center for Health Statistics (NCHS), which is part of the Centers for Disease Control and Prevention (CDC) (Centers fo r Disease Control and Prevention [CDC], 2007; Flegal, 2005). The NHANES provides an estimate of the health and nutritional status of adults and children in the
28 U.S. (CDC, 2007). The survey began in 1960 and as of 1999 became a continuous survey without bre aks between exam cycles (Flegal, 2005). The NHANES provides a national estimate from a sample of 5,000 people each year from counties across the country (CDC, 2007). The interview includes health related questions, medical tests, and laboratory tests and s tudies a number of health indicators including obesity (CDC, 2007). Overweight and obesity prevalence has increased over the past five decades (Parikh et al., 2007). Results from the 2007 2008 NHANES indicate that 68.3% of U.S. adults aged 20 and older ar e overweight or obese (Flegal et al., 2010), an increase of nearly 4% from a decade ago (Flegal, 2002). However, obesity rates have only slightly increased during the same time span. According to the 1999 2000 NHANES, 33.4% of men and women were obese, and as of the 2007 2008 NHANES, obesity prevalence among U.S. adults was 33.9%. These rates have increased substantially from the same age cohorts of men and women who were obese in 1960, 11% and 16% respectively (Flegal, Carroll, Ogden, & Johnson, 2002). Wh ile increases in overweight and obesity have been seen among all age groups (Parikh et al., 2007) current trends indicate that the largest prevalence is among individuals between the ages of 40 59 and those who are 60 years of age or older (Flegal et al., 2010). The 2007 2008 NHANES data revealed that 72.1% of men and women aged 40 59 years old (at the time of the study) and 73.5% of persons aged 60 or older were either overweight or obese, compared to 61.5% of persons aged 20 to 39 years old. Obesity rates are also highest among the two older cohorts at 36.3% for the 40 59 year olds and 35.5% for the 60 and older age group compared to 30.8% for
29 persons 20 39 years old (Flegal et al., 2010). These figures are concerning, as adults who are obese at age 40 liv e an average of six to seven years less than their same age counterparts of normal weight (Villareal, Apopvian, Kushner, & Klein, 2005). When comparing men and women in the 40 59 year old cohort, men had a greater prevalence of overweight or obesity in 2 007 2008 then women of the same age (77.8% to 66.3%), but lower rates of obesity than women of the same age (34.3% to 38.2%). Men in the 60 and older age group also had a greater prevalence of overweight or obesity than women in the same age group (78.4% t o 68.6%), but also had higher obesity rates than women (37.1% to 33.6%) (Flegal et al., 2010). Trends in overweight and obesity prevalence in the NHANES 1999 2000 and NHANES 2007 2008 studies show that overweight prevalence has increased in 40 59 year old men from 70.0% in 1999 2000 to 77.8% in 2007 2008, while 40 59 year old women remained relatively steady from 66.1% to 66.3% within the same time span. Men in the 60 and older age group have increased from in overweight and obesity prevalence in 1999 2000 of 74.1% to 78.4% in 2007 2008. While women in the 60 and older increased from 68.1% to 68.6% in the same span. Comparing obesity, 40 59 year old men have gone from an obesity prevalence of 28.8% in 1999 2000 to 34.3% in 2007 2008 compared to a minimal in crease in 40 59 year old women of 37.8% to 38.2% between 1999 2000 and 2007 2008 respectively. Obesity prevalence in men aged 60 years and older increased from 31.8% to 37.1% while women decreased from 35.0% in 1999 2000 to 33.6% in 2007 2009 (Flegal et al ., 2010). These increases are nothing new as obesity prevalence among men has grown by 29% every decade since 1950 (Parikh et al., 2007).
30 While these figures are no doubt concerning for both genders, over a ten year time span men have seen a significant l inear trend while there has been no significant trend among women (Flegal et al., 2010). The increases in obesity prevalence among men in the 40 59 and 60 years and older age groups are more troubling, given the fact that men overall already have higher d eath rates within 12 of the 15 leading causes of death (including heart disease and cancer) and a lower life expectancy (Hoyert, Heron, Murphy, Kung, 2006). At the time of the 2007 2008 NHANES study the 40 59 year old participants were born between 1949 19 68 which most closely fits the age range of a generation. The Baby Boomer Generation There is much debate regarding the cause of the increase in birth rates after 1946. What can be best estimated is the effect of the post war economy on job availability increasing the percentage of persons employed whereby people could afford to have large group of chi ldren that were born between the years of 1946 and 1964 (Wasserstein, 2004). The Baby Boomer generation, to date, is currently the largest group of persons in the United States and presently the 76 million Baby Boomers make up approximately one third of th e United States population (Himes, 2001; U.S. Census Bureau, 2001) and 39% of the population over the age of 18 (Gillon, 2004). In 2011 the oldest of Baby Boomers will turn 65 years old and be eligible for early retirement. Current estimations indicate th at by 2030 there will be 61 million Baby Boomers (aged 66 84) in the U.S. (Knickman & Snell, 2002), nearly twice that of the 35 million individuals aged 65 and older as of the 2000 Census (Meyer, 2001). By the time
31 the last of the Baby Boomers reaches reti rement age, almost 20 % of the U.S. population will be 65 or older compared to less than 13 % today (American Hospital Association, 2007). In addition, these individuals will be eligible for Medicare. While Medicare has been the traditional for m of health care insurance that is used by the elderly it was not designed to pay for long term or chronic health conditions (Edlund, Lufkin, & Franklin, 2003) such as diabetes, hypertension, arthritis, and cancer (National Institutes of Health, National H eart, Lung, and Blood Institute, 1998). According to the US Department of Health and Human Services (HHS Fact Sheet, 2000) more than 39 million people receive health care coverage through Medicare and in 1999 total Medicare spending was $181.3 billion. Ne arly 80% of Americans today will live past the age of 65 with age expectancy for men extending another 15 years (Edlund, et al., 2003). With the increase in life milli on individuals aged 65 or older need long term care or assistance with activities of al., 2003, p. 89). With Baby Boomers living longer due to advancements in medicine and technology there is an increased likelihood that they will develop chronic illnesses and need assistance with ADLs (Yeaworth, 2002). The Baby Boomer generation has a higher prevalence of obesity and is becoming obese at a younger age than previous ge nerations. Compared to the previous obesity was almost twice as high among Baby Boomers in their 30s and 40s (28 32%) as it was for the same age cohort in the Silent Gene ration (14% 18%) (Leveille et al,
32 2005). Thus, Baby Boomers have a higher percentage of individuals who are living more of their adult years (with obesity) than the previous generation. Despite being more educated than previous cohorts (Blanchette & Valcou r, 1998) the Baby Boomer generation is developing chronic diseases at earlier ages. In a study by Shoob, Croft, and Labarthe (2007), Baby Boomers had greater numbers of coronary heart disease and stroke hospitalizations than 45 54 year olds in both 1980 an d 1990. Men aged 45 54, as of 1999 2002, also had higher rates of hypertension compared to 45 54 year olds in 1988 1994. Oddly enough, even with the increasing prevalence of obesity, male Baby Boomers may not perceive that their weight is a health risk and thus are less likely to be ready to change the behaviors that are necessary to lose weight (Wee, Davis, & Philips, 2005). Men and Weight There are many benefits of having a healthy weight. Healthy body weight composition reduces the risk for high blood pr essure, type 2 diabetes, coronary heart disease, congestive heart failure, stroke, gout, sleep apnea and other respiratory problems, some types of cancer including both prostate and colon cancers, and psychological disorders such as depression and body dis satisfaction (DHHS, 2010). Moreover, a healthy body weight increases overall quality of life and life expectancy (Hoeger & Hoeger, 2010, p. 150). Research indicates that middle aged men who are obese will lose six years of life and are 81% more likely than men of normal weight to die before the age of 70 (Peeters et al., 2003). A health survey that is used to collect data on health related behavior such as weight loss is the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a state based tel ephone survey that was established in 1984 by the CDC and interviews
33 more than 350,000 adults each year in all 50 states, the District of Columbia, Puerto Rico, U.S. Virgin Islands, and Guam (CDC, 2008). An analysis of weight loss trends from BRFSS data re vealed that the prevalence of obese persons who were trying to lose weight increased significantly from 1996 to 2003 while the percentage of overweight persons trying to lose weight remained stable (Baradel et al., 2009). These results indicate that while overweight and obesity prevalence increased during the same time span (Ogden, Carroll, Curtin, McDowell, Tabak, & Flegal, 2006), weight loss among overweight persons did not (Baradel et al., 2009). Rates of weight loss among overweight and obese adults wer e also lower in men than women. In 2003, 60.2% of overweight women were trying to lose weight yet only 36.0% of overweight men reported that they were trying to lose weight. That same year, 72.9% of obese women were trying to lose weight compared to 63.5% of obese men (Baradel et al., 2009). Gregory, Blanck, Gillespie, Maynard, and Serdula (2008) found that overweight and obese men were less likely to be trying to lose weight than women. While not all overweight and obese individuals are attempting to lose weight, a large percentage of them appear to be discontent about their present condition. In an analysis of the 2003 BRFSS data by Muenning, Haomiao, Lee, and Lubetkin (2008), only 20% of overweight people and 5% of obese people expressed that they were h appy with their weight. A study of weight satisfaction by Kuk, Ardern, Church, Hebert, Sui, and Blair (2009) found similar results, with only 2% of men and 1% of obese women reporting satisfaction with their weight. Men typically report having more body sa tisfaction than women (Frederick, Forbes, Grigorian, & Jarcho, 2007; Muenning, Haomiao, Lee, & Lubetkin, 2008; Ogden & Taylor, 2000; Reboussin et al., 2000, Yates,
34 Edman, & Aruguete, 2004), even obese men (James, 2003), but still report that they are unhap py with their weight. Body satisfaction in the form of general appearance has also been associated with wanting to lose weight (Obrien et al., 2007; Yates et al., 2004). In addition, a study by Wolfe and Smith (2002) found that among 72 male participants, 69% reported wanting to lose weight for appearance reasons, 72% wanted to look better, and 75% wanted to feel stronger or fitter. Body dissatisfaction in men has also previously shown to depend on weight status, with men who are underweight or of a normal weight wanting to gain weight and men who are overweight or obese wanting to lose (De Souza & Ciclitira, 2005; Frederick et al., 2007; Grieve, Wann, Henson, & Ford, 2006). These studies, however, were conducted with collegiate men. A study of middle age S cottish men by McPherson and Turnbull (2005) found that overweight men were more likely to be happier with their weight than underweight men who wanted to gain, and obese men who wished to lose. Research has also indicated that married men may be satisfied with their body if their partner is also satisfied with their body (Ogden & Taylor, 2000). These findings may suggest that a man whose partner is not satisfied may report greater levels of body dissatisfaction. For men who do wish to lose, health reasons have been shown to be a motivating Smith, 2002). 1999 study by Roberts and Ashley, half of the participants who had successfully lost weight, over a three month period, li sted receiving a warning from a doctor or nurse and discovering a risk factor after a health screening as the key initiators to weight loss. Sabinsky, Toft, Raben, and Holm (2007) found similar results
35 weight. Being diagnosed with a health risk such as high cholesterol was also a motivator for weight loss, however, once cholesterol levels decreased so did motivation to continue with the weight loss program. This woul d seem to indicate that the presence of disease appears to be a greater motivator than prevention in general. Improving productivity in the workplace was also found to be a motivator to lose weight. In a study of males in Denmark, subjects identified wanti ng to be more effective in the work place (decreased sick leave) as the biggest reason for losing weight (Sabinsky, Toft, Raben, & Holm, 2007). Hence, it would seem that potential lost days of work, relating to the health plight of a friend or colleague an d/or death are stronger motivating factors for men who possess previous knowledge as to the risks of being overweight or obese. Weight Loss Recommendations Recommendations for the prevention and treatment of overweight and obesity include a reduction of 5 00 to 1,000 kcal/day in order to achieve a 1 2lb weight loss per week (American Diabetic Association [ADA], 2009; DHHS, 1998, 2005). Furthermore, the recommendations include a combination of reducing caloric intake, and 30 minutes or more of moderately int ense physical activity on most, if not all days of the week, with up to 60 minutes of moderate to vigorous physical activity per week to prevent unhealthy weight gain (DHHS, 2005). Adults wishing to prevent weight regain should increase to 60 90 minutes of daily moderate physical activity or lesser amounts of vigorous activity (DHHS, 2005). In studies examining the prevention of weight regain after weight loss, participants that included moderate physical activity with diet control were more likely to maint ain weight loss than those who used diet control alone (McGuire, Wing, Klem, & Hill, 1999; Schoeller, Shay, & Kushner, 1997; Weinsier, et al.,
36 2002). While trends indicate that there has been a significant increase among those using recommended strategies to lose weight there has been little change in the percentage of obese and overweight individuals who are actually trying to lose weight (Baradel et al., 2009). Strategies Men Use to Lose Weight Men typically do not use unhealthy strategies to lose weight, such as fasting, using laxatives, diet pills, or skipping meals (James, 2003; Kruger et al., 2004; Weiss et al., 2006) but instead may choose to not do anything at all to lose weight (Kruger et al., 2004). For men that do participate in healthy weight los s practices, eating less food or increasing exercise are most frequently listed. In analysis of data from the 1998 National Health Interview Survey, a large scale household interview survey (CDC, 2009), Kruger, Galuska, Serdula, and Jones (2004) found that men most frequently reported eating fewer calories, eating less fat, and exercising more as weight loss. However, only 32.3% of men were using the recommended strategies of eating fewer calories with exercising more (Kruger et al., 2004). In a similar stu dy, Baradel et al. (2009) examined weight loss strategies used by men in women as reported in the BRFSS between 1996 and 2003. As of 2003, 57.1% of overweight men and 59.0% of obese men were eating fewer calories while 80.1% of overweight men and 72.4% of obese men were increasing physical activity. Looking at recommended weight loss strategies, 46.3% and 43.2% of overweight and obese men respectively were using this strategy (Baradel et al., 2009). These rates were higher, however, than what was reported i n 1996, at 34.3% among overweight men and 34.1% among obese men (Baradel et al., 2009). In addition, these rates were also higher than the data from the 2001 2002 NHANES that found 28.1% of men were successfully using the
37 recommended strategy (Weiss et al. 2006). However, this study used the 2005 Dietary et al., 2006) and thus may more accurately depict the prevalence of U.S. men using this strategy. Other weight loss stra tegies from the 2001 2002 data that men reported were eating less fat (44.0%), switching to lower calorie foods (34.9%), and drinking water (24.2%). Barriers to Weight Loss Research that is available on barriers to weight loss most frequently includes ba rriers to making dietary changes and increasing physical activity (Burke, Steenkiste, Music, & Styn, 2008; Chang, Chang, & Cheah, 2009; Sabinsky et al., 2007). In a study concerns regarding the changes they would have to make to their diet to lose weight, and having to avoid beer and wine as the most common barriers to losing weight. In addition, participants reported that they perceived diet food as eating more vegetables and having little to no meat and alcohol. A common barrier for weight loss was abstaining from beer consumption (for both younger and older men), and having to avoid red wine among middle aged men. Men also had concerns about not having time to exercise or prepare healthy meals, having to sacrifice time spent with family, and concerns about the expenses associated with joining a fitness center (Sabinsky, et al., how to los e weight, had previously tried to lose weight and failed, and had difficulty resisting eating as barriers to losing weight (Chang, Chang, & Cheah, 2009). A study by Burke, Steenkiste, Music, and Styn (2008) looked at past experiences with weight loss of U .S. adults. The most frequently listed barriers to successfully losing weight that
38 were indentified were having difficulty making changes, not having time, a lack of social support, and because of food being readily available. However, only 16% of particip ants in the study were men and comparisons between men and women were not made in the study. In examining strategies for losing weight among men and women, a study by Nothwehr, Snetslaar, and Wu (2006) found that men reported social support as an increasing physical activity. Men had less self efficacy than women in using diet related skills nevertheless there were no differences between men and women in their self efficacy to stick with the diet or with physical activity. These findings may suggest that weight loss programs can best meet the needs of men by providing more social support in the dietary components of the program than in the physical activity portions. Eating Ha bits of Men Contributing to the ongoing struggle for weight loss is the increasing amount of calories that men are consuming. In a study of the dietary intake of men aged 40 59, the daily caloric intake increased from 2,303 to 2,590 from 1971 to 1999 (Brie fel & Johnson, 2004). In addition, what they are eating and drinking has also not been the healthiest. In a comparison of data from the NHANES III (1988 1994) and data from NHANES 2001 2006, King, Maainous, Carnemolla, and Everrett (2009) reported that ov er the past 20 years, consumption of eating five or more fruits and vegetables a day decreased from 42% to 26% among 40 to 74 year olds while alcohol consumption increased from 40% to 51%. In a study investigating the motivators to healthy eating among se nior military officers, participants indicated that appearance and health were the leading motivators
39 to eating healthy. Meeting specific body fat standards and being motivated by family members were also listed (Sigrist, Anderson, & Auld, 2005). Artinian (2001) assessed perceived benefits of a low fat, high fiber diet among 60 to 86 year olds. Subjects most frequently identified that reducing fat in the diet would help prevent heart attacks and lower cholesterol levels, while consuming more fiber would pre vent constipation. Men have previously identified that they have difficulty eating healthy because they have a lack of time to prepare healthy meals (Burke et al., 2008). In addition, having trouble controlling what they eat, staying motivated to eat pro perly, difficulty resisting high calorie foods, difficulty with controlling their eating when they were with friends, and not being able to estimate appropriate portion sizes were also listed as barriers to eating healthy (Burke et al., 2008). Previous res earch by Lappalainen, Saba, Holm, Mykkanen, and Gibney (1997) found similar barriers to eating healthy with a lack of time, having to give up favorite foods, and a lack of willpower to eat healthy. In a study by Artinian (2001) adults over 60 listed having difficulty sticking to a low fat diet on special occasions, difficulty eating healthy when traveling, and needing extra time planning, shopping, and preparing meals as barriers to following healthy eating guidelines. Among an adult population in Missouri, the most common barriers reported were finding dietary recommendations confusing and difficult to follow, healthy foods being more expensive, needing more time and effort to prepare healthy foods, and having difficulty keeping track of what they should ea t when dining out (Hagdrup, Simoes, & Brownson, 1998). In a one year follow up study of overweight and obese adults who had used the Dietary Attempts to Stop Hypertension (DASH) diet, participants identified barriers to eating healthy once they were no lon ger on the
40 program. These individuals also reported difficulty estimating portion control and calculating caloric needs on their own (Jehn, Patt, Appel, & Miller, 2006). In a study on the health related beliefs of Australians several barriers to eating lo w fat and high fiber diets were provided. Being surrounded by friends and family eating restricted food, not having enough money to buy nutritious foods, limited availability of health foods in stores and in the work place, not having transportation to acq uire food, lack of time, boredom with healthy foods, not being able to understand the food labels to purchase healthy foods, and not having adequate cooking skills to prepare healthy meals (Smith & Owen, 1992). Barriers listed in a 1995 study of adults in the United Kingdom found similar barriers such as poor taste and increased cost of healthy foods as well as lack of family support, inconvenience when shopping and not being able to properly judge fat content (Lloyd, Paisley, & Mela, 1995). A study addres sing barriers to healthy eating among men in the U.K. found that promotion efforts and that healthy food was poor in taste and unsatisfying (Gough & Conner, 2006). These results a re similar to those reported in the Sigrist, Anderson, and Auld study (2005) with senior military officers who indicated confusion from the media/research as a barrier to eating healthy in addition to being too busy, healthy eating not being a priority, an d disliking cooking. Looking specifically at barriers to increasing fruit and vegetable intake among men and women in Missouri, Hagdrup et al., (1998) found that confusing dietary recommendations was the most commonly reported barrier. Healthy foods bein g expensive, eating out frequently, and not having
41 time to prepare healthy foods were also listed as barriers to eating fruits and vegetables. Physical Activity Recommendations To receive cardiorespiratory health benefits, the Centers for Disease Control a nd Prevention (CDC), the U.S. Department of Agriculture (USDA), and the American College of Sports Medicine (ACSM) recommend that adults receive a minimum of 30 minutes of moderate physical activity on five or more days of the week (Pate et al., 1995; U.S. Department of Agriculture [USDA], 1998; U.S. Department of Health and Human Services [DHHS], 1996) or a total of 150 minutes moderate activity per week or 75 minutes per week if vigorous (DHHS, 2008). The Institute of Medicine reports that these minimal r ecommendations should be based upon vigorous physical activity and further recommends that adults participating in moderate physical activities should receive 60 minutes per day (2002). Recent research has also suggested that health benefits can be achiev ed through longer bouts of exercise on fewer days of the week. Data from the Harvard Alumni Health Study suggests that burning 1000 k/cal per week (approximately 30 minutes of physical activity per day) will help in lowering mortality rates in elderly men (average age 61 years in this study). However, men with no major risk factors can lower mortality rates by burning 1000 k/cal in one or two bouts per week (Lee, Sesso, Oguma, & Paffenbarger, 2004). Men that fell in this 1 2 bouts category were identified a s with each bout of exercise. Participation in several sessions of physical activity per day (i.e., jogging a total of 30 minutes in a day split up into two sessions) will also decrease cardiovascular risks as compared to the longer sessions as long as the energy
42 to be physical active, participating 1 2 times per week for longer periods of time or through multiple, shorter sessions may better fit their schedules. Physical Activity and Men Physical inactivity has also had a direct impact on the increasing prevalence of overweight and obesity (Surgeon General, 2001). Furthermore, low level s of physical activity and high consumption of calories together contributed to an estimated 400,000 deaths in 2000 (Mokdad, Marks, Stroup & Gerberding, 2004). As obesity prevalence continues to expand, deaths from heart disease are estimated to rise by 13 0 % from 2000 2050 (American Heart Association, 2006). Participation in regular physical activity can help minimize the chances of developing the health risks that are common among men. Physical activity is associated with increasing both the quality and quantity of life by decreasing the risk for cardiovascular disease, hypertension, osteoporosis, colon cancer, diabetes mellitus while improving mood and increasing the ability to perform daily tasks (DHHS, 1996, 2000; Hoeger & Hoeger, 2010, p. 8; Pate et al., 1995). Studies have indicated that regular physical activity may be a more important predictor of mortality than smoking, high blood pressure, high cholesterol, and obesity (Blair et al., 1989; Blair et al., 1996). The Harvard Alumni Study found that men who exercised at least one day a week had a 36% reduction in risk for diabetes. Men who exercised at least five days a week were 42% less likely to develop diabetes. Active men were also 26% less likely to develop hypertension. Men achieving at le ast 2000 calorie (k/cal) (60 minutes of daily physical activity depending on the intensity of the exercise) expenditure per week through exercise were 39% less likely to experience a heart attack (Simon, 2002). The importance of physical activity for decre asing the risk of
43 heart attacks is made further evident by the estimations that 12.2% of myocardial infarction in the world can be attributed to physical inactivity (Carnethon, Gulati, & Greenland, 2005). Exercise has also been associated with decreasing t he risk of stroke. Men who burned 1000 1999 k/cal a week reduced their stroke risk by 24%, while men who burned 2000 3000 k/cal reduced the risk by 46%. Evidence was also provided that cipants who remain physically active compared to those who are not active (Carnethon et al., 2005). Exercise benefits are also attainable when exercise behaviors are adopted later in life. Men who did not exercise until age 45 had 23% decreased risk of mo rtality compared to those who remained inactive (Simon, 2002). A study of men aged 45 75 years showed that men who were more active had a lower body mass index (BMI) and a lower prevalence for hypertension. Men who ran for one or more hours per week had a 42% reduction in risk for coronary heart disease compared to men who did not run one or more hours per week (Tanaseascu et al., 2002). In addition, men who burn roughly 1000 k/cal per week (approximately 30 minutes of daily physical activity) have a 20% re duction in coronary heart disease. Even when coronary risk factors are present men who burn 1000 k/cal per week may have smaller increases in CHD risk than those who do not meet recommended levels (Sesso, Paffenbarger, & Lee, 2000). Despite numerous healt h benefits and the well documented reduction in the risks associated with physical inactivity, the majority of American adults are not physically active. Recent studies show that over 60% of American adults do not participate in physical activity regularly or are not active enough to receive cardiorespiratory benefits, (Adams et al., 2003; Lee et al., 2000; Sesso et al., 2000; Towers et al., 2005). Leisure
44 activity levels are also on the decline. In a comparison of physical activity among adults in 2000 and 2005 the percentage of adults who participated in no leisure time physical activity increased from 38.5% to 40.0% while the percentage of adults participating in regular leisure time physical activity decreased from 31.2% to 29.7% (Barnes, 2007). These f igures are more alarming in the male population. Looking specifically at persons in the Baby Boomer generation, men aged 40 to 74 years have had greater decreases than women in monthly physical activity since 1998 (King,et al., 2009). Regardless of previo us engagement in physical activity, as people age daily participation in physical activity decreases (DHHS, 2000). This is of greater concern for overweight individuals who may already have limited activity. In a study of obese adults in South Carolina, ov erweight males were less likely to be active than their non overweight counterparts (Adams et al., 2003). Carnethon, Gulati, and Greenland (2005) also found that adults with low fitness levels were two to four times more likely to be overweight or obese th an individuals in moderate and high fitness categories. Determinates of Physical Activity in Men Among adults, chronic disease management, weight control, and personal enjoyment are key benefits to being physically active (Brown, 2005). In a study of phys ical activity among three different age groups in Belgium, males in the 35 45 age group identified body image and health as perceived benefits to physical activity. In the 50 65 year old age group, males listed having someone to workout with as a motivator while having health problems was a determinate of physical inactivity. Among all age groups receiving social support from friends and family, in the form of those individuals either exhibiting an active lifestyle themselves and/or holding the belief that physical activity is important, was a motivator to being physically active (De Bourdeaudhuij &
45 Sallis, 2002). Consistent with these findings, Janzen and Cousins (1995), previously reported that individuals who have spouses who are active are 20% more like ly to be physically active than those whose partners are not active and are 41% more likely to be regularly active if their friends are active. Lack of encouragement or support from a physician to be physically active was associated with decreased levels o f physical activity (Fink & Wild, 1995). Reasons that men state they are not physically active are again attributable to barriers related to time. In a review of behavioral determinants to exercise, Sherwood and Jeffery (2000) reported that both active an d sedentary adults frequently list time constraints as a barrier to participating in physical activity. Pertaining to men specifically, lack of time (Booth, Bauman, Owen, & Gore, 1997; Brown, 2005; Brownson, Baker, Housemann, Brennan, & Bacak, 2001; Buman et al., 2010; De Bourdeaudhuij & Sallis, 2002; Sherwood & Jeffery, 2000), limited motivation to be physically active (Brown, 2005; Brownson et al., 2001), getting enough physical activity while working (Brownson et al., 2001), lack of interest, limited hea lth (Booth et al., 1997) and fear of injury (Buman et al., 2010) are listed as barriers to physical activity. Regarding men reporting poor health conditions as a barrier, a more recent study of 72 middle aged men in New Zealand found that individuals who s elf rated their health as and functional status (Towers, Flett, & Seebeck, 2005). These findings are consistent with previous studies (Booth et al., 1997) that indicate d older men were more likely than younger cohorts to list limited health as a barrier.
46 In a study looking specifically at determinants of vigorous physical activity, Sallis et al. (1989) found that lack of interest in exercising and not getting enjoyment from exercise were the most frequent barriers among individuals not interested in exercise. Lack of social support, self discipline, and not having the skills or knowledge to exercise were also listed. Unlike other studies, lack of time was not mentioned a mong this group of non exercisers and instead the others suggested that they were simply not interested in exercising to begin with. Environmental barriers such as unsafe neighborhoods, lack of sidewalks, and not having access to parks or exercise facilit ies also decrease the likelihood for participation in physical activity. In a study of people in five selected states, individuals who felt their neighborhoods were safe had physical activity rates that were twice as high as those who deemed their neighbor hood unsafe (Centers for Disease Control and Prevention [CDC], 1999). Research, however, indicates that men report having little difficulty with finding places to exercise (Brownson, et al., 2001) suggesting that environment may not be as much as of a conc ern for men. Simply put male Baby Boomers are overweight, unsatisfied with their weight, and lack the time, motivation, and skills to change their weight. While each of these barriers lt question: What will enable male Baby Boomers to lose weight before they develop conditions that will impair their health and overall quality of life? Determining how to provide proper assistance to weight loss remains a constant issue as evidenced by th e amount of money in U.S. spending on the treatment of overweight and obesity.
47 Health Behavior Theory Theory is used to systematically understand events and explain occurrences by identifying concepts and constructs to determine relationships and make pred ictions (Glanz & Rimer, 1995; Morse & Field, 1995). Health behavior theories are testable and can be generalized to various health behaviors making them effective guidelines in program development (van Ryn & Heaney, 1992). The application of a health behav ior theory to any research design ensures that research will be based upon previously tested and well defined theories that will improve the coherence, effectiveness, and evaluation of interventions (van Ryn & Heaney, 1992). Theory helps explain what facto rs influence the behavior of interest, the relationship of those factors, the conditions for the relationships to occur, and ways to modify the factors for different populations (van Ryn & Heaney, 1992). Having knowledge of a particular health behavior the ory improves the design of the intervention as well as provides assistance to the researcher to appropriately implement and tailor the theory to best meet the health needs of the given population (Glanz, Rimer, & Lewis, 2002). Theory assists in the various stages of planning, implementing, and evaluating behavioral interventions and serves as a guide to determine: the data to be collected on the current health behavior, what should be measured or compared, and how interventions can reach people and make an impact on them (Glanz et al., 2002). Theories help to explain the elements of a health behavior as well as the processes for changing behavior (Glanz & Rimer, 1995; Glanz, et al., 2002). Finally, theory helps to identify the population that would most bene fit from the intervention and what outcomes should be evaluated (Glanz & Rimer, 1995).
48 Transtheoretical Model and Stages of Change The stages of change of the Transtheoretical Model were chosen based on previous research with exercise behaviors which sugge st that theoretical models like stages of change categorize individuals into a stage of exercise adoption and follow them to determine how a person becomes exercise adherent (Sonstroem, 1988). The model will help identify what stages male Baby Boomers are currently in with regard to weight management, healthy eating, and physical activity. This information will assist in designing interventions that will best recruit individuals who are currently in the precontemplation stage and help them to progress towar d maintenance of a weight management program. Subsequently, exercise researchers have suggested using the or phenomenon. Instead the cyclical nature of the stages explains tha t individuals who drop out during any stage may start up again (Prochaska & Marcus, 1994; Sonstroem, 1988). Moreover, many exercise programs are designed for those who are already active or wanting to be active (Prochaska & Marcus, 1994), through the use o f the stages of change weight loss interventions and can be designed for individuals in each stage of change. When attempting behavior change, a possibility exists that individuals will be unsuccessful and can actually regress to previous stages. Thus, the stages should be viewed as cyclical rather than as a linear sequence (Prochaska & DiClemente, 1982). In other words persons may relapse during the action stage of changing behavior and decide that they are unable to change, thus returning to the precontem plation stage. Even persons in the maintenance stage are still at risk for relapse unless they are able to terminate the problem completely (1982). Each individual will progress at various
49 rates through the stages and may regress and re enter at various st ages of the continuum (Marcus & Simkin, 1993) (See Table 2 1). Precontemplation The precontemplation stage exists prior to any conceived thoughts about changing behavior in the next six months. People in this stage may be uninformed about the potential neg ative outcomes of their current behavior, and may have already been unsuccessful at changing their behavior (Prochaska et al., 2002), and/or may resist being informed about their behavior (Prochaska & DiClemente, 1982). These persons avoid thinking, talki ng, or reading about their behaviors (Prochaska et al., 2002) and may even be defensive about their behavior (Prochaska & DiClemente, 1983). Contemplation The contemplation stage is defined as persons wanting to actively change their behavior within the ne xt six months. These individuals begin to assess the pros and cons associated with behavior change. Evaluation of pros and cons can result in long Prochaska el al., 2002, p. 100). Preparation Individuals in the preparation stage intend to change their behavior within the next 30 days. These individuals have taken some significant action in the past year such as gathering information on their behavior joining a gym, taking a health education class, or consulting a counselor or physician (Prochaska & Velicer, 1997). They may have taken some steps toward behavior change such as increasing their physical activity or reducing the amount of cigarettes they smoke (Prochaska & Marcus, 1994) but have not yet achieved abstinence (Prochaska, DiClemente, & Norcross, 1992).
50 Action In this stage behavioral changes have occurred within the past six months. In the action stage the former behavior is no longer present (e.g., abstinence from smoking), instead of a mere reduction in cigarettes smoked (Prochaska & Marcus, 1994). This is not to suggest they are not at risk for relapse, but merely have met the criterion of the particular behavior being changed. Maintenance Individuals in the maintenance stage are trying to prevent relapse, but are less tempted than persons in action stages and involves the period from six months after the given criterion has been met to a point where there is no risk for relapse (Prochaska & Marcus, 1994). The maintenance stage lasts between six months and five years (Prochaska & Velicer, 1997) supported by evidence from the 1990 Surgeon General report that found among persons with five continuous years of smoking abstinence the risk of relap se was 7% compared to 43% risk after one year of abstinence (DHHS, 1990). For some behaviors, such as those that are addictive in nature, relapse may always be possible and thus maintenance can last a lifetime (Prochaska et al., 1992). Termination In this final stage there is no longer any temptation to return to the former behavior (Prochaska & Marcus, 1994), no matter their emotional state (Prochaska & Velicer, 1997), and maintenance had been achieved for five continuous years (Prochaska & Velicer, 1997) However, for some behaviors like weight control Prochaska and Velicer (1997) argue that termination may be unrealistic and individuals should more practically aim for a lifetime of maintenance instead of adopting an all or none mentality. The review of l iterature provided very few studies that included the termination stage. This
51 may be due to the feasibility of conducting lengthy follow up studies and because termination is not given much emphasis in TTM research (Prochaska et al., 2002). Therefore, this literature review will not include this stage. Stages of Change and Healthy Eating In a study examining stage of change and calcium rich food intake among elderly men and women (mean age 74.6 years) 59% of participants self reported they were in the maint enance stage (six months or more of eating 2 3 servings of calcium rich foods daily) prior to the intervention. Following an education program 73% of the remaining 41% that had previously indicated they were in stages other than maintenance had advanced on e or more stages toward maintenance (Wellman, Kamp, Kirk Sanchez, & Johnson, 2007). In another study looking at stages of change for five servings of fruits and vegetables per day among men and women over 60 (mean age 75 years), 15% were in the precontempl ation stage, 64% perceived they were in the maintenance stage, 18% in the preparation stage and less than 2% were in the contemplation or action stage. Participants who were married were more likely to be in the action and maintenance stage. Individuals in the action and maintenance stages had higher intakes of fruits and vegetables than those in other stages. With regard to fat consumption participants in the action and maintenance stages had lower fat intake than those in other stages and individuals in t he contemplation and preparation stages had lower intakes than those in precontemplation (Greene et al., 2004). In a cohort study looking at baseline fat and fruit and vegetable intake, Kristal, Hedderson, Patterson, and Neuhauser (2001), found that male a nd female participants in the latter stages of change for eating a low fat diet and reading food labels made the largest reductions in fat intake in the two year follow up. These results may indicate that
52 current stage of change for dietary behaviors may p redict future dietary change. Participants who indicated that they were in the maintenance stage at baseline had maintained a low fat or high fruit and vegetable diet for at least six months at follow up. A 1994 survey of dietary practices found that 38% o f male and female respondents were in the precontemplation stage for eating fewer than five servings of fruits and vegetables. Twenty eight percent usually ate fewer than five servings and were in the contemplation stage, 18.5% were in the preparation stag e and were currently eating three to four servings daily, 13% were in the maintenance stage of five servings a day and two percent were in the action stage. Men were significantly more likely than women to eat two or fewer servings of fruits and vegetables a day and be in the precontemplation stage. In addition, individuals with less education were significantly more likely to be in the precontemplation stage (Laforge, Green, and Prochaska). Robinson et al. (2008) also looked at dietary changes across stage s in their weight loss intervention study. With regard to fruit and vegetable consumption 92% of the women were in either the precontemplation/contemplation or preparation stages with 50% in the preparation stage alone. Women in these stages consumed about one serving of fruits and vegetables daily compared to three to four servings consumed in the action/maintenance stage. Dietary fiber consumption had similar patterns with 89% of women in either the precontemplation/contemplation or preparation stages and 48% in the preparation stage. Women in these stages consumed less dietary fiber than women in the action/maintenance stage. Dietary fat consumption was lower in the action and maintenance stages than the precontemplation/contemplation, and
53 prepara tion stages. Fifty six percent of women were classified in the action/maintenance stage for dietary fat. Wee, Davis, and Philips (2005) looked specifically at stages of change and overall weight loss, combining the components of losing weight, improving d iet, and increasing exercise. Of the respondents in the preparation, action, or maintenance stage for losing weight, 61% were also at a similar stage for improving diet and exercise. Individuals who perceived their weight to be a health risk were also more likely to be in the latter stages for all three areas. Therefore, individuals who are ready to lose weight are seemingly ready to change the behaviors associated with weight gain. In the same study, 35% of the participants were in the latter stages of im proving their diet and 26% in the latter stages to improve exercise yet were at the precontemplation and contemplation stages for losing weight (Wee, Davis, & Philips, 2005). With the disconnection between behavior change and weight loss, these results ma y represent a population who is improving diet or exercise for health benefits outside of weight loss. Thus, motivating individuals to want to lose weight may be a more successful strategy than promoting benefits of healthy eating and physical activity. S tages of Change and Physical Activity Previous studies on exercise behavior and the stages of change have shown differences in physical activity levels among the different stages. In a study looking at the physical activity participation of employees from two similar worksites, Marcus and Simkin (1993) found that individuals in the action/maintenance group self reported significantly more vigorous and moderate physical activity than those subjects in the precontemplation/contemplation stages. The five stage s were collapsed in this study to three stages that would include the same amount of physical activity: no exercise, some
54 exercise, and regular exercise. A 2001 study by Sarkin, Johnson, Prochaska, and Prochaska yielded similar results with participants in the action and maintenance stages reporting significantly more bouts of strenuous exercise than individuals in the other stages. With regard to confidence in exercise, individuals in the action stage were more confident than those in the precontemplation and contemplation stages. Individuals in precontemplation stages had significantly less confidence than all other stages. These findings are similar to those found in a study by Robinson et al. (2008) who conducted a 12 month weight loss intervention stud y of overweight women. The stages were again collapsed in this study with precontemplation and contemplation being combined as well as the action and maintenance stages. Eighty eight percent of women were in either the precontemplation/contemplation or pre paration stage of change for physical activity. Level of activity also differed among women who were in the combined action/maintenance stage. Women in these stages participated in more moderate and vigorous physical activity than participants in all other stages. Pros and cons to change as well as self efficacy across stages were also measured in this study. Pros to change generally increased and cons decreased from precontemplation/contemplation stage to the action/maintenance stage. Self efficacy also i ncreased with greater self efficacy in the action/maintenance stage. A 2005 study of men and women 65 years and older found that a majority of individuals were in the precontemplation (21%) or maintenance (50.4%) stages for physical activity, with more me n being in the maintenance stage than women. Individuals in the action and maintenance stages self reported more physical activity than participants in the other stages of change, with those in the maintenance stage
55 reporting more activity than those in th e action stage (Riebe et al., 2005). These findings are consistent with the expectation that those who intend to exercise are more likely to exercise than those who do not. Wellman, Kamp, Kirk Sanchez, and Johnson (2007) conducted an intervention to impro ve physical activity among elderly men and women. Fifty eight percent of participants indicated that they were in the maintenance stage of regular physical activity pre intervention. Following the intervention of a walking and education program 75% of the remaining 42% who were not in the maintenance stage advanced one or more stages toward maintenance, with 38% advancing two or more stages. While physical activity was measured by steps walked, the amount of steps necessary to equate with daily physical act ivity was not provided. Barriers to physical activity have also been shown to differ depending upon an Tai Seale (2003) individuals in the precontemplation stage liste d not having the ability or not being able to maintain activity as the number one barrier. This was followed by lack of time and not having a need for more physical activity. With regard to the influence of age on stage of change Booth et al. (1993) conduc ted a study on Australian adults. Twenty two percent of participants were physically inactive, 40% exercised occasionally, and 38% exercised regularly and intended to continue. Older individuals were less likely to intend to increase exercise level than th e younger participants. These findings suggest that as individuals age it becomes increasingly difficult to change behavior patterns with regard to physical activity.
56 Summary With Baby Boomers nearing the age of retirement they will soon be eligible for go vernment assisted health care. Medicare by design was not intended to provide long term care for chronic conditions such as those associated with obesity. As the literature attests, obesity numbers are increasing from one generation to the next (Leveille e t al., 2005) and as obesity rates go up the health risks associated with obesity such as hypertension, high blood cholesterol, type 2 diabetes, coronary heart disease, and stroke will also increase (DHHS, 2010). The American Heart Association estimates tha t death from heart disease alone will also increase 130% from 2000 2050 (2006). As of 2003, 63.5% of obese men and 36.0% of overweight men were trying to lose weight (Baradel et al., 2009) yet only 20% of overweight and 5% of obese individuals report being happy with their weight (Kuk, Ardern, Church, Hebert, Sui, & Blair, 2009). While men are motivated to attempt to lose weight when a doctor or nurse instructs them to do so, this unfortunately only occurs (most often) after the discovery of a health risk f actor (Roberts & Ashley, 1999). The reasons men have difficulty losing weight are well documented: lack of motivation, lack of time, and a lack of the skills necessary to make dietary changes ( Sabinsky et al., 2007) Lack of time and motivation are also li sted as barriers to eating healthy and physical activity (Booth et al., 1997; Brown, 2005; Brownson et al., 2001; Lappalainen et al., 1997) which are two behaviors closely associated with weight management ( Surgeon General, 2001). Determining the specific needs of Baby Boomer men for overcoming the barriers of initiating and adhering to weight loss/weight management could decrease the cost in treatment of the health risks associated with overweight and obesity.
57 Table 2 1. Description of Stages of Change Stage of Change Description Precontemplation Has no intention to take action in the next 6 months Contemplation Intends to take action in the next six months Preparation Intends to take action within the next thirty days and has taken some behavio ral steps in this direction Action Has changed behavior for less than six months Maintenance Has changed behavior for more than six months Termination No temptation to engage in the old behavior and 100% self efficacy in all previously tempting situ ations
58 CHAPTER 3 METHODOLOGY The goals of this study were to: 1) assess body satisfaction and obesity status among male Baby Boomers, 2) identify weight loss strategies used by male Baby Boomers, 3) identify barriers and motivators to weight loss among male Baby Boomers, 4) assess physical activity levels among male Baby Boomers, 5) assess areas of improvement that are needed in the diets of male Baby Boomers, and 6) make programmatic recommendations for developing weight maintenance programs for male B aby Boomers. The methods that were used for this research project are described below. The research design, population, instruments, data collection, and data analysis are included in this section. The study was reviewed and approved by the Institutional R eview Board of the University of Florida. Research Design sectional research design to examine the weight managemen t, physical activity, and healthy eating sectional design entails the collection of data on more than one case and at a single point in time (Bryman, 2001, p. 41). In addition, this research design allows for severa l subjects to be tested at the same time and is not threatened by testing or history effects since subjects are only tested one time (Portney & Watkins, 2000). This descriptive, exploratory study used self administered surveys to collect data. Survey resea rch is a common research method for collecting descriptive data (Portney & Watkins, 2000) based on real world observations
59 series of questions that are posed to a group of subjects and may be conducted as an are composed of questions that may be conducted in oral or written form (Portney and provide a snapshot of how things are at the usefulness of this type of research, some common problems with social survey research are poorly worded questions (Bryman, 2001) and low response rate (Denscome, 2003). Due to these concerns, surveys were only administered to subjects who agreed to participate and the principal investigator provided clarification as needed. Sample Population A sample is used in research to serve as a reference group for drawing conclusions about the population it represents (Portney & Watkins, 2000). The size of the sample has an important affect on statistical power and the larger the sample, the greater the statistical power (Portney & Watkins, 20 00). A priori sample sizes were calculated for the present study using G*Power 3.1.2, a free, online program commonly used in social and behavioral research to conduct power analyses (Faul, Erdfelder, Lang, & Buchner, 2007). Table 3 1 provides the results of three a priori power analyses for t test, ANOVA, and Chi Square statistical tests. Power was set at 1 has previously been suggested to provide reasonable protection against Type II error (Portney & Watkins, 2000). The sample sizes neede d for the statistical tests used in the study were as follows: 128 for t tests, 195 for One way Analysis of Variance, and 143 for Chi Square analysis. Data were collected from 211 participants living in North Central Florida. The target population for th is study was a convenience sample of men born between the
60 years of 1946 and 1964. Participants were recruited from the local university, sporting events, male church groups, fraternal organizations (such as the Freemasons), and other community agencies, bu sinesses, and functions. The inclusion criteria for the study were: 1) ambulatory males born between 1946 and 1964, 2) residing within 50 mile radius of Gainesville, and 3) able to give verbal consent to complete the survey. Instruments The current surv ey instrument was adapted from an instrument previously developed by James (2003, 2004, 2006). The development of this original instrument used qualitative and quantitative measures and has been adapted for use with several populations including adult male s and females, and college students. The development, use, and validation of the original instrument are discussed elsewhere (James 2003, 2004, 2006). To adapt the survey for male Baby Boomers, an extensive review of the literature was conducted in the ar Content validity of the survey instrument was tested during the construction of the 2000, p. 83) and is used to determine if any of the items are irrelevant to the purpose of the measurement (Portney & Watkins, 2000). Content validity was determined through multiple revisions of the instruments by two researchers who had expertise in the field as well as by two members of the target population. After agreement that the instruments included items that adequately sampled the content domain they were said to have content validity. s to test what it is p. 82). While face validity is subjective and considered scientifically weak, it does serve
61 an important purpose for increasing the likelihood that those who are tested by it find the questions relevant and thus answer the questions more hones tly (Portney & Watkins, 2000). Face validity of the survey instrument was determined by asking three untrained observers if the questions appeared valid to them Any items that were Minor revisions were then made in the wording and ordering of some of the questions and again measured for face validity. The final survey instrument consisted of 8 4 items (See Appendix A) and took approximately 30 minutes to complete. The self administered survey included 14 demographic items: year of birth, marital status, sexual orientation, number of children, number of children living at home, employment status, home ownership, type of home, location, U.S. citizenship, years of U.S. residency, race/ethnicity, educational attainment, and yearly income. There were 22 items on the survey that were focused on topics related to healthy eating practices. Eight dichoto mous items asking about eating breakfast, super sizing meals, grocery shopping, packing lunches, using diet sodas, using sugar substitutes, reading food labels, and understanding food labels. One five point Likert item (1 = excellent; 5 = poor) asked parti cipants to describe their diet and five five point Likert items (1 = everyday; 5 = rarely or never) were used to gather frequency data about eating at fast food restaurants, eating at buffet style restaurants, preparing meals at home, drinking sodas, and d rinking sweetened beverages. Five multiple selection items pertained to the predominate focus on food labels, barriers to eating healthy, motivators to eating healthy, foods needing to be consumed to improve diet, and foods needing to be reduced to improve diet. One contingency question concerning overeating was
62 included that led to a multiple selection item with choices for cause of overeating. Finally, one single selection item pertained to the stage of change for eating healthier. The weight status port ion of the survey included 21 items. Four fill in the blank questions asked participants to self report current weight, height, ideal weight, and waist size. The self reported height and weight was used to determine Body Mass Index (BMI) was calculated by dividing weight in kilograms by height in meters squared (kg/m 2 ). Self reports are commonly used measurements for collecting data on height and weight and are good methods for quickly collecting data on large samples of individuals (Gorber, Tremblay, Moher & Gorber, 2007). These measurements were used to determine what percentage of male Baby Boomers surveyed were overweight and/ or obese and will later be analyzed with other survey items to determine significance between, weight loss practices, healthy ea ting, and physical activity levels with self reported weight. One five point Likert item (1 = very satisfied; 5 = very unsatisfied) was used to determine weight satisfaction and one five point Likert item (1 = few times a day; 5 = never) to assess freque ncy of thoughts about weight. Two single selection items were used to gather information about weight description and weight management. One dichotomous question asked participants if they had ever been told by a doctor to lose weight. One contingency ques tion was included to assess weight loss in the previous 12 months which was followed by three single selection questions about weight loss, duration in the weight loss program, and length of time the weight was kept off; with one additional five point Like rt item (1 = very satisfied; 5 = very unsatisfied) assessing satisfaction with previous weight lost. Five multiple selection items pertained to sources
63 of dieting information, previously used weight loss strategies, barriers to losing weight, motivators to losing weight, and information needed to lose weight. One single selection answer was also included to assess the possibility of having surgery to lose weight. Finally, one single selection item pertained to the present stage of change for losing weight. There were 20 survey items that addressed physical activity. One contingency question was used to assess disability or injury and led to one single selection question about current physical activity level. One final contingency question was used to determi ne transportation to work which led to a fill in the blank question about travel occupations and the presence of sidewalks in the neighborhood for physical activity. Eigh t single selection items were used to assess frequency cardiovascular activity, duration of cardiovascular activity, frequency of muscular activity, frequency of flexibility activity, involvement in single weekend bouts of exercise, frequency of watching t elevision, frequency of surfing the Internet, and frequency of online gaming. Five multiple selection questions addressed type of cardiovascular activity, locations used for exercise, types of competitive activities used for exercise, barriers to increasin g physical activity, and motivators to increasing physical activity. Finally, one single selection item pertained to the present stage of change for exercise. The last section of the survey included seven items about lifestyle and medical history. Two dich otomous items pertained to having health insurance and smoking. One five point Likert item (1 = excellent; 5 = poor) asked participants to describe their health. One contingency question assessed alcohol use and was followed by one dichotomous
64 question abo ut binge drinking. Finally, two multiple selection items gathered data about supplements and history of disease. Data Collection Procedures Prior to beginning any portion of this study an application was submitted to and approved by the University of Flor ida Institutional Review Board (UFIRB), protocol number 2008 U 0061 (See Appendix B). The survey approved for this study did not require written consent and the participants verbally consente d to participate in the study. Data were collected over a one yea r period. All potential participants were asked if they were willing to participate in the study and to complete a self administered survey onsite. Those who agreed by verbal consent were given the survey, pencil, and a clipboard to complete the survey. The survey was completed in person and was collected for each participant on a single occasion. The instrument took 20 to 30 minutes to complete. Purposive sampling was used by the principle investigator and volunteer recruiters in selecting men born bet ween 1946 and 1964. Purposive sampling is a non probability sample in which the researcher selects subjects based on some form of specific criteria (Denscombe, 2003; Portney & Watkins, 2000). In addition, snowball sampling, was used whereby initial partici pants could identify other individuals who meet the selection criteria. Snowball sampling, or chain sampling, has previously been identified as a useful technique when recruiting subjects whose inclusion characteristics are difficult to locate (Portney & W atkins, 2000). Through the use of snowball sampling the researcher can accumulate subjects quickly from participant nomination of others who are relevant
65 for the study. The nominator can then be used in reference when contacting each new identified subject rather than approaching them cold (Denscombe, 2003). Data were collected at various sites in the North Central Florida region that were identified by the principle investigator as locations men were likely to attend. Data collectors were recruited from u ndergraduate classes at a local university and were trained on how to administer the survey instrument. Training was provided by the researcher. Survey participants were approached at recruiting sites by the data collectors and asked if they were born bet ween the years of 1946 1964 and if they lived in the community. If the participants met the inclusion criteria they were invited to take part in the study. The data collectors informed the participants that the survey instrument would take approximately 30 the participant agreed to complete the survey the data collector provided them with a clipboard, pen, and the survey instrument. Upon completion of the survey instrument, the data collectors p laced the completed survey in a manila envelope and thanked the participant for their time. To ensure confidentiality and anonymity, no indentifying information was collected from participants. The surveys were numbered, but were distributed in random orde r so that participants could not be associated with a number based on the date they had completed the survey. There were no incentives for participation. Data Analysis Survey data was analyzed using SPSS v. 17.0 software package. The level of significanc e was set at a 95% confidence level, with a p value of .05. Each survey response was given a numeric code to simplify data entry and analysis (Portney &
66 t test, ANOVA, and Chi squar e ( X 2 ). Multiple post hoc comparisons were done with Tukey Kramer HSD test. Table 3 1 provides the variables and statistic analysis used to address five of the research aims. Aim 6: To make programmatic recommendations for developing weight maintenance pr ograms for Baby Boomer men, will be addressed in Chapter 5. Summary Chapter 3 describes the methods used to examine the research aims of the study. The chapter includes a description of the research design, the sample population, the instruments used in t he study, data collection procedures, and data analysis procedures. Data was collected during the spring of 2008 and summer of 2009. A total of 200 participants were desirable. Ethical Issues Prior to beginning the study, the survey questions were sent to the Institutional Review Board (IRB). Participants completing the surveys were asked to give verbal consent prior to answering any questions. They were not asked to give their names so their information could be kept anonymous.
67 Table 3 1. Sample sizes c omputed from a priori power analyses Statistical test Effect size (1 t test 0.50 0.05 0.80 128 0.8015 ANOVA 0.25 0.05 0.80 195 0.8098 2 0.30 0.05 0.80 143 0.8015
68 Table 3 2. Statistical analysis for variables within in each re search aim Aim Variables Analysis Post hoc 1 BMI; BMI classification; Weight description Univariate BMI X Demographics t test; ANOVA Tukey Weight describe X BMI ANOVA Tukey Weight describe X Demographics; BMI Class Chi Square Doctor X BMI t test Doctor X BMI classification Chi Square Surgery X BMI ANOVA Tukey Disease diagnosis X BMI t test Disease diagnosis X BMI classification Chi Square Thoughts about weight; Current WL X BMI ANOVA Tukey Current weight loss X BMI classification; Disease Chi Square Advised by a doctor X BMI classification Chi Square Lost in last 12; Stage for weight loss X BMI ANOVA Tukey Info needed to lose X BMI t test Info needed to lose X Demographics Chi Square 2 Weight loss strategies X BMI t test Weight loss strategies X Demographics Chi Square 3 Barriers to WL; Motivators to WL X BMI t test Barriers to WL; Motivators to WL X Demo Chi Square 4 Physical activity; Cardio X BMI ANOVA Tukey Type of cardio X BMI t test Type of cardio X Demographics Chi Square Strength activity; Flexibility; Stage of PA X BMI ANOVA Tukey Strength activity; Flexibility X Demo Chi Square Venue for PA X BMI t test Venue for PA X Demographics Chi Square Barriers to PA; Motivators to PA X BMI t test Barriers to PA; Motivators to PA X Demo Chi Square 5 Eating habits (Fast food, breakfast) Univariate Overeating; Cause of overeating X BMI t test Cause of overeating X Demographics Chi Square Source of dieting info X BMI ANOVA Tukey Source of dieting info X Demographics Chi Square Eating habits to increase; decrease X BMI t test Eating habits to increase; decrease X Demo Chi Square Stage of Healthy eating X BMI ANOVA Tukey Barriers to HE; Motivators to HE X BMI t test B arriers to HE; Motivators to HE X Demo Chi Square
69 CHAPTER 4 RESULTS This descriptive, exploratory study examined the current weight status of male Baby Boomers, the strategies they use to achieve and maintain a healthy weight, current physical activity levels, healthy eating habits, and the barriers and motivators to weight loss, physical activity, and healthy eating. In addition, the stage of change for weight loss, physical activity, and healthy eating were also assessed. This chapter describes the ch aracteristics of study participants including age cohort, income, race/ethnicity, education, and marital status. The chapter will also present data analyses for the research aims of the study. Participant Characteristics Study participants included men b orn between the years of 1946 and 1964 at the time of data collection. Participants lived within a 50 mile radius of Gainesville, Florida. Cross sectional surveys were administered to research participants in the summer of 2009. Data collection procedures produced 211 surveys. The level of significance was set at a 95% confidence level, with an alpha of .05. Power was set at 80, with a beta of .20. The demographic statistics are illustrated in Table 4 1. There were 104 (49.3%) participants who were categori zed into the older cohort of Baby Boomers (born between the years of 1946 1955) and 107 (50.7%) placed in the younger cohort of Baby Boomers (born between the years of 1956 1964). A wide range of salaries were represented from 33.2% making $70,000.00 or mo re down to 5.9% making less than $20,000.00. The sample consisted of 158 (74.9%) White participants; with 34 (16.1%)
70 African Americans; 8 (3.8%) Hispanic; and 11 (5.2%) who identified themselves as With regard to educational level attained, one i ndividual had less than an eighth grade education, 5 (2.4%) did not finish high school, 71 (33.7%) had graduated high school or had their GED, 47 (22.3%) had an A.A. degree or professional license; 39 (18.5%) had no higher than a bachelors degree, and the remaining 48 (22.8%) had a graduate or professional degree. The majority of participants (158) were married (74.9%), 27 (12.8%) were single, not in a committed relationship, 21 (10%) were single but in a committed relationship, and five (2.4%) were married but separated. Nearly 97% were heterosexual, 3.3% were homosexual, and no one identified themselves as bisexual. Over 79% had children, with 39.4% having one or more children aged 13 18 years old living in their household, 14.7% reported they had one or m ore children aged 6 12 years old living in their household, and 3.5% had one or more children under five years old currently living in their household. Seventy nine percent worked full time, 3.8% worked part time, 10% were unemployed, and 4.7% were unable to work due to disability. Sixty seven (35.8%) participants indicated that they work in a physically demanding job. Eighty seven percent owned their own home, and 81.5% lived in a house. Ten percent lived in an apartment or condominium and 8.5% lived in a mobile home. Forty three percent lived in rural areas. Over 91% were born in the United States. Nearly 52% of participants self described their health as very good or excellent (35.9% and 16.0% respectively), 35.4% described their health as good, 10.7% s tated their health was fair, and 1.9% felt their health was poor. The majority (87.5%) had
71 some form of health insurance. Less than 19% were smokers. Thirty percent indicated they had high cholesterol, 27.6% had hypertension, 13.7% had diabetes, 8.5% had b een diagnosed with obesity, 4.8% had heart disease, 2.4% had prostate cancer, and 1.0% had experienced a stroke. Due to sample small size, several of the demographic categories were collapsed prior to analysis. The racial/ethnic group item was reduced fro m four levels (Black/African American, Hispanic, White/Caucasian, and Other) to two levels, 155 White (74.9%) and 52 non White (25.1%). The highest level of education categories one category categories. The four categories of marital status were collapsed into two categories due arate were single and 158 (74.9%) were married. Research Aims Research Aim # 1 Assess the w eight s tatus of Baby Boomer men To first assess the current weight status of s tudy participants, BMI was calculated based on their self reported weight and height using self reported weight and height (kg/m 2 ). Mean BMI for participants was 29.355.07 and the range was 34.25 (20.67 to 54.92). Based on the standard BMI classification, 43.1% were overweight, 39.2% were obese, and 17.7% were normal. Of individuals who were considered obese, 3.4% were (See Table 4 2).
72 A boxplot was produced to determi ne the distribution of the data. Figure 4 1 shows the distribution of the calculated BMI. Five scores were identified as outliers. The BMI for each of the five scores was over 40 which is considered extremely obese (DHHS, 2010). In addition, individuals wh o have a BMI exceeding 40 kg/m2 meet the criteria for bariatric surgery that were established by the National Institutes of Health Consensus Development Panel (NIH, 1991). These five scores, plus two participants whose BMI was over 40, and two participants with missing values for height and weight were omitted from BMI analysis. To determine differences in weight status for the demographic variables of age, race/ethnicity, and marital status, three separate independent samples t Tests were conducted. BMI was not significantly different between the older cohort and the younger cohort, between White and non White, or for single and married men ( p > .05). Separate one way ANOVAs performed on mean BMI and demographic variables revealed that groups did not diff er based on income or education ( p > .05). Eleven participants (5.4%) described themselves as underweight, 40 (19.8%) felt described themselves as very overweight, and two (1.0%) said that they were extremely differences in BMI among the four self described wei ght groups, F (3, 198) = 52.29, p = 0.000. Tukey post hoc tests revealed that BMI for the underweight group (24.383.50) was significantly lower than all other weight self describe groups ( p < .05) except for the just right group, which had a BMI of 25.24 2.07. The just right group was significantly
73 lower than two succeeding weight categories, slightly overweight (29.043.27) and very overweight (33.132.87), p < .05. The slightly overweight group had a significantly lower BMI than the very overweight group p < .05. Among men who were at a normal weight (18.5 24.9), eight (22.2%) felt that they overweight and none of the men at normal weight described their weight as very o r extremely overweight. Looking at overweight men (BMI 25.0 29.9), two (2.2%) felt overweight, and five (5.6%) felt that they were very overweight. None of the men in the overweight category indicated that they were extremely overweight. Finally, looking only at men who were classified as obese revealed that only one individual (1.3%) thought 30 (40.0%) very overweight, and two (2.7%) reported extremely overweight. Accuracy of self identification was then calculated by determining the percentage of men in each weight category who described themselves in each of the following: underweight (< 1 24.9), slightly overweight (25.0 29.9), and very weight and described their weight, with 73 (36.3%) self describing a weight below their actual w eight, and 16 (7.9%) self describing a weight above their actual weight. Weight preference Participants were then asked to identify their preferred weight. The preferred weight was then calculated with self reported height to determine what their BMI would be at the ideal weight. Based on the preferred weight, 57 (29.5%) were in the normal category, 128 (66.3%) were in the overweight category, and eight (4.1%) were in the
74 obese category. Looking within each weight category, 94.6% of normal weight men h ad a preferred weight in the normal range whereas only 25.9% of overweight men and 1.3% of obese men had a preferred weight in normal weight range. In the overweight category, 5.4% of normal weight men, 74.1% of overweight men, and 88.0% of obese men had a preferred weight in the overweight range. Results of a paired samples t test revealed mean ideal weight was significantly lower than mean reported weight. The results of a one way ANOVA revealed a significant difference to exist between the means of the B MI for the classification groups, F (2, 198) = 19.861, p = 0.000. Tukey post hoc tests revealed that the obese group had a significantly higher ideal BMI than the normal weight and overweight groups. Approximately 40% had been told by a doctor to lose wei ght and had a significantly higher BMI (31.583.40) than those who had not been told by a doctor to lose weight (26.953.26), t= 9.691, df = 199, p = 0.000. Among obese and overweight men, 29.2% of overweight men and 70.7% of obese men had been told by a do ctor to lose weight. A Chi Square analysis of overweight and obese revealed that obese men 2 (1, = 164) = 28.013, p = 0.000). Medical weight loss history When asked if they w ould ever consider having surgery to lose weight, 172 (86.8%) said no, 14 (7.4%) said maybe, and 10 (5.9%) said yes. Results of a one way ANOVA revealed that individuals who would consider having surgery to lose weight had a significantly higher BMI (31.87 2.80) than individuals who said they would not consider having surgery (28.383.82), F (2, 193) = 5.947, p = 0.000. A posteriori
75 When comparing BMI to diagnosed diseases and conditions, BMI was significantly higher among individuals who had been diagnosed with obesity (34.172.97) than those who had not (28.403.78) t= 5.575, df = 199, p = 0.000. Individuals with diabetes had a significantly higher BMI (31.513.80) than those who did not (28.413.89), t= 3.738, df = 199, p = 0.000. BMI was also significantly higher among individuals with high cholesterol (29.793.64; 28.404.09), t= 2.266, df = 199, p = 0.025 and hypertension (30.594.18; 28.133.73), t= 4.031, df = 199, p = 0.000. Chi Square analysis was conducted to determine if there were significant differences in disease diagnosis and weight status. Men who were classified as obese were significantly more likely be diagnosed with obesity, diabetes, and hypertension, p < .05. Weight s atisfaction Overall satisfa ction with current body weight varied from very satisfied to very unsatisfied. Twenty one participants (10.4%) were very satisfied with their weight, 39 (19.3%) were satisfied, 67 (33.2%) were somewhat satisfied, 64 (31.7%) were unsatisfied, and 11 (5.4%) were very unsatisfied. Twenty seven (73.0%) normal weight men were satisfied with their weight, but only 29 (32.2%) overweight men and four (5.3%) obese men were satisfied or very satisfied with their weight. BMI increased significantly as level of satisfa ction decreased, F (4, 197) = 26.933, p = 0.000. There were no significant differences in BMI for the very satisfied and satisfied groups, 24.632.36 and 26.202.73 respectively, but both were significantly lower than the somewhat satisfied (28.733.52), u nsatisfied (31.093.38), and very unsatisfied (32.783.84) groups. The BMI for the somewhat satisfied group was significantly lower than the unsatisfied and very unsatisfied groups, p < .05. There was no significant difference in BMI for the unsatisfied an d the very unsatisfied groups ( p > .05).
76 The participants were asked how often they thought about their weight. Twenty eight (13.9%) thought about their weight at least a few times a year. Seventy four (36.6%) thought about their weight a few times a mont h, 64 (31.7%) thought about their weight almost every day, and 13 (6.4%) thought about their weight a few times a day. Twenty three (11.4%) indicated that they never thought about their weight. Results of a one way ANOVA found that as frequency of thoughts about weight increased BMI also increased, F (4, 197) = 7.146, p = 0.000. Tukey post hoc tests revealed that individuals who thought about their weight a few times a day had a significantly higher BMI (31.533.31) than the few times a year (27.454.08) an d never (26.012.94) groups, p < .05. The almost every day group had a significantly higher BMI than the few times a year and never groups, p < .05. The never group had a significantly lower BMI than the few times a day, almost every day, and the few times a month groups, p < .05. Weight loss status Over 55% (n=112) of participants were currently trying to lose weight, 46 (22.8%) were not doing anything at all about their weight, 37 (18.3%) were trying to stay the same weight, and seven (3.5%) were trying t o gain weight. Significant differences in BMI were found among the four groups, F (3, 198) = 23.734, p = 0.000. Those who wanted to lose weight had a significantly higher BMI (30.463.67) than those who wanted to gain weight (23.351.51), stay the same wei ght (26.062.52), and those who were not trying to do anything with their weight (27.713.74), p < .05. Individuals who were trying to stay the same weight had a significantly lower BMI than those who were not doing anything about their weight, p < .05. Re sults of a Chi Square analysis revealed a significant difference between weight classification and current weight loss, 2 (6, = 202) = 53.896, p = 0.000). Fifty nine (78.7%) obese men, 46 (51.1%)
77 overweight men and 7 (18.95%) normal weight men were cu rrently trying to lose weight, indicating that obese men were significantly more likely to be trying to lose weight than normal weight men. However, it should be noted that more than 20% of expected cell counts were less than five percent. Chi Square anal ysis revealed significant differences in the current weight loss status and disease diagnosis. Participants who had been diagnosed as obese were significantly more likely to be currently trying to lose weight than individuals who were not diagnosed as obes 2 (3, = 201) = 12.201, p = 0.007). In fact, all individuals who had been diagnosed as obese were currently trying to lose weight. In addition, 2 p = 0.002) and hypertensio 2 (3, = 201) = 9.781, p = 0.021) were significantly more likely to be trying to lose weight. Looking at professional advice and weight loss among overweight individuals, those who had been told by a doctor to lose weight (73.1%) were significantly mo re likely to be losing weight that those who were not told by a 2 (3, = 89) = 9.874, p = 0.020). Doctor advice to lose weight and current weight loss status in the obese group was not significant ( p > .05). Half of all participan ts, 106 (52.5%), had tried to lose weight in the past year and had a significantly higher BMI (30.273.63) than those who had not (27.143.75), t= 6.035, df = 200, p = 0.000. Among those who had lost weight in past 12 months, 20 (18.9%) had lost less than five pounds, 42 (39.6%) lost 5 10 pounds, 19 (17.9%) lost 11 15 pounds, 13 (12.3%) lost 16 20 pounds, and 12 (11.3%) lost more than 20 pounds. There were no significant differences between BMI and previous weight lost in the past 12 months, F (4, 101) = 1. 824, p = 0.130.
78 Among those who had lost weight in the previous 12 months, 19 (17.9%) were very satisfied with the weight they lost, 36 (34.0%) were satisfied, 31 (29.2%) were somewhat satisfied, 14 (13.2%) were unsatisfied, and five (5.7%) were very unsa tisfied. With regard to how long they stayed on the weight loss program, five (4.9%) said less than one week, three (2.9%) said one week, 14 (13.6%) said two to three weeks, 20 (19.4%) stayed on four to six weeks, and 61 (59.2%) stated that they stayed on the weight loss program for more than six weeks. Twelve (11.6%) said they kept the weight off for less than one month, 14 (13.6%) one to three months, 26 (25.0%) four to six months, 23 (22.1%) seven months to one year, and 29 (27.9%) said they had kept the weight off more than one year. Research Aim # 2 Identify weight loss strategies used by Baby Boomer men The purpose of this section is to identify what knowledge and skills participants felt that male Baby Boomers need in order to lose weight. Stage of c hange for weight loss and weight loss strategies currently being used or strategies that have been used in the past will also be determined. For the stage of change and weight loss strategy analyses, all men who were in the normal BMI category (18.5 24.9 ) were excluded. Information needed to lose weight Participants were asked to select information that they felt men their age needed to lose or maintain a healthy weight. They were allowed to choose as many as applicable from the list provided. Information identified were: portion control/serving size (58.3%), recommended amount of physical activity (58.3%), healthy recipes (52.1%), how much food they should eat (46.0%), how to control stress (34.6%), and how to choose a weight loss program (22.3%) (See Tab le 4 3). BMI was significantly lower
79 (28.28+/ 3.98) for men who indicated that men their age would benefit from information on how much exercise they need than men who did not (29.47+/ 3.96), t= 2.110, df = 200, p = 0.036. There were no other significant differences between BMI and information needed to lose weight ( p > .05). A Chi Square analysis, conducted to examine group differences in knowledge and skills needed to lose weight, yielded that White men were significantly more likely than non White men t o identify that men their age needed information on portion control and serving size, 2 (1, = 211) = 6.461, p < 0.05 (See Table 4 4). There were no other significant group differences ( p > .05). Stage of change for weight loss Univariate statistical analysis was conducted to determine the proportions of men in each stage of change for c urrently trying to lose weight. The results for each stage were: precontemptaion (22.0%), contemplation (15.5%), preparation (6.5%), action (36.3%), and maintenance (19.6%). Mean BMI was then calculated for each stage of change for weight loss and are prov ided in Table 4 5. Results of a one way ANOVA and Tukey post hoc test, comparing BMI and stage of change, revealed that the BMI for participants who had no intention to lose weight (precontemplation) was significantly lower than the BMI for all other stage s for weight loss, F (4, 158) = 4.645, p = 0.001. Weight loss strategies currently being used or attempted in the past Participants were asked to identify healthy and unhealthy weight loss strategies that they were currently using or had tried in the past The strategies provided came from those identified in the weight loss literature. They were allowed to choose as many as applied from the list provided. The current or previous healthy weight loss strategies that were most commonly identified were: eat l ess food (63.0%), exercise more often (51.5%), cut back on fried foods (42.4%), cut back on sweets and desserts (41.2%), cut
80 back on alcohol (15.2%), and join a weight loss program (7.9%). Unhealthy strategies used were: fasting or skipping meals (9.1%), m eal replacement drinks/bars (9.1%), and diet or water pills (4.2%). Ten percent indicated that they had never tried to lose weight (See Table 4 6). A Chi Square analysis test, conducted to examine if persons who selected eat less food also selected exercis e more often, resulted in a significant effect 2 (1, = 165) = 18.765, p = 0.000). In the total sample, 40.6% listed eating less food and exercising more often. To determine differences in BMI and reported weight loss strategies, independent samples t Tests were used. The categorical variables of using one for yes and two for no for each weight loss strategy were compared to the calculated BMI (See Table 4 7). There were significant differences in mean BMI for men who reported yes to eating less food, s kipping meals, joining a weight loss program, using meal replacement bars, and using diet or water pills, p < .05. In addition, men who had never tried losing weight had a significantly lower BMI than those who had tried to lose before, p < .05. Chi Square analysis was used to determine demographic group differences for weight loss strategies used. Results indicated that White men were significantly more likely than non 2 (1, = 165) = 5.743, p < .05) and cut 2 (1, = 165) = 5.247, p < .05). Non White men were more likely to 2 (1, = 165) = 4.662, p < 0.05). Single men were significantly more likely than married men to have never tried to lose 2 (1, = 165) = 5.312, p < 0.05) and married men were significantly more likely 2 (1, = 165) = 6.810, p < 0.05) (See Table 4 8). There were no other significant group differences ( p > .05).
81 Research Aim # 3 Identify barriers and motivators to weight loss among Baby Boomer men This section will describe the current barriers participants identified that are preventing them from losing weight. As a follow up question, the men were then asked to provide what they feel would best motivate them to lose weight. For the barriers and motivators to weight loss analyses, all men who were in the normal BMI category (18.5 24.9) were excluded. Barriers to weight loss Participants were asked to identify barriers to losing weight; they were allowed to choose as many as applied from the list provided. Nearly 14% indicated that they did not need to lose weight. The most frequently reported barriers to losing weight were: not disciplined/no will power (28.5%), not a priority (2 8.5%), not motivated to lose weight (22.4%), and have not found a plan that works for me (17.6%) (See Table 4 9). Independent t tests comparing mean BMI to the reported barriers to weight loss revealed significantly higher BMI in men who identified that th ey were not disciplined or had no will power to lose weight, were not motivated to lose weight, could not lose weight because they had not found a plan that worked for them, and said that nothing they had previously tried had worked, p < .05. BMI was signi ficantly lower for men who indicated that weight loss was not a priority for them and who said that they (or reported) did not need to lose weight or were happy with their weight, p < .05. There were no other significant differences in BMI and reported bar riers to losing weight ( p > .05) (See Table 4 10).
82 Chi Square analysis indicated that the younger cohort was significantly more likely 2 (1, = 165) = 3.990, p = 0. 46). With regard to race, non White were significantly more 2 (1, = 165) = 4.575, p = 0.032). There were no other significant relationships between barriers to weight loss and age cohort, incom e, race/ethnicity, education, or marital status ( p > .05). Motivators to weight loss Participants were asked to select as many motivators to losing weight as applied from a provided list (See Table 4 11). The main factors that would motivate individuals to lose weight were: to feel stronger and fitter (65.5%), to look better (54.6%), being dissatisfied with my body (38.2%), to prevent from getting certain diseases (36.4%), being diagnosed with a disease or illness (30.9%), if a doctor tells them to (24.2% ) and of their partner is dissatisfied with their body (16.4%). Although not significantly different, there were a greater percentage of single men (21.6%) who reported being motivated if their partner was dissatisfied with their body than married men (15. 2%). BMI was significantly higher for men who were motivated to lose weight in order to look better and among men who were dissatisfied with their body, p < .05 (See Table 4 12). A Chi Square analysis test comparing motivators to weight loss for the two ag e cohorts indicated a significant difference in wanting to look better as a motivator for weight loss. The younger was significantly more likely to list to look better as a motivator 2 (1, = 165) = 4.086, p = 0.043 ). There were no other significant group differences for age cohort and motivators to weight loss ( p > .05). Chi Square analysis was used to investigate the relationship between race/ethnicity and motivators to weight loss. Forty four percent of White men indicated
83 that they would be motivated to lose weight if they were dissatisfied with their body, as compared with 19.0% of non White 2 (1, = 165) = 8.739, p = 0.003). White men were also more likely than non White to be motivated to lose weight in order to feel 2 (1, = 165) = 4.259, p = 0.039). There were no other significant group differences for race/et hnicity and motivators to weight loss ( p > .05). Chi Square analysis was used to investigate the relationship between education level and motivators to weight loss. Fifty six percent of men with graduate or professional degrees, 44.1% of men with bachelor associates or professional degrees indicated that they would be motivated to lose weight to prevent from getting certain diseases, as compared with 20.0% of men with high school degrees and 20.0% of men who did not finish 2 (4, = 165) = 13.369, p = 0.010). There were no other significant group differences at for education and motivators to weight loss ( p > .05). With regard to marital status and motivators to weight loss, married men were significantly more likely to list to be more productive at 2 (1, = 165) = 5.368, p = 0.021). There were no significant demographic differences for income ( p > .05). Research Aim # 4 Assess current physical activity levels of Baby Boomer men This se as current participation in cardiovascular, muscular, and flexibility exercises. For the cardiovascular exercises, occurrence, duration, and type of activity will also be ident ified. Preferred exercise venue(s) and competitive activities most frequently participated in on a regular basis will be listed. Finally, stage of change for physical activity and the barriers and motivators to increasing physical activity will be determin ed.
84 Amount, type, frequency, and duration of physical activity When asked to describe their current physical activity level 15.1% self described themselves as very active and had a BMI of 27.054.03, 31.9% were active with a BMI of 27.843.83, and 43.8% w ere moderately active with a BMI of 29.483.93. Due to 31.313.72 (See Table 4 13). One way ANOVA was performed and determined significant differences existed in BMI and described physical activity level, F (3, 181) = 6.232, p = 0.000. Follow up Tukey multiple comparisons tests found that mean BMI for the not active group was significantl y higher than active and very active groups ( p < .05), and the mean BMI for the very active group was significantly lower than the moderately active and not active groups, p < .05. With regard to planned moderate cardiovascular activity, 14.2% exercised 5 7 times per week, 26.9% exercised 3 4 times per week, 26.4% exercised 1 2 times per week, and 32.5% did not exercise regularly. Mean BMI according to exercise frequency are provided in Table 4 14. One way analyses of variance revealed significant differenc es between groups, F (3, 193) = 2.294, p = 0.035. Means were compared with exercised 5 7 times per week (26.683.40) and individuals who did not exercise regularly (29.154.19) p < .05. On days of planned moderate cardiovascular activity, 38 (22.9%) exercised for less than 30 minutes, 77 (46.4%) exercised for 30 45 minutes, 24 (14.5%) for 46 minutes to 1 hour, and 27 (16.3%) for more than 1 hour. There were no significant diff erences in BMI between groups.
85 Walking was chosen as the primary cardiovascular activity by 60.9% of the participants, followed by biking (20.3%), and running (18.8%). Swimming (7.6%) and playing basketball (3.1%) were the least selected activities (See Ta ble 4 15). This survey question also allowed for participants to write in any other forms of preferred cardiovascular activity, 5.1% of write in responses consisted of exercise machines (elliptical, treadmill, cardio machine, etc.). Individuals who partici pated in running had a significantly lower BMI (27.093.88) than those who did not (29.113.95) ( t= 2.816, df = 195, p = 0.005). There were no other significant BMI differences for cardiovascular activities that were significant ( p > .05). Results of a Ch i Square analysis indicated that the younger cohort was significantly more likely to list running as a cardiovascular 2 (1, = 205) = 8.551, p = 0.003) and non White men 2 (1, = 205) = 4.427, p = 0.035). There were no other significant group differences for demographics and cardiovascular activity ( p > .05). With regard to lifting weights, 0.5% lifted 5 7 times per week, 18.7% lifted 3 4 times per week, 14.1% lifted 1 2 times per week, and 66.7% did not lift weights regularly. There were no significant differences in BMI between groups ( p > .05). Looking at participation in flexibility exercises such as stretching or yoga, 8.1% participated 5 7 times per week, 13.6% parti cipated 3 4 times per week, 22.7% participated 1 2 times per week, and 55.6% did not stretch regularly. Individuals who participated in flexibility exercises 5 7 times per week had a significantly lower BMI (26.842.39) than those who did not participate a t all in flexibility exercises
86 (29.404.18), F (3, 194) = 2.934, p = 0.035.). There were no other significant group BMI differences for flexibility exercises that were significant ( p > .05). The most common places that participants usually exercised were: at home (55.1%), at the gym (30.3%), at work (23.7%), around their neighborhood (19.2%), and at a nearby park (16.7%) (See Table 4 16). There were no significant differences in BMI between groups. A Chi Square analysis indicated the younger cohort was sign ificantly 2 (1, = 206) = 4.938, p = 0.026), while the older cohort was more likely than the younger cohort to exercise in the 2 (1, = 206) = 4.374, p = 0.036). With regard to e ducation, men with graduate or professional degrees were significantly more likely than men with high 2 (4, = 206) = 15.807, p = 0.003). Married men were significantly more likely than single men to exercise at ho 2 (1, = 206) = 5.101, p = 0.024). There were no other significant group differences for demographics and places of exercise ( p > .05). Golf was the most frequently chosen competitive activity participated in on a regular basis by 12.1% of participa nts, followed by 5K 10K run/walk (9.6%), coaching or refereeing youth sports (5.6%), softball (5.1%), cycling or bike racing (4.5%), and tennis (2.0%). BMI was significantly lower (24.522.00) for participants who participated in tennis than those who did not (28.823.98) ( t= 2.153, df = 196, p = 0.033), however, this may have been due to the group size of participants who selected tennis ( n =4). There were no other significant differences in BMI, between groups ( p > .05). Chi Square analysis indicated that married men were significantly more likely than single 2 (1, = 206) = 4.116, p = 0.042). Looking at 5K 10K
87 participation, the younger cohort was significantly more likely than the older cohort to 2 (1, = 206 ) = 5.118, p = 0.024) and non White were significantly more 2 (1, = 206) = 5.178, p = 0.023). There were no other significant group differences for demographics and physical activity type ( p > .05). Stage of chang e for physical activity Univariate statistical analysis was conducted to determine the proportions of men in each stage of change for currently trying increase exercise. The results for each stage of change for exercise were: precontemplation (16.0%), cont emplation (13.0%), preparation (5.0%), action (19.5%), and maintenance (46.5%). The calculated BMI for each stage of change for current weight loss are provided in Table 4 17. Results of a one way ANOVA and Tukey post hoc test, comparing BMI and stage of c hange, revealed that participants in the maintenance stage for increasing exercise had a significantly lower mean BMI than individuals in the contemplation stage, F (4, 195) = 3.029, p = 0.019. Barriers to physical activity Participants were asked to sele ct barriers that prevented them from being physically active on a regular basis from a provided list and were allowed to choose as (33.5%), get home too late (25.6%), not mot ivated (21.0%), not a priority (18.0%), get enough exercise at work (16.0%) I would rather rest and relax than be active (15.0%), ave health problems (7.0%), cannot afford to join a gym (5.0%), and my neighborhood is to unsaf e to exercise in (1.5%) (See Table 4 18). Independent t tests were conducted to determine differences in mean BMI and barriers
88 have time to exercise and for those who wer e not motivated to be physically, p < .05 (See Table 4 19). A Chi Square analysis was used to determine differences among age cohort and barriers to physical activity. Results indicated that the younger cohort was significantly more likely than the older c as a barrier to physical 2 (1, = 200) = 5.175, p = 0.023). There were no significant demographic differences for income and barriers to physical activity ( p > .05). A Chi Square analysis was used to investigate the relationship between race /ethnicity and barriers to physical to physical activity than non 2 (1, = 200) = 7.376, p < 0.007). There were no other significant group differen ces for race and barriers to physical activity ( p > .05). Chi Square analysis was used to investigate the relationship between educational level and barriers to physical activity. Men with high school degrees were significantly more likely to list getti ng enough exercise as work as a barrier to physical activity than 2 (4, = 200) = 13.835, p = 0.008). There were no other significant group differences for education and barriers to physical activity ( p > .05). A Chi Square analysis test comparing barriers to physical activity and marital status indicated a significant difference in reporting not being motivated to be physical active. Married men were significantly more likely to list not motivated as a barrier t o 2 (1, = 200) = 6.108, p = 0.013). There were no other significant group differences for marital status and barriers to physical activity ( p > .05).
89 Motivators to physical activity Participants were then asked to s elect motivators that helped them to be more physically active on a regular basis and were again allowed to choose as many as applied. The reported motivators to physical activity were: to lose weight (53.2%) being diagnosed with a disease or illness (36.8 %), if a doctor tells me to (32.3%), having someone to exercise with (28.9%), if my partner was physically active (21.4%), having more convenient places to exercise (12.4%), to be a better role model (12.4%), if my friends were more physically active (7.5% ), having a membership to a gym (7.0%), and if I had transportation (1.5%) (See Table 4 20). Independent t tests were conducted to determine differences in mean BMI and the reported motivators to increasing physical activity. Mean BMI was significantly hi gher for those who would be more active in order to lose weight and if their friends were more active, p < .05 (See Table 4 21).Chi Square analysis was used to investigate the relationship between race/ethnicity and motivators to physical activity. Forty p ercent of White men indicated that they would be motivated to be physically active if they were diagnosed with a disease or illness, as compared with 19.1% of non 2 (1, = 201) = 4.210, p = 0.040). There were no other significant group differe nces for race/ethnicity and motivators to weight loss ( p > .05). A Chi Square analysis was used to investigate the relationship between education level and motivators to physical activity. Men with a B.A./B.S. degree were significantly more likely than men with high school degrees to list if my partner was more physically 2 (4, = 201) = 10.791, p = 0.029). There were no other significant group differences for education and motivators to physical activity ( p > .05). A Chi Square analysis test comparing motivators to physical activity
90 and marital status indicated a significant difference in wanting to lose weight. Married men were significantly more likely to be motivated to be physically active in order to lo se weight 2 (1, = 201) = 6.270, p = 0.012). There were no other significant group differences for marital status, age cohort, or income and motivators to physical activity ( p > .05). Research Aim 5 Assess areas of improvement that are needed ea ting habits of Baby Boomer men The purpose of this section is to describe the eating habits of participants, including what they are eating, drinking, and prevalence and cause of overeating. Sources of dieting information will be determined as well as comp rehension and use of food labels. Eating habits that need to be either increased or decreased in order to eat a healthier diet will also be assessed. Finally, the stage of change for healthy eating will be determined as well as the reported barriers and mo tivators to eating healthier. Eating habits When asked to describe their diets, 19 (9.0%) indicated that their diet was excellent, fifty (23.7%) stated that their diet was very good, 94 (44.5%) said their diet was good, 43 (19.9%) felt their diet was fair and 6 (2.8%) had a poor diet. Over half (64%) indicated that they usually ate breakfast. Three individuals (1.4%) ate at fast food restaurants every day, 8 (3.8%) ate fast food almost every day, 31 (14.7%) went a few days a week, 84 (39.8%) a few days a month, and 85 (40.3%) ate fast food rarely or every day, 4 (1.9%) went a few days a week, 46 (21.8%) a few days a month, and 155 (74.2%) went rarely or never (See Table 4 22).
91 Just over 40% were primarily responsible for doing the grocery shopping in their household. Thirty four (16.1%) cooked meals in their home every day, 48 (22.7%) almost every day, 63 (29.9%) a few days a week, 34 (16.1%) a few days a month, and 32 (15.2%) cooked meals in their home rarely or never. Over 54% packed a lunch to take to work. Forty two (20.0%) drank sodas every day, 28 (13.3%) almost every day, 34 (16.2%) a f ew days a week, 41 (19.5%) a few days a month, and 65 (31.0%) drank sodas rarely or never. When asked about consumption of sweetened beverages (Kool Aid, sweet tea, lemonade, etc), 17 (8.1%) drank them every day, 25 (11.8%) almost every day, 25 (11.8%) a f ew days a week, 38 (18.0%) a few days a month, and 106 (50.2%) drank them rarely or never. Over 37% usually drank diet sodas and 36.0% usually used sugar substitutes. With regard to alcohol use, 26.1% did not drink, 38.7% had low usage, 26.6% were in the middle (neither low nor high), 7.7% considered their use high, and 1.0% reported very high alcohol use. Overweight m en were significantly more likely to be in 2 (8, = 199) = 15.921, p = 0.044). Among those who did drink, 34.9% listed they had at least one occasion in the past 30 days when they consumed more than five drinks in one sitting. Results of a Chi Square analysis revealed that men who reported middle to very high alcohol use were significantly more likely to have consumed more than five drinks in one setting then men who repo rted low use ( 2 (4, = 156) = 52.526, p = 0.000). Participants were asked how frequently they overate. Four (1.9%) said they overeat at every meal, 19 (9.0%) one meal a day, 55 (26.1%) a few times a week, 69
92 (32.7%) a few times a month, 40 (19.0%) a few times a year, and 24 (11.4) said they never overate. Persons who overate a few times a week had a significantly higher BMI (29.85 4.33) than men who only overate a few times a year (26.96 3.82), F (5, 196) = 2.873, p = 0.016. Of those who indicated they overate at least a few times a year, the 125 (65.8%) participants, stress (22.6%), and boredom (14.7%). The least frequently listed reasons for overeating were: depression (6.3%), t iredness (5.3%), being overwhelmed (3.2%), and 2.6% listed both loneliness and anger. Table 4 23 shows the results of independent t Tests on BMI and causes of overeating. BMI was significantly higher for individuals who indicated they overate because they were stressed, depressed, overwhelmed, and bored, p < .05. Sources of dieting information Participants were asked where they got most of their nutrition and dieting information and could select as many choices as applied from a list provided (See Table 4 24). Wife, female friend or relatives was most frequently listed by 38.1% of participants followed by doctor (32.2%), Internet (30.2%), television (27.2%), books (26.2%), magazines (23.8%), newspapers (14.9%), buddies (7.9%), and commercial weight loss we bsites (3.5%). Results of a one way ANOVA and Tukey post hoc analysis found significant group differences and sources of dieting information. Non White men were significantly more likely than White men to get their information from a television, F (1, 202) = 8.037, p = 0.005. Participants whose highest attained education was graduate or professional degree were more likely than participants with high school/GED to get info from the internet, F (4, 202) = 20.277, p = 0.000, as well as from a book, F (4, 202) = 12.342, p = 0.015. Married men were significantly more likely than
93 single men to list wife, female friend, or relative as a source of nutrition and dieting information, F (1, 202) = 21.371, p = 0.000. Over half of the participants (57.8%) usually read f ood labels however, nearly half at comprehension of those who did read food labels, 59.5% indicated that understood everything on food labels. Table 4 25 provides the information most frequently looked for on food labels. Participants most frequently listed fats (65.1%) followed by calories (58.9%), sugar (46.9%), sodium (45.9%), cholesterol (41.2%), serving size (36.4%), carbohydrates (31.6%), protein (25.4%), fiber (2 4.9%), and vitamins and minerals (18.2%). Eating habits that need to be improved Participants were asked to identify foods that they needed to eat more of in order to improve their diets. They were allowed to choose as many as applied from the list provid ed (See Table 4 26). The items that were selected to increase were: fruits (58.9%), vegetables (42.1%), water (41.6%), healthier snacks (39.1%), fiber (27.7%), low fat foods (22.8%), whole grains (22.8%), protein (10.4%) and dairy products (5.5%). Result s of independent t tests comparing BMI and foods Baby Boomers needed to eat more of, revealed that BMI was significantly higher for individuals who reported needing to eat more low fat foods, grains, and healthier snacks, p < .05 (See Table 4 27). There w ere no other significant differences in BMI between selected food items ( p > .05). There were also no significant differences by demographic variables and food items that needed to be increased ( p > .05).
94 Eating habits that need to be decreased Participant s were asked to identify any eating habits that they needed to decrease in order to eat healthier. The items that participants selected to consume less of were: fried foods (37.6%), food in general (35.2%), junk food (30.7%), salt and salty foods (29.2%), sugar (28.7%), meat (14.9%), and alcohol (13.9%) (See Table 4 28). Results of independent t tests comparing BMI and reported eating habits, revealed that BMI was significantly higher for individuals who indicated they needed to eat less fried foods, less food in general, and less junk food, p < .05 (See Table 4 29). There were no other significant differences in BMI between groups ( p > .05). Results of a Chi Square analysis indicated non White men were significantly more likely than White men to choose I n 2 (1, = 202) = 9.825, p < 0.002). Men with 2 (1, = 202) = 10.281, p < 0.036). There we re no other significant group differences ( p > .05). Stage of change for healthy eating Univariate statistical analysis was conducted to determine the proportions of men in each stage of change for healthy eating. The results for each stage of change were : precontemplation (22.7%), contemplation (12.1%), preparation (8.1%), action (23.7%), and maintenance (33.3%). The calculated BMI for each stage of change for current weight loss was precontemplation (27.403.54), contemplation (31.293.77), preparation (30.264.58), action (30.063.62), and maintenance (27.683.80) (See Table 4 30). Results of a one way ANOVA and Tukey post hoc test, comparing BMI and stage of change, revealed that participants who had no intention to eat healthier (precontemplation) had a significantly lower mean BMI than participants in the
95 contemplation and action stages, individuals in the contemplation stage had a significantly higher mean BMI than individuals in the maintenance stage, and individuals in the action stage had a signif icantly higher BMI than persons in the maintenance stage, F (4, 193) = 7.558, p = 0.000. Barriers to eating healthy The participants were asked to identify their barriers to eating healthier. The reported barriers to consistently eating a healthy diet wer e: I do not want to give up some of my favorite foods (40.6%), I have a very busy life (34.7%), I already eat healthy (18.3%), not a priority (16.8%), I am not motivated (13.4%), healthy foods are not available at work (12.9%), healthy foods are expensive (12.4%), healthy foods take too much time to prepare (9.4%), healthy foods do not taste good (7.4%), and I do not know how to cook (2.5%) (See Table 4 31). Results of independent t tests comparing BMI and barriers to eating healthy, revealed that mean BMI was significantly higher for those who indicated they could not eat healthy because they had a very busy life and for individuals who indicated healthy foods were not available at work, p < .05. Individuals who reported that they already eat healthy had a significantly lower BMI than those who were not currently eating healthy consistently, p < .05 (See Table 4 32). There were no other significant differences in BMI and reported barriers to consistently eating healthy ( p > .05). A Chi Square analysis test comparing barriers to consistently eating a healthy diet for the two age cohorts indicated that men in the younger cohort were significantly more likely than men in the older cohort 2 (1, = 202) = 4.504, p < 0.034), as a barrier. In addition, the older cohort was significantly 2 (1, = 202) = 5.282, p < 0.022). White men
96 were significantl y more likely than non White men to not want to give up their favorite 2 (1, = 202) = 5.427, p < 0.020). There were no other significant group differences for barriers to consistently eating a healthy diet ( p > .05). Motivators to eating healt hy. The participants were then asked to identify what would motivate them to eat healthier. The reported motivators to consistently eating a healthy diet were: to lose weight (48.5%) being diagnosed with a disease or illness (40.1%), to prevent from gettin g certain diseases (30.2%), I already eat healthy (29.2%), to be a better role model for my kids (15.8%), if restaurants offered healthier foods (11.9%), if my family members were willing to change (8.9%), if someone close to me is diagnosed with a disease (8.4%), and nothing would motivate me (5.5%) (See Table 4 33). Results of independent t tests comparing BMI and motivators to eating healthy revealed that mean BMI was significantly higher for individuals who would be motivated to eat healthy to lose we ight and being diagnosed with a disease or illness, p < .05. Individuals who already ate healthy consistently had a significantly lower BMI than those who did not eat healthy, p < .05 (See Table 4 34). A Chi Square test comparing motivators to consistentl y eating a healthy diet for the two age cohorts indicated that men in the older cohort were significantly more likely 2 (1, = 202) = 6.453, p < 0.011). Comparing race/ethnicity, White men w ere significantly more likely than non 2 (1, = 202) = 8.447, p < 0.004) but non White men were significantly more likely than White men to list to prevent from getting certain disea 2 (1, = 202) = 4.872, p < 0.027). White men were also more likely to list if restaurants offered more healthy foods as a motivator
97 than non 2 (1, = 202) = 6.633, p < 0.010). Within marital groups, married men were significantly more l ikely than single men to list wanting to lose weight as a 2 (1, = 202) = 8.301, p < 0.004).There were no other significant group differences for motivators to consistently eating a healthy diet ( p > .05). Summary This chap ter reports the findings from the participant survey. Most participants were white, married, and evenly split between the younger and older cohorts. Findings indicate that the overall prevalence of overweight and obesity was 82.3% with 39.2% falling in the obese range, yet 87.3% self described their health as very good to excellent. High cholesterol was present in 30% of men and hypertension in 28%. Only 8.5% had been formally diagnosed with obesity and less than 40% had been told by a doctor to lose weight Only 30% expressed that they were satisfied or very satisfied with their bodies, while 37% stated that they were unsatisfied or very unsatisfied. Over one third of participants (38%) thought about their weight almost every day if not more. Overall, parti cipants had an accurate perception of where their weight was at and had a preferred weight that would put them in a healthier weight category. Fifty six percent were in the action or maintenance stage for weight loss and as such 52.5% indicated that they h ad tried to lose weight in the past 12 months. Among those trying to lose weight, all lost weight and only 20% were unsatisfied with their weight loss. However, 72% had gained their weight back within a year. The strategies for weight loss that were most frequently reported were eating less food, exercising more often, and cutting back on certain foods such as fried foods and desserts. Forty percent used the recommended weight loss strategy of combining exercise with reduced caloric intake. In order to los e weight they reported needing more
98 information on portion control, the amount of physical activity that was sufficient for weight loss, how to prepare healthy recipes, how much food they should eat, and how to manage stress. The reported barriers to losin g weight were not being disciplined, not being motivated, and that weight loss was not a priority. The reported motivators to losing weight were to look stronger, look better, increasing body satisfaction, preventing disease, being diagnosed with a disease or being told to lose weight by their doctor. One third did not participate regularly in cardiovascular activity and accordingly 34% were in the precontemplation, contemplation, and preparation stages for increasing exercise. Over half (67%) did not par ticipate regularly in muscular strength exercises, and 56% did not participate regularly in flexibility exercises. The preferred venues for exercise were in the home, at the gym, at work, or in the neighborhood. Walking was the preferred cardiovascular exe rcise by 61% of participants. The reported barriers to increasing physical activity were not having time, getting home too late, and not being motivated. The reported motivators to physical activity were to lose weight, being diagnosed with disease, being told by their doctor to exercise more, having someone to exercise with, and if their partner was more physically active. The majority of men ate healthy with 77% reporting that their diet was good, very good, or excellent yet only 57% reported that they w ere in the action or maintenance stages for healthy eating. Over half ate breakfast regularly, 80% did not go out regularly to fast food, and 96% frequented buffets style restaurants a few times a month or less. One third drank soda almost every day and 32 % drank sweetened beverages a few days a week. Thirty seven percent of men said they overate a least a couple times per
99 indicated they needed to eat more fruits and vegeta bles, drink more water, and eat healthier snacks and eat less food in general including fried foods, junk foods, salty foods, and foods high in sugar content. Men in this study get their dieting information primarily from their wives, physicians, the Inter net, television, and from books. Half read food labels but only 60% understood everything that they were reading on them. Some of the barriers that they reported to eating healthier included not wanting to give up their favorite foods, being too busy to ea t healthy, and not being motivated to eat healthier. The motivators to eating healthy were to lose weight, being diagnosed with a disease or illness, and to prevent from getting certain diseases. Chapter 5 presents a discussion of the major results, implic ations for health educators, practitioners, and clinicians, and recommendations for weight loss programs that will best meet the needs of Baby Boomer men.
100 Table 4 1. Demographical distribution by age cohort, income, race/ethnicity, education and marital status Demographic variables n % Age cohort Older cohort 104 49.29 Younger cohort 107 50.71 Income Less than $19,999 12 5.85 $20,000 to $29,999 25 12.20 $30,000 to $39,999 20 9.76 $40,000 to $49,999 19 9.27 $50,000 to $59,999 35 17.07 $60,000 to $69,999 26 12.68 More than $70,000 68 33.17 Ethnicity Black/African American 34 16.11 Hispanic 8 3.79 White/Caucasian 158 74.88 Other 11 5.21 Education Eight grade or less 1 0.47 Did not complete high school 5 2.37 High school graduate/GED 71 33.65 A.A. degree/professional license 47 22.49 B.A./B.S. degree 39 18.66 Graduate or professional degree 48 22.75 Marita l Status Single, not in a relationship 27 12.80 Single, committed relationship 21 9.95 Married, separated 5 2.37 Married, living with spouse 158 74.88 Table 4 2. Classification according to Body Mass Index (BMI) Classificati on BMI (kg/m 2 ) n % Underweight < 18.5 0 0 Normal 18.5 24.9 37 17.70 Overweight 25.0 29.9 90 43.06 Obese 75 35.89 Extremely Obese 7 3.35
101 Table 4 3. Information needed for weight loss identified by Baby Boomers Information needed n % Portion control/serving sizes 123 58.29 Recommended amount of physical activity 123 58.29* Healthy recipes 110 52.13 How much they should eat 97 45.97 How to control stress 73 34.6 0 How to choose a weight loss program 47 22.27 Online dieting 10 4.74 Other 10 4.74 Table 4 4. Information needed for weight loss by race/ethnicity Non White White Information needed n % n % X 2 df p Portion control/serving sizes 23 43.4 100 63.3 6.461 1 0.011* Recommended amount of PA 28 52.8 95 60.1 0.869 1 0.351 Healthy recipes 27 50.9 8 3 52.5 0.040 1 0.841 How much they should eat 21 39.6 76 48.1 1.149 1 0.284 How to control stress 16 30.2 57 36.1 0.608 1 0.436 How to choose a program 11 20.8 36 22.8 0.094 1 0. 759 Online dieting 4 7.5 6 3.8 1.236 1 0.266 Other 2 3.8 8 5.1 0.146 1 0.702 p < .05. Table 4 5. Stage of change for currently trying to lose weight and BMI Stage of change n % BMI SD Classification Precontemplation 37 22.70 27.95 2.70 Overweight Contemplation 25 15.34 30.44 3.27 Obese Preparation 10 6.13 30.80 4.52 Obese Action 60 36.81 30.34 3.32 Obese M aintenance 31 19.02 30.97 3.53 Obese Table 4 6. Weight loss strategies currently being used or used in the past Strategies n % Eat less food 104 63.03 Exercise more often 85 51.52 Cut back on fried foods 70 42.42 Cut back on sweets and desserts 68 41.21 Cut back on alcohol 25 15.15 I have never tried to lose weight 17 10.30 Fast or skip meals 15 9.09 Meal replacement drinks/bars 15 9.09 Join a weight loss program 13 7.88 Diet pills or water pills 7 4.24
102 Table 4 7. Reported weight loss strategies by BMI BMI BMI Strategy used yes SD no SD df t p Eat less food 30.38 3 .69 29.22 2.89 163 2.103 0.037* Exercise more often 30.25 3.57 29.63 3.31 163 1.153 0.251 Cut back on fried foods 30.26 3.62 29.72 3.33 163 0.984 0.327 Cut back on sweets and desserts 30.45 3.49 29.6 0 3.40 163 1.551 0.123 Cut back on alcohol 30.69 3.93 29.82 3.36 163 1.171 0.243 I have never tried to lose weight 27.60 2.70 30.22 3.48 163 3.044 0.003* Fast or skip meals 32.09 3.60 29.74 3.38 1 63 2.558 0.011* Meal replacement drinks/bars 32.11 3.90 29.73 3.34 163 2.582 0.011* Join a weight loss program 32.65 2.34 29.72 3.44 163 3.004 0.003* Diet pills or water pills 32.87 2.26 29.82 3.44 163 2.320 0.022* p < .05. Table 4 8. Cross tabulation table for demographics and weight loss strategies Cohort Marital Race Edu Income Strategy p p p p p Eat less food 0.307 0.747 0.017* 0.288 0.772 Exercise more often 0.069 0.436 0.346 0.419 0.124 Cut back on fried foods 0.359 0.694 0.250 0.999 0.055 Cut back on sweets and desserts 0.366 0.009* 0.022* 0.962 0.927 I have never tried to lose weight 0.621 0.021* 0.031* 0.208 0.381 Cut back on alcohol 0.937 1.000 0.497 0.282 0.473 Fast or skip meals 0.622 1.000 0.910 0.853 0.351 Join a weight loss program 0.933 0.248 0.126 0.581 0.637 Meal replacement drinks/bars 0.300 0.498 0.611 0.715 0.319 Diet pills or water pills 0.811 0.176 0.847 0.947 0.348 p < .05. Table 4 9. Reported barriers p reventing Baby Boomers from losing weight Barrier n % Not disciplined, no will power 47 28.48 Not a priority for me 47 28.48 I am not motivated to lose weight 37 22.42 Have not found a plan that works for me 29 17.58 I do not need to lose weight 23 13.94 Not sure if I can do it 9 5.45 9 5.45 Nothing I have tried has worked 8 4.85 8 4.85 6 3.64
103 Tabl e 4 10. Reported barriers to losing weight and BMI BMI BMI Barrier yes SD no SD df t p Not disciplined, no will power 31.13 3.71 29.48 3.24 163 2.834 0.005* No t a priority for me 28.50 2.85 30.53 3.51 163 3.517 0.001* I am not motivated to lose weight 31.23 3.41 29.58 3.39 163 2.602 0.010* Have not found a plan that works 31.34 3.01 29.65 3.48 163 2.425 0.016 I do not need to lose weight 27.20 2.03 30.40 3.43 163 4.335 0.000* Not sure if I can do it 31.13 2.85 29.88 3.48 163 1.056 0.293 31.20 3.04 29.88 3.47 163 1.117 0.26 6 Nothing I have tried has worked 32.70 4.82 29.81 3.33 163 2.340 0.021* 29.50 3.54 29.97 3.46 163 0.381 0.704 30.37 3.43 29.93 3.46 163 0.303 0.762 p < .05 Table 4 11. Reported motivators for Baby Boomers to lose weight Motivator n % To feel stronger and fitter 108 65.45 To look better 90 54.55 Being dissatisfied with my body 63 38.18 To prevent me from getting certain diseases 60 36.36 If I am diagnosed with a disease or illness 51 30.91 If a doctor tells me to 40 24.24 If my partner was dissatisfied with my body 27 16.36 To be a better role model for my kids 26 15.76 To be more productive at wo rk 19 11.52 If someone close to me is diagnosed with a disease 13 7.88 Table 4 12. Reported motivators for Baby Boomers to lose weight and BMI BMI BMI Motivators yes SD no SD df t p To feel stronger and fitter 30.23 3.51 29.43 3.31 163 1.418 0.158 To look better 30.66 3.55 29.10 3.15 163 2.941 0.004* Being dissatisfied with my body 30.65 3.97 29.52 3.03 163 2.065 0.041* To p revent certain diseases 29.83 3.66 30.02 3.35 163 0.337 0.736 If I am diagnosed with a disease 30.34 3.48 29.78 3.44 163 0.967 0.335 If a doctor tells me to 29.15 3.53 30.21 3.30 163 1.699 0.091 If my partn er was dissatisfied w/ body 29.87 3.85 29.97 3.38 163 0.132 0.895 To be a better role model for my kids 29.71 3.90 30.00 3.37 163 0.388 0.699 To be more productive at work 30.26 3.80 29.91 3.42 163 0.411 0.6 82 Someone close diagnosed w/disease 29.98 3.60 29.95 3.45 163 0.028 0.978 p < .05.
104 Table 4 13. Current level of physical activity Current activity n % BMI SD Classification Very active 28 15.14 27.05 4.03 Overweight Active 59 31.89 27.84 3.83 Overweight Moderately active 81 43.78 29.48 3.93 Overweight Not active 17 9.19 31.31 3.72 Obese Table 4 14. Planned moderate cardiovascular activity Exercise bout n % BMI SD Classification 5 7 times per week 28 14.21 26.68 3.40 Overweight 3 4 times per week 53 26.90 29.00 4.05 Overweight 1 2 times per week 52 26.40 28.95 3.71 Overweight I do not exercise regularly 64 32.49 29.15 4.1 9 Overweight Table 4 15. Primary cardiovascular activity Physical activity n % Walking 120 60.91 Biking 40 20.30 Running/jogging 37 18.78 Swimming 15 7.61 Other (exercise machines) 10 5.08 Basketball 6 3.05 Table 4 16. Preferred venue(s) typically used for exercise Venue n % Home 109 55.05 Gym 60 30.30 Work 47 23.74 Around the neighborhood 38 19.19 At a nearby park 33 16.67 At a stadium 3 1.52 At the YMCA 2 1.01 Community center 1 0.51 Table 4 17. Stage of change for trying to increase physical activity and BMI Stage of change n % BMI SD Classification Precontemplation 32 16.00 28.46 4.27 Overweight Contemplation 26 13.00 30.22 3.87 Obese Preparation 10 5.00 30.87 5.14 Obese Action 39 19.50 29.55 3.39 Overweight Maintenance 93 46.50 27.95 3.91 Overweight
105 Table 4 18. Reported barriers to physical activity Barrier n % 67 33.50 I get home too late 51 25.50 I am not motivated to be physically active 42 21.00 It is not a priority for me 36 18.00 I get enough exercise at wor k 32 16.00 I would rather rest and relax than be active 30 15.00 19 9.50 I have health problems 14 7.00 10 5.00 My neighborhood is unsafe 3 1.50 Table 4 19. Reported barri ers to physical activity and BMI BMI BMI Barrier yes no df t p 29.63 28.42 198 2.037 0.043* I get home too late 29.58 28.56 19 8 1.567 0.119 I am not motivated to be active 29.95 28.52 198 2.081 0.039* It is not a priority for me 28.56 28.88 198 0.440 0.661 I get enough exercise at work 28.57 28.87 198 0.387 0.699 I wou ld rather rest and relax 28.88 28.81 198 0.467 0.931 30.04 28.69 198 1.393 0.165 I have health problems 28.24 28.86 198 0.560 0.576 27.55 28.89 198 1.032 0.303 My neighborhood is unsafe 31.57 28.78 198 1.199 0.232 p < .05. Table 4 20. Reported motivators to increase physical activity Motivator n % To lose weight 107 53.23 Being diagnosed with a disease or illness 74 36.82 If a doctor tells me to 65 32.34 Having someone to exercise with 58 28.86 If my partner was physically active 43 21.39 If I had more convenient places to exercise 25 12.44 To be a better role m odel 25 12.44 If my friends were more physically active 15 7.46 If I had a membership to a gym 14 6.97 If I had transportation 3 1.49
106 Table 4 21. Reported motivators to be more physically active and BMI BMI BMI Motivator yes SD no SD df t p To lose weight 30.46 3.81 26.93 3.33 199 6.941 0.000* Being diagnosed with a disease 29.11 4.23 28.64 3.86 199 0.806 0.421 If a doctor tells me to 28.19 4.21 2 9.11 3.87 199 1.532 0.127 Having someone to exercise with 29.09 4.41 28.70 3.83 199 0.630 0.530 If my partner was physically active 29.36 4.32 28.66 3.90 199 1.017 0.310 If I had more convenient places 29.02 4.39 28.78 3.95 199 0.277 0.782 To be a better role model 28.28 4.49 28.88 3.93 199 0.704 0.483 If my friends were more active 30.81 4.65 28.65 3.91 199 2.028 0.044* If I had a membership to a gym 28.78 4.98 28.81 3.93 199 0.028 0.9 78 If I had transportation 26.75 6.29 28.84 3.97 199 0.897 0.371 p < .05. Table 4 22. Eating habit frequency Almost Daily daily Weekly Monthly Never Eating pattern n % n % n % n % n % Eat at fast food restaurants 3 (1.4) 8 (3.8) 31 (14.7) 84 (39.8) 85 (40.3) 1 (0.5) 3 (1.4) 4 (1.9) 46 (21.8) 155 (74.2) Cook own meals 34 (16.1) 48 (22.7) 63 (29.9) 34 (16.1) 32 (15.2) Drink sodas 42 (20.0) 28 (13.3) 34 (16.2) 41 (19.5) 65 (31.0) Drink sweetened beverages 17 (8.1) 25 (11.8) 25 (11.8) 38 (18.0) 106 (50.2) Table 4 23. Cause of overeating BMI BMI C ause n % yes SD no SD df t p Free food 117 64.64 28.77 4.03 29.12 3.99 179 0.567 0.571 Stress 41 22.65 30.80 3.79 28.3 3 3.91 179 3.575 0.000* Boredom 29 16.02 30.96 4.30 28.50 3.84 179 3.108 0.002* Depression 11 6.08 32.20 3.78 28.68 3.94 179 2.881 0.004* Tiredness 10 5.52 30.83 4.31 28.78 3.97 179 1.583 0.115 Overwhelmed 6 3.31 33.36 4.07 28.74 3.93 179 2.829 0.005* Loneliness 5 2.76 26.55 4.24 28.96 3.99 179 1.327 0.186 Anger 4 2.21 31.46 1.90 28.83 4.03 179 1.298 0.196 p < .05.
107 Table 4 24. Sources of information about nutrition and dieting Information source n % Wife, female friend, or relative 77 38.12 Doctor 65 32.18 Internet 61 30.20 Television 55 27. 23 Books 53 26.24 Magazines 48 23.76 Newspaper 30 14.85 Buddies 16 7.92 Commercial weight loss website 7 3.47 Table 4 25. Information looked for on food labels Information n % Fats 136 65.07 Calories 123 58.85 Sugar 98 46.89 Sodium 96 45.93 Cholesterol 86 41.15 Serving size 76 36.36 Carbohydrates 66 31.58 Protein 53 25.36 Fiber 52 24.88 Vitamins and minerals 38 18.18 Table 4 26. Items Baby Boomers need to consume more of to improve their diet Food item n % I need to eat more fruits 119 58.91 I need to eat more vegetables 85 42.08 I need to drink more water 84 41.58 I need to choose healthier snacks 79 39.11 I need to eat more fiber 56 27.72 I need to eat more low fat foods 46 22.77 I need to eat more whole grains 46 22.77 I need to eat more protein 21 10.40 I need to eat more dairy products 11 5.45
108 Table 4 27. Items Baby Boomers n eed to consume more to improve their diet and BMI BMI BMI Food item yes SD no SD df t p I need to eat more fruits 28.99 4.06 28.49 3.92 200 0.863 0.389 I need to eat more vegetables 29.32 4.09 28.39 3.91 200 1.638 0.103 I need to drink more water 28.60 3.75 28.92 4.18 200 0.556 0.579 I need to choose healthier snacks 29.87 4.27 28.09 3.67 200 3.148 0.002* I need to e at more fiber 29.20 3.96 28.62 4.02 200 0.920 0.359 I need to eat more low fat foods 30.56 4.11 28.26 3.83 200 3.528 0.001* I need to eat more whole grains 29.91 3.77 28.45 4.02 200 2.193 0.029* I need to eat more protein 29.75 4.36 28.67 3.96 200 1.176 0.241 I need to eat more dairy products 28.19 3.46 28.82 4.04 200 0.502 0.616 p < .05. Table 4 28. Items Baby Boomers need to consume less of to improve their diet Food item n % I need to eat less fried foods 76 37.62 I need to eat less food 71 35.15 62 30.69 I need to eat less salt and salty foods 59 29.21 I need to eat less sugar 58 28.71 I need to eat less meat 30 14.85 I need to drink less alcohol 28 13.86 Table 4 29. Items Baby Boomers need to consume less and BMI BMI BMI Food item yes SD no SD df t p I need to eat less fried foods 29.66 3.86 28.26 4.0 1 200 2.446 0.015* I need to eat less food 30.66 3.44 27.77 3.93 200 5.202 0.000* 30.21 4.48 28.15 3.61 200 3.473 0.001* I need to eat less salt and salty foods 28.85 4.12 28.75 3.97 200 0.160 0.873 I need to eat less sugar 29.20 4.49 28.61 3.79 200 0.945 0.346 I need to eat less meat 29.76 3.58 28.61 4.05 200 1.448 0.149 I need to drink less alcohol 28.42 3.62 28.84 4.07 200 0.517 0.606 p < .05. Table 4 30. Stage of change for currently trying to eat healthier and BMI Stage of change n % BMI SD Classification Precontemplation 45 22.73 27.40 3.54 Overweight Contemplation 24 12.12 31.29 3.77 Obese Preparation 16 8.08 30.26 4.58 Obese Action 47 23.74 30.06 3.62 Obese Maintenance 66 33.33 27.68 3.80 Overweight
109 Table 4 31. Reported barriers to consistently eating healthy Barrier n % I do not want to give up favorite foods 82 40.59 I have a busy life 70 34.65 I consistently eat a healthy diet 37 18.32 It is not a priority for me 34 16.83 Not motivated to eat healthy 27 13.37 Healthy foods are not available at work 26 12.87 Healthy foods are expensive 25 12.38 Healthy foods take too long to prepare 19 9.41 Healthy foods do not taste good 15 7.43 I do not know how to cook 5 2.48 Table 4 32. Reported barriers to consistently eating healthy and BMI BMI BMI Barrier yes SD no SD df t p I do not want to give up favorite foods 28.91 3.77 28.70 4.17 200 0.371 0.711 I have a busy life 29.93 3.95 28.17 3.91 200 3.028 0.003* I con sistently eat a healthy diet 27.01 4.22 29.18 3.85 200 3.047 0.003* It is not a priority for me 28.96 4.00 28.75 4.01 200 0.277 0.782 Not motivated to eat healthy 29.82 4.57 28.62 3.90 200 1.444 0.150 Healthy foods are n ot available at work 31.38 4.02 28.40 3.86 200 3.658 0.000* Healthy foods are expensive 30.00 3.74 28.61 4.02 200 1.624 0.106 Healthy foods take too long to prepare 29.82 4.03 28.66 3.99 200 1.188 0.236 Healthy foods do not taste good 29.16 3.99 28.75 4.01 200 0.382 0.703 I do not know how to cook 28.77 4.20 28.78 4.01 200 0.006 0.995 p < .05. Table 4 33. Motivators for Baby Boomers to consistently eat healthy Motivator n % I want to l ose weight 98 48.51 Being diagnosed with a disease or illness 81 40.10 To prevent me from certain diseases 61 30.20 I already eat healthy 59 29.21 To be a better role model for my kids 32 15.84 If restaurants offered more healt hy foods 24 11.88 If family members are willing to change 18 8.91 Someone close is diagnosed with a disease 17 8.42 Nothing would motivate me 11 5.45
110 Table 4 34. Motivators to consistently eat healthy and BMI classification BMI BMI Motivator yes SD no SD df t p I want to lose weight 30.32 3.67 27.34 3.78 200 5.676 0.000* Being diagnosed with a disease 29.61 4.44 28.23 3.59 200 2.437 0.016* To prevent me from certain diseases 29.20 4.18 28.60 3.92 200 0.971 0.333 I already eat healthy 26.82 3.24 29.59 4.02 200 4.711 0.000* To be a better role model for my kids 29.35 4.32 28.68 3.94 200 0.873 0.383 If restaurants offered healthy foods 29.28 4.19 28.72 3.98 200 0.644 0.520 If family members are willing to change 30.42 4.77 28.62 3.90 200 1.827 0.069 Someone close diagnosed with disease 28.75 4.25 28.79 3.99 200 0.041 0.967 Nothing would motiv ate me 28.70 3.60 28.79 4.03 200 0.067 0.947 p < .05.
111 Figure 4 1. Boxplot distribution of calculated BMI
112 CHAPTER 5 SUMMARY, DISCUSSION, AND RECOMMENDATIONS Summary In 2008, obese Americans cost the United States $147 billion in medical bills which pales in comparison to the $1.8 trillion spent in medical costs for the treatment of chronic diseases associated with obesity (Hellmich, 2009). With medical expenses for obese individuals estimated to reach $344 billion by 2018, prevention is imper ative. The risks associated with obesity are well known, hypertension, high blood cholesterol, sleep apnea, respiratory diseases, stroke, type 2 diabetes, and some forms of cancer (DHHS, 2010). While recent data indicates that obesity prevalence does not a ppear to be increasing at the same rates as previously seen (Flegal et al., 2010), 68.3% of adults in the United States are overweight and of that percentage, 38.9% are obese (Flegal et al., 2010). While the obesity epidemic is present among all age groups the greatest prevalence is among persons aged 40 and older (Flegal et al., 2010). This is even more concerning for men who on average have a lower life expectancy and higher death rates within 12 of the 15 leading causes of death (Hoyert et al., 2006). The modifiable risk factors of obesity, physical inactivity, sedentary behavior, and poor diet, are well known, yet only 36% of overweight men and 68% of obese men are trying to lose weight (Baradel et al., 2009). With the aging population of Baby Boomers this is concerning as the earliest members of this generation became eligible for social security in 2008 and will be eligible for Medicare by 2011. As they continue to retire, social security payments will increase and those who are continuing to develop or continue to live with the chronic medical conditions associated with obesity, will cause long term care costs to grow (Knickman & Snell, 2002). Moreover, survival rate among
113 this population may decrease. Data from the Framingham Heart Study found that m en who are obese at 40 live 6 7 years less and are 81% more likely to die before the age of 70 than their normal weight counterparts (Peeters et al., 2003). Thus, understanding how these men view their weight, what weight loss or weight management strategi es they are using, and what is preventing them from losing weight is essential. This study examined the weight status, healthy eating behaviors, and physical activity patterns of a sample of male Baby Boomers living in North Central Florida. The following sections provide a discussion of these findings. Discussion Study Findings Weight status Consistent with national data (2007 2008 NHANES), there was a high prevalence of overweight and obesity among men in this study indicating that this sample of men was representative of the greater population. Combined, the prevalence for overweight and obesity was 82.3% which was higher than the 2007 2008 NHANES data of 77.8% (Flegal et al., 2010) for men aged 40 59 and 78.4% for men 60 and over. Obesity rates were als o higher than national data at 39.2% compared to 34.3% in men 40 59 and 37.1% in men 60 and older. The percentage of men who were overweight or obese is not shocking, given the current weight status of male Baby Boomers, but what is concerning is the fact that many overweight and obese adults do not perceive their weight to be a health risk (Gregory, Blanck, Gillespie, Maynard, & Serdula, 2008) or perceive themselves to be overweight (Johnson Taylor, Fisher, Hubbard, Starke Reed, & Eggers, 2008). Previous research on weight perception indicates that 30% of men place themselves in weight
114 categories that are not consistent with public health classifications (Chang & Christakis, 2003). In the present study, 44% of men inaccurately described their weight accord ing to their BMI classification. Further examination of the data revealed that 53% of obese men reported that they were one category below their actual classification (slightly below their actual classification. In an examination of NHANES data from 2001 2006, Merrill and Richardson (2009) assessed that 47% of overweight men thought that they were men may view their weight as about right, a greater percentage of obese men may consider their weight to be only slightly higher than normal weight, which may be indicative of increased acceptance of a heavier weight (Merrill & Richardson, 2009). Despite the discrepancies between perceived weight and actual weight, obese individuals less frequently reported very good or excellent health than those who were closer to normal weight. Consistent with the data from the 2008 National Health Interview Survey (Ple is, Lucas, & Ward, 2009) that indicated 56.1% of adults 45 to 65 years old assessed their own health at very good or excellent, 52% of all participants in this study felt that they were in very good or excellent health. However, only 34.7% of obese partici pants reported very good or excellent health. These individuals were also significantly more likely to be diagnosed with obesity, diabetes, and hypertension. These findings support evidence (Hart, Hole, Lawlor, & Smith, 2007; Villareal et al., 2005) that p ersons who are obese are at an increased risk for developing these life threatening conditions In addition, the health risks associated with obesity are more severe than in persons who are overweight (Field et al., 2000; Hart et al., 2007; Villareal
115 et al ., 2005 ), thus the overweight participants may not have felt their weight was a health risk which may be cause of their increased perception of very good or excellent health. Previous research on preferred weight suggests that self reported ideal weight h as increased over time (Kuk et al., 2009). Although 88% of obese men indicated preferred weights in a healthier range, they still had a preferred weight that was considered overweight. Only 26% of overweight men had a preferred weight in the normal weight range. A study by McPherson and Turnbull (2005) on Scottish men produced similar findings with obese men reporting they would like a smaller body and overweight men wanting to remain the same size. The authors suggested that the way in which men report wei ght satisfaction is in terms of adiposity. Thus, overweight men may not feel that their current weight is aesthetically undesirable. In addition, with 81% of overweight and obese men combined preferring a weight in the overweight range it is possible that they may be identifying more feasible weights for them to achieve. There is evidence to support that men are more realistic than women with regard to goal and ideal weight losses, including obese men (Linde, Jeffery, Levy, Pronk & Boyle, 2005), and thus th eir preferred weight may be more in line with recommended weight loss goals of 1 2 lbs of weekly weight through a reduction of 500 to 1,000 kcal/day (DHHS, 1998). Research has shown that even modest weight loss has been shown to reduce the risk for some di seases. A study by Hamman et al. (2006) that a reduction of weight of 1 kg (2.2 lbs) reduced the risk of diabetes in obese adults by 17% and estimated that a loss of 5 kg (~11 lbs) could reduce the risk of diabetes by as much as 55%. Nevertheless, the high percentage of overweight men and obese men preferring a weight in the overweight
116 range may provide further evidence that a certain level of overweight is acceptable among men (McPherson & Turnbull, 2005; Rand & Resnick, 2000). Motivators for weight loss Predominate research on body satisfaction has provided conflicting evidence with regard to men. Men are typically more satisfied with their weight than women (Feingold & Mazzella, 1998; Frederick, Forbes, Grigorian, & Jarcho, 2007; McCabe & Ricciardelli, 2 004; Ogden & Taylor, 2000; Yates et al., 2004), even overweight and obese men (James, 2003; Markey & Markey, 2005) but do report some dissatisfaction, with an equal split for men who desired to gain weight and lose weight (De Souza & Ciclitira, 2005). In a study of body dissatisfaction among adult men and women by Phillips and deMan (2010), overweight men wished to be thinner whereas normal and underweight men wished to have a larger physique. However, studies that report men wanting to gain weight predomin ately focus on younger men and college students (Ochner, Gray, & Brickner, 2009; McCabe & Ricciardelli, 2004). Given the current overweight and obese prevalence, older men are more likely to be heavier than younger men and thus may have a greater desire t o lose weight than gain. As such, in this population of Baby Boomers, 51% of overweight men and 79% of obese men were currently trying to lose weight which may indicate why only 32% of overweight men and 5% of obese men reported body satisfaction. While t here were no underweight men in the present study, 19% of the normal weight men were trying to lose weight which may indicate why 73% of normal weight men were either satisfied or very satisfied with their bodies. Analysis of weight loss trends of BRFSS d ata from 1996 2003, (Baradel et al., 2009) revealed that while there has been little change in weight loss among overweight adults over the time period, weight loss among obese adults has increased significantly. Weight loss
117 prevalence in the present study was slightly higher than weight loss prevalence of 40 59 year olds for both overweight and obese in 2003, 48% and 71% respectively. However, this may be indicative that weight loss trends continue to increase as overweight and obesity prevalence increases Nevertheless, study findings support that a high percentage of obese men are less satisfied with their bodies and more likely are trying to lose weight. Although previous research by Ogden and Taylor (2000) found that married men derive their body dissa tisfaction with reference to the beliefs of their partner, only 15% of married overweight and obese men in the present study were motivated to lose weight if their partner was dissatisfied with their body. Further, partner dissatisfaction was less frequent ly reported than self dissatisfaction, thus men may be less concerned dissatisfaction were not addressed, overweight and obese men did indicate that they were motiv ated to lose weight predominately for appearance reasons, such as feeling stronger, looking better, and being dissatisfied with their bodies. The motivation of appearance is not uncommon among men and has been previously reported in the literature (Hankey, Yates et al., 2004). Thus, much like younger men, overweight and obese Baby Boomers would be more satisfied with a stronger physique, but will be more likely to need to lose weight rather th an gain weight to achieve it. Health reasons have also previously been shown to motivate men to lose weight men indicated they would be motivated to prevent from gett ing diseases than indicated
118 they would lose weight if they were diagnosed with disease. Men who were diagnosed with high cholesterol or hypertension were significantly more likely to be trying to lose weight which may suggest that the presence of disease m ay serve as a greater motivator for some men than is actualized. The observation of an illness of a colleague or friend had previously been identified as a motivator for weight loss (Sabinsky et al., 2007), but only 8% of men in this study said they would be motivated by someone close disease may have a greater impact than merely knowing someone who is diagnosed with disease. Men also stated that they would be motivated if t heir doctor told them to lose weight. Clinicians are a highly trusted source of health information and thus they can be a powerful motivator in advocating for changing lifestyle habits (DHHS, 2010). Previous findings suggest that patients who are advised to lose weight by their physician are more likely to attempt weight loss (Sciamanna, Tate, Lang & Wing, 2000). In a study of trends in professional advice data from 1994 2000 BRFSS (Jackson, Doescher, Saver & Hart, 2005) the percentage of obese persons re ceiving advice to lose weight fell from 44.0% to 40.0%. Findings in this study were much higher at 71% of obese men reporting that they had been told by a doctor to lose weight. Among overweight men, 29% reported that they had that a doctor had told them to lose weight. Receiving advice to lose weight has previously been shown to have strong associations with trying to lose weight among overweight individuals (Sciamanna et al., 2000). While not statistically significant among obese men, overweight men who had been told to lose weight were significantly more likely to be currently trying to lose weight than those who had not
119 been told to lose weight These findings may suggest that for overweight men who do not feel that their weight is a health concern, a doctor advising them to lose weight may serve as a motivator to attempt weight loss. Barriers to weight loss A lack of motivation had previously been identified by adult men as a barrier to weight loss (Sabinsky et al., 2007). While motivation was also li sted as barrier in this study, the barriers to weight loss differed for overweight men and obese men. Obese men were significantly more likely to not be motivated or have the will power to lose weight whereas overweight men were significantly more likely t o state that weight loss discrepancies in these weight loss barriers may provide support that overweight men do not have the same concerns about their weight as obese men. While not defined specifically as barriers, men identified three major areas where they felt increased education was needed to assist in losing weight: appropriate portions serving sizes, and healthy meals; necessary physical activity for weight loss; an d how to manage stress. Increasing knowledge in these seemingly intertwined areas may enhance the skills and abilities further enabling overweight and obese men to lose weight. Portion sizes have increased in marketplaces and fast food restaurants over the past two decades (Young & Nestle, 2003) and while there is no empirical evidence linking portion sizes to obesity (DHHS, 2005), controlling portion sizes will assist men with consuming fewer calories. Regular participation in moderate physical activity is a necessary component for weight management. For adults to receive health benefits, current recommendations are for 150 minutes a week of moderate physical activity (DHHS, 2008). However, if weight loss is desired, the duration of weekly participation
120 sho uld be increased to 300 minutes (DHHS, 2008). Education should be provided that clearly delineates the recommendations and desired outcomes of physical activity. previou sly been identified as a contributing factor in abdominal obesity and may contribute to an increase in caloric consumption (Bjorntorp, 2001). Providing education on the connection between healthy stress management, reduced caloric consumption, and appropri ate levels of physical activity, is essential for men to manage and or lose weight. Weight loss strategies According to the 1998 Clinical Guidelines from the U.S. Department of Health and Human Services for the treatment of overweight and obesity, to lose weight a caloric deficit of 500 1000 kcal/day is needed. Further, this caloric deficit can be achieved through a reduction in calories consumed or an increase in calories burned (DHHS, 1998). The weight loss strategies most frequently listed to lose weigh t were eating less food and exercising more often, both of which are consistent with previous research (Baradel et al., 2009: Kruger et al., 2004; Weiss et al., 2006). However, because achieving weight loss through physical activity may be difficult for mo st adults (ADA, 2009) recommendations for weight loss include a combination of exercising more with consuming fewer calories (DHHS, 2005). In previous studies of overweight and obese men, 45% were using this strategy (Baradel et al., 2009). Results from th e present study were slightly lower at 41% of men reporting use of this weight loss strategy, but still higher than national average of 34% reported in the 1998 National Health Interview Survey (Kruger et al., 2004). Data from the 2001 2002 NHANES found th at less than one fourth of adults combined caloric restriction with higher levels of physical activity
121 (Weiss et al., 2006). However, this study used the U.S. Department of Health and Human Services and U.S. Department of Agriculture 2005 dietary guideline s for weight loss of 300 or more minutes of physical activity per week. Thus, fewer men may be properly using recommended weight loss strategies than is reported. In addition to eating less food and increasing exercise, cutting back on fried foods and swe ets and desserts was also mentioned. While these foods have not specifically been identified in previous research on weight loss strategies, Weiss, Galuska, Khan, and Serdula (2006) found that switching to foods with lower calories was a strategy used by m en to lose weight. Identifying ways for men to include many of their preferred foods, using lower calorie options, may assist them with realistic weight loss options. Results of this study also support past research that suggests that men are less likely to use unhealthy strategies to lose weight (James, 2003; Kruger et al., 2004; Weiss et al., 2006). Less than 10% of overweight and obese men reported fasting or skipping meals, using meal replacement drinks or bars, and using diet or water pills. Men who did use unhealthy strategies to lose weight were on average heavier which may suggest that men who are obese may opt for unhealthier strategies, which in turn may cause their weight loss to be ineffective. With regard to formal weight loss programs, less t han 10% of men in this study had ever joined a weight loss program to lose weight. This is consistent with previous research that indicates that men typically make up only 10% to 15% commercial weight loss program clientele (Wolfe & Smith, 2002). Physica l activity participation While physical activity has known benefits which the risks for hypertension, diabetes, heart attacks (Simon, 2002) and mortality (Leitzmann et al., 2007), over 60%
122 of American adults are not active enough to receive cardiorepirator y benefits (Adams et al., 2003; Lee et al., 2000; Sesso et al., 2000; Towers et al., 2005). Consistent with the literature, only 47% of men in this study described their current physical activity level as active or very active. On average, as reported acti vity went up, BMI went down which is consistent with previous research on the activity levels of overweight individuals (Adams et al., 2003; Carnethon et al., 2005). In order to receive cardiorespiratory benefits, adults should receive at least 150 minute s of moderate intensity training per week or 75 minutes of vigorous intensity (DHHS, 2008). The recommendation for moderate activity roughly equates to a minimum of 30 minutes, five or more days per week (Pate et al., 1995; USDA, 1998; DHHS, 1996). Only 14 % of men in this study participated in at least five days per week of planned moderate cardiovascular activity. Health benefits can still be achieved with participation in physical activity on fewer days of the week. However, research shows that the exerci se bout needs to be longer in duration to receive benefits (Lee et al., 2000; 2004). In this study, 77% of men exercised for at least 30 minutes, thus, it may be possible that while men are not exercising on most days of the week they may still be exercisi ng long enough to receive the minimum of 150 minutes or intense enough to achieve the 75 minutes recommended for vigorous intensity that are necessary to receive cardiorespiratory benefits. However, men wanting to manage or lose weight may need to increas e their weekly physical activity minutes from 150 to 300 minutes or roughly 60 minutes per day depending upon intensity (DHHS, 2008). In addition, research indicates that 45 60 minutes of moderate physical activity is required to prevent overweight individ uals from
123 transitioning to obese (Saris et al., 2003). With only 16% of men in this study reporting cardiovascular workouts longer than 60 minutes and 15% reporting workouts of 45 60 minutes in duration it would seem unlikely that the majority of overweigh t and obese men were exercising long enough or intense enough to change their weight status or to prevent themselves from gaining more weight. These findings may further support that men are in need of education on how much physical activity is sufficient for weight loss. The 2008 Physical Activity Guidelines for Americans identified moderate physical activity as brisk walking (walking 3 miles per hour or faster, but not speed walking) (DHHS). While the intensity was not determined, walking was the primary cardiovascular activity as identified by 60% of the men which is consistent with previous research (James, Hudson, & Campbell, 2003; Kaiser, Brown, & Baumann, 2010; Littman, Kristal, & White, 2005). In a 10 year follow up study, James, Hudson, & Campbell (2003) found that fast walking was associated with less weight gain over the ten year period while slow walking was not. Thus, men who are not walking for long periods of time will likely not be walking at a pace that is sufficient for weight loss. Biking, swimming, and golf was also listed by participants, but mentioned far less frequently than walking. Golfing without a cart is also considered a moderate physical activity and along with walking, recreational biking, and swimming has a low injury rate (DHH S, 2008; Sherwood & Jeffery, 2000). Cart use was not identified with regard to subjects who selected golf, so it is unknown how many were potential receiving benefits from golf, but regardless there appears to be little moderate physical activity beyond wa lking among this group of men. Moreover, they indicated little participation in more vigorous activities such as running, only identified by 19% of participants. However,
124 those who did participate in running activities had a significantly lower BMI than th ose who did not. While barriers to vigorous physical activity were not specifically addressed, age may play a role in running participation. Men in the younger cohort were more likely to report participation than men in the older cohort. This may have been due to concern for injury as running is a higher impact activity and has a greater risk for injury than walking (DHHS, 2008; Sherwood & Jeffery, 2000). Unfortunately, while lesser amounts of vigorous physical activity are needed for weight loss (Saris et al., 2003), participation in vigorous physical activity was less preferred. Understanding, key barriers and motivators to increasing participation in both moderate and vigorous physical activity may assist with potentially more efficient weight loss in the se men. Adults should also participate in muscle strengthening activities at a moderate intensity on two or more days of the week that involve major muscle groups (DHHS, 2008). In the present study, 67% of the men reported that they did not lift weights r egularly (less than 1 time per week). While not as effective as aerobic activities alone (DHHS, 2008) muscle strengthening activities, when combined with aerobic activity and proper diet, may be helpful in promoting weight loss (Masley, Weaver, Peri, & Phi llips, 2008). The high percentage of men who did not participate regularly in muscle strengthening activities, indicates that men may not be aware of the benefits that weight training has on weight management or may not have the skills to participate. Mos t men indicated that they preferred to work out at home, and may not have access to facilities or equipment that would enable to them to participate in these activities. However, those who did participate regularly in weight training exercises did not diff er in BMI from those who did not.
125 The benefits of participation in flexibility exercises are unknown, but may help to increase flexibility for activities that require more flexibility (DHHS, 2008). Recommendations for older adults are to participate in fl exibility activities two or more days per week at a minimum duration of 10 minutes per bout (Houston et al., 2009). In the present study, 56% did not participate regularly in flexibility exercises. While there are no known links between flexibility and wei ght control, those who participated 5 7 times per week in flexibility exercises had lower BMIs than those who did not participate at all. This may simply be due to those who are participating regularly in flexibility exercises may be more active in general Barriers and motivators to physical activity Research on physical activity determinants indicates that there are numerous barriers preventing adults from being physically active. As with previous studies (Booth et al., 1997; Brown, 2005; Brownson et al. 2001; Buman, Yasova, & Giacobbi, 2010; De Bourdeaudhuij & Sallis, 2002; Sherwood & Jeffery 2000), not having time to be physically active was the most frequently listed barrier by 34% of men in the study. Similarly, 26% said that they get home too late w hich may also be an issue of time for these individuals, particularly the younger individuals in this study who were more likely to list getting home too late as a barrier. Consistent with barriers to weight loss and in line with previous research (Brown 2005; Brownson et al., 2001), motivation was an issue for 21% of men in the study. Individuals who said that they were not motivated to be active were also more likely to be heavier or married. This may suggest that individuals who weigh more may lose mo tivation as they continue to put on weight whereas those who weigh less may feel that weight control is still within reach. In addition, married men may feel less of a need
126 to lose weight than single men who are still trying to look more attractive to a po tential partner. Physical activity was not a priority for 18% of the men, which again may have been due to time being allotted to more pressing responsibilities. While 36% of men worked in a physically demanding job only 16% said that they get enough exer cise at work. This is even less prevalent among men with more education as, men with graduate or professional degrees in the study were less likely to list this barrier than men with high school degrees. Quite possibly, those with less education may be wor king in more labor intensive positions and thus may be more likely to report more physical activity on the job. Poor health has previously been identified as a barrier to physical activity (Booth et al., 1997) especially among older populations (Towers et al., 2005) yet only 7% of men reported that their health was a barrier. This may have been a result of the large of percentage of individuals in this study who reported that their health was very good or excellent. The least frequently reported barriers, reported by less than 5% of subjects, were not being able to afford the gym and having unsafe neighborhoods. While environmental barriers, such as unsafe neighborhoods, have previously shown to limit physical activity among some populations (CDC, 1999), me n in this study either did not live in unsafe areas or did not perceive their areas unsafe, so as to prevent them from being active. These findings may also be explained by previous research that suggests men have little difficulty with finding places to e xercise (Brownson, et al., 2001). Weight control has been previously identified as a motivator for physical activity (Brown, 2005; Buman et al., 2010). With 51% of overweight men and 79% of obese
127 men in this study trying to lose weight, it is not surprisi ng that the leading motivator to increasing physical activity was to lose weight, mentioned by 53% of participants, who were on average, obese. Health reasons have previously been cited in the literature as motivators to increase physical activity levels (Brown, 2005; Buman et al., 2010; De Bourdeaudhuij & Sallis, 2002), and 37% said they would be more active if they were diagnosed with a disease while 32% said they would increase their physical activity level if their doctor told them to do so. The role t hat physicians play in increasing physical activity is seemingly an important one as previous research indicates that lack of encouragement to be physically active from a physician is associated with decreased levels of physical activity (Fink & Wild, 1995 ). Social support for physical activity in the form of a spouse, friends, or family members has been previously identified as a motivator among younger age and older age groups to increase exercise levels (De Bourdeaudhuij & Sallis, 2002). In this study, 29% of men said that they would be motivated to be more physically active if they had someone to exercise with and 21% said they would if their partner was physically active. Research suggests that individuals whose spouses are active are 20% more likely to be physically active if their partner is more active and 41% more likely to be active if their friends are active (Janzen & Cousins, 1995). The activity levels of friends was less concerning among men in this study as only 7.5% indicated they would be m ore active if their friends were active. Thus, it would seem among these men that having social support for physical activity from a spouse may serve as a greater motivator than active friends. However, the mean BMI was significantly higher and in the obes e range for
128 those who listed they would be more active if their friends were active. This may suggest that obese men may be in greater need of support from everyone in their life than non obese men. While convenience in the form of access has previously b een correlated with physical activity (Brownson et al., 2001) having more convenient places to exercise was only listed by 12% of participants. In addition, only 7% stated they would be motivated to be more physically active if they had a gym membership. W ith 55% of participants indicating that they preferred to work out from home, convenience may not be a concern walking is the most preferred physical activity among these men the issue of access may not be as much of a barrier for them as other forms of activity. Eating habits Small reductions in caloric intake are recommended for preventing weight gain and a reduction of 500 calories or more per day is recommended for w eight loss (DHHS, 2005). Over 35% of men in the present study indicated that they needed to eat less food (in general). These men, on average had a BMI within the obese category, which was higher than those who felt they did need to eat less food. Availabi lity of food may lead to higher consumption as 66% of men indicated that on occasions that they consistent with previous research on failed weight loss attempts that par ticipants complained it was difficult to lose weight because food was readily available, having difficulty controlling what they ate, and not being able to estimate appropriate portion sizes (Burke et al., 2008). Thus, helping individuals buy foods that ar e more nutrient dense and readily available or to reduce the overall availability of all foods, may help
129 with unnecessary eating. With portion sizes increasing (Young & Nestle, 2003), health educators need to provide training that helps men understand how portion sizes compare to the recommended serving sizes and reduce the occurrence of overeating (DHHS, 2005). Some men did, however, indicate that they overate because they were stressed, which has been previously shown to contribute to increased calorie co nsumption and abdominal fat (Bjornthorp, 2001). In addition these men had a significantly higher BMI than those who did not overeat, due to stress. Thus, stress management techniques for this population may need to go beyond physical activity recommendatio ns and address the influence of stress on increased caloric consumption. While only a small percentage indicated overeating due to being depressed, depression has also been an associated risk for developing cardiovascular disease, type 2 diabetes, and accu mulating additional body fat (Bjorntorp, 2001). Stress management techniques such as increasing energy output through physical activity may An examination of dietary patterns reported in the 198 7 and 1992 National Health Interview Surveys by Kant, Graubard, and Schatzkin (2004), revealed that consumption of fruits, vegetables, whole grains, low fat dairy, and lean meats, is associated with a lower risk for mortality. The men most frequently liste d that they needed to consume more fruits and vegetables to improve their diets. This is consistent with the 2005 Dietary Guidelines for Americans which found that men aged 31 50 currently do not meet the recommended consumption of nine daily servings of f ruits and vegetables (DHHS, 2005). The servings of fruits and vegetables were not included in the present study. Increasing daily intake of fruits and vegetables may offset the consumption of
130 foods that have a higher caloric content and help sustain weight loss (DHHS, 2010). Thus, incorporating more fruits and vegetables into the diets of these men may be an important strategy for successful weight management. Consumption of grains and low fat foods were only mentioned by 23% of subjects, however, BMI was significantly higher among those who did indicate needing to eat more grains and low fat foods. Previous research on the benefits of eating a low fat diet revealed that adults do perceive that reducing fat prevents heart attacks and lowers cholesterol leve ls (Artinian, 2001). Despite the small percentage identifying a need to increase the consumption of low fat foods, the most frequently listed foods that men indicated that they needed to eat less of were fried foods, reported by 38% of participants who on average had a significantly higher BMI. Fried foods are typically high in trans and saturated fats and consumption of these foods in excess is associated with obesity (DHHS, 2010). Eating healthier snacks was also listed by 39% of individuals who on avera ge had a higher BMI than those who did not list healthier snacks. Snacks can also be high in fat, cholesterol, sugar, and sodium, which may lead frequently listed as important to those reading food labels, only 58% of the men indicated that they read food labels, and only 60% of them understood everything on the label. This further suggests that while they are aware of the associations between fat consumption and health, they m ay not be aware of the potential sources of fat. Eating more fiber was listed by 28% of men. With a high percentage of individuals indicating a need to increase fruits and vegetables, it is likely that a far greater percentage may need to increase their fiber consumption. Inadequate fiber intake
131 reflects a low consumption of grains, fruits, and vegetables (DHHS, 2005). In a previous study assessing the perceived benefits to eating high fiber foods, men over 60 indicated that consumption of fiber helped p revent constipation. While men aged over 60 do not encapsulate the entire sample of this study, these findings may suggest that the benefits of fiber may not be well known among men. In addition, fiber was infrequently looked for on nutrition labels furthe r suggesting that men might not be aware of suggested fiber intake. Most Americans consume more salt than they need on average (DHHS, 2005) yet only 30% of men in this study indicated that they needed to eat less salt or salty foods. Salt consumption help s regulate blood pressure which if too high can lead to hypertension and increase the risk for coronary heart disease, stroke, and kidney disease (DHHS, 2005). Sugar, another contributor to obesity, was mentioned by 29% of men. Consumption of sugars can l ead to excessive calorie intake with little to no essential nutrients. Sugar sweetened foods, like soda for example, provide calories, but consumption was high, 50% of men dran k sodas at least a few times a week. Another 32% drank sweetened drinks at least a few days a week. Diet sodas and sugar substitutes were usually consumed by 37% and 36% of men respectively. Diet sodas and sugar substitutes have been used as weight loss strategies in previous studies (Kruger et al., 2004; Levy & Heaton, 1993). Drinking more water was listed by 42% of men in this study which has previously been identified by adults a weight loss strategy (Weiss et al., 2006). Increased consumption of water can help keep the body hydrated,
132 which will help starve off hunger sensations and help with the digestion and absorption of nutrients (Hoeger & Hoeger, 2010, p. 136). In a comparison of data from NHANES III and NHANES 2001 2006, moderate alcohol c onsumption in men 40 74 increased from 49.8% to 57.2% (King et al., 2009). While moderate alcohol use was not specifically addressed, 26% of men in the present study had a consumption that was not considered high but not considered low, and thus may be com parable to the moderate. However, actual quantity was not identified. Still, use may have been lower than national average for men in this age range. In addition, alcohol consumption fell from 40.0% in NHANES III to 32.6% in NHANES 2001 2006 (King et al., 2009) and was even lower among participants, with only 26.1% stating that they did not drink at all. While many of these men drink, their drinking levels are relatively low which might indicate why only 14% reported that they needed to drink less alcohol t o improve their diet. Alcohol consumption provides additional calories but few essential nutrients, and while one to two per day may lower the risk of heart disease overall caloric consumption may increase (DHHS, 2005). Overweight men were significantly mo re likely to be in the middle range of use, while normal weight men were more likely to report low use. Thus, the added calories from alcohol consumption might be contributing to weight gain in these men. However, having to give up alcohol and meat has pre viously been identified as a barrier to losing weight (Sabinsky et al., 2007). This may indicate that these men may not be willing to include reducing alcohol consumption as part of a weight loss strategy. This may also explain why only 15% of men reported that they needed to eat less meat and may indicate why the least mentioned food items that men indicated that they needed to improve upon was protein.
133 The average daily consumption of high protein foods such as meat and beans for men aged 31 50 is current ly above recommended levels (DHHS, 2005). In addition, men do not eat enough dairy products (DHHS, 2005), but consumption of dairy products was also less frequently identified as an area needing improvement. Thus, men in this study may be getting the reco mmended amounts of dairy or may not be familiar with how much dairy they actually should be consuming. Barriers and motivators to healthy eating Men typically do not make dietary changes to manage their weight (Davis et al., 1991; Verbrugge, 1985) and fr equently list lack of time and having to give up favorite foods as barriers to eating healthy (Hagdrup et al., 1998; Lappalainen et al., 1997). Consistent with previous research, 40.6% of men in the present study most frequently listed that they did not wa nt to give up their favorite foods, with younger men reporting this barrier more often than the older cohort. The second most listed barrier, by 35% of the subjects, was life being too busy to make time to eat healthier. Men who listed having a very busy l ife were also heavier on average. Twenty nine percent of men indicated that they ate a healthy diet, while 33% self described their diet to be very good or excellent. The men who ate healthy had a significantly lower BMI than those who did not eat healthy but were still in the overweight category. The older cohort was more likely to list that they were eating healthy, which may explain why the younger cohort had greater concerns about giving up their favorite foods. Thirteen percent indicated that they did not have healthy options at work which has also been previously identified in the literature (Smith & Owen, 1992). These men were on average obese and had a significantly higher BMI than those who did not list
134 this barrier. One solution to unhealthy f ood options at work would be for individuals to pack their own lunches to take to work. In this study 54% did pack their own lunch which suggests that this barrier is relatively easy for Baby Boomers to overcome. Unlike barriers to weight loss and physical activity, a lack of motivation was listed by only 13% of subjects. Lack of motivation has not been previously reported in the literature to be a barrier to healthy eating. As eating is something necessary for basic survival, one rarely needs to be motivat ed to eat and thus individuals may not need motivation to change their diets, but rather be provided with the skills necessary in preparing healthier foods. Another reported barrier to healthy eating that has been identified specifically among men is healt hy eating not being a priority (Sigrist et al., 2005) and in this study this was listed by 17% of participants. Consistent with the literature on barriers to healthy eating, healthy foods being too expensive (Hagdrup et al., 1998; Lloyd et al.,1995; Smith & Owen, 1992), taking too much time to prepare (Artinian, 2001), not tasting good (Gough & Conner, 2006), and not knowing how to cook (Smith & Owen, 1992) were all listed as barriers in this study. However, each of these barriers was listed by 12% or less of participants. There appears to be less of a concern about expense and being able to prepare healthy meals and more of a concern with enjoying eating healthy foods and having time to eat healthy. Thus, greater emphasis can be placed on improving the eati ng habits of male Baby Boomers by helping them find ways to incorporate healthier meals into their busy schedules that include foods that they enjoy. Limited research is available on what motivates men to eat healthy beyond eating healthy for appearance reasons, to improve health or prevent disease, and being
135 motivated by family members (Sigrist et al., 2005; Artinian, 2001). Consistent with previous studies, losing weight was again the main concern and was identified as a motivator by 49% of subjects. Si milar to motivators to physical activity, those who selected lose weight were obese on average and more likely to be married. While 30% were motivated to prevent certain diseases, 40% were motivated if they were diagnosed and had a significantly higher BMI than men who did not state they were motivated by disease diagnosis. White men were also more likely than non White men to be motivated by diagnosis of disease or illness but non White men were more likely to list prevention. Thus, it would seem individua ls are more motivated to eat healthy for treatment of disease rather than for prevention. This is alarming as individuals who wait for diagnosis to eat healthier may put themselves further at risk for other chronic medical conditions. Similar to the motiv ators to weight loss, only 8% of men would be motivated to eat healthy if someone close to them was diagnosed with disease. As evidenced by the increase in motivation simply through diagnosis over prevention it is not surprising that the diagnosis of someo ne beyond themselves would not have as great of an impact. Furthermore, they might not perceive themselves as susceptible to the same disease, thus limiting any potential motivation for change. Two motivators relating to family members were listed by part icipants. While only 12% listed to be a better role model for my kids as a motivator to be more physically active, 16% were motivated to eat healthier for their children. With the potential influence parents have on their children in the areas of physical activity and eating habits, this may provide some insight as to the level of concern parents may have for
136 being a role model. Nine percent of men stated that they would be motivated to change if their family members were willing to change. Men who have chi ldren living at home may find it difficult to avoid certain foods that teens or children may enjoy. Health educators need to help families plan meals that everyone can enjoy that focus more on portion control and variety. Healthier foods consumption should be a practice that is adopted by the family rather than viewed as temporary avoidance of certain foods. Finally, 12% reported that they would be motivated to eat healthier if restaurants offered healthier foods. While it is unknown what restaurants these men were frequenting, and with 19% eating at fast food restaurants at least a few days a week and 8% eating at all you can eat buffet restaurants at least a few days a week, health educators need to help men make healthier choices when they choose to eat out. Moreover, assistance with meal planning and grocery shopping may further aid in the avoidance of eating out. Stage of change for weight loss Looking at stage of change for weight loss, 36.3% were in the action stage (trying to lose weight but for les s than 6 months) and 19.6% were in the maintenance stage (trying to lose weight for more than 6 months). Of those in these two stages the mean BMI indicated that they were in the obese category. Those who were not interested in losing weight also reported the lowest mean BMI which was significant, however at 27.95 they were still in the overweight category. However, the findings that these individuals possessed the lowest mean BMI are encouraging in that at least those who are obese are in the later stages of change for weight loss.
137 Stage of change for physical activity A combined 66% of men in this study were in either the maintenance (46.5%) or action (19.5%) stage of change with regard to exercise. These findings are higher than the 47% of men in this stu dy that self described their current physical activity as active or very active. Only 5% of men were in the preparation stage, and the remaining men were either in the precontemplation (16%) or contemplation (13%) stages. Men who were in the maintenance st age for exercise had a significantly lower mean BMI than men who were in the contemplation stage. Unlike stage of change for weight loss, those in the later stages of change had the lowest mean BMI. This is not surprising as physical activity involvement i s necessary to maintain weight whereas individuals who have lost weight would no longer need to continue to be actively losing weight once they had reached their goal weight. Stage of change for healthy eating Over half of the men in this study were makin g some sort of positive changes in their eating with 57% indicating they were in the action or maintenance stages for healthy eating. Similar to weight loss, the 23% in the precontemplation stage had a significantly lower mean BMI than those in the contemp lation stage who had the highest BMI. While, their BMI was still in the overweight category this would again seem to indicate that those who are not thinking about eating healthier, either already eat healthy or do not perceive their current weight as a co ncern as far as eating healthier. The 12% of men in the contemplation stage had the highest mean BMI which was significantly higher than the action and maintenance stages. This indicates that these men are concerned about their weight and understand that t hey need to eat healthier, but may be unsure how to change or have the necessary skills.
138 Limitations The study has limitations that should be addressed. First, the subjects were recruited from North Central Florida region and results cannot be generalized to other populations of in other regions of the United States. Second, because purposive and snowball sampling were used, a true representation of the population in the North Central Florida region may not have been attainted. Third, the recruitment proce dures involved men from fitness centers and thus may have been more homogenous in nature which may have influenced the findings. Fourth, the use of self report surveys may have lead participants to provided responses that were more socially desirable. Fift h, the participants may have unable to accurately remember the occurrence or frequency of their behaviors. Sixth, men who are motivated to lose weight may have been more inclined to participate in the study than men who were not interested in losing weight Finally, there may have been inconsistency with how participants reported how they typically behave and how they actually behave. Recommendations With Baby Boomers entering retirement age, the looming health care costs for treating the chronic health co nditions associated with obesity will no doubt put a significant strain on the resources available to treat these conditions. The overweight and obesity prevalence in this population of men is among the highest in the United States, yet many are not concer ned about their weight or may not perceive their weight to be a problem. While obese men reported less body satisfaction and high rates of current weight loss, overweight men typically did not express the same concerns and as such were less likely to be tr ying to lose weight. Unfortunately, overweight men tend to take a more reactive than proactive stance with regard to their weight loss. Thus, more
139 predominant motivators to weight loss that were found in this study were disease diagnosis and being told by a doctor to lose weight. Fortunately, a doctor recommendation for weight loss may have a greater impact on the weight change status of overweight men than obese men who may already be aware of their risks. Thus, clinicians play an important role in helping men who are overweight with initiating change. The strategies that men who were trying to lose weight were consistent with the literature, however, it is apparent that men may not fully understand the amounts of physical activity needed for weight loss. With walking as the primary source of cardiovascular activity, men will need to walk an hour a day for most, if not all, days of the week in order to lose weight. Thus, healt h practitioners must provide education to this population of men on the recommended amounts and intensity of walking needed to lose weight. In addition, more low impact activities beyond walking must be made available as well as training in the skills nece ssary for participation. Furthermore, education on healthy portions can assist those who reportedly overeat, quite often due to food being in front of them. Social support appears imperative to improving physical activity and healthy eating habits and shou ld be utilized when developing weight loss programs for this population. Implications for the roles of practitioners, clinicians, health educators, and recommendations for future research follow. Implications for Practitioners The study findings provide i mportant information for practitioners interested in assisting men with losing weight. Results indicate that motivations for weight loss differ depending on age. Younger individuals may be more receptive to physical activity that can be incorporated earlie r in the day. Thus, partnerships with worksite health
140 promoters are needed to develop physical activity programs that can be conducted before work or at a company sponsored gyms. In addition, the younger population is more likely to want to participate in running activities and thus programs can be created that provide group training for 5K 10K races within the community. With regard to healthy eating, programs that include lower calorie substitutions of their favorite foods are going to be best received. F or the older Baby Boomers, walking programs can be designed in their own neighborhoods as well as other low impact physical activities such as tennis, golf, bicycling, and swimming. Finally, group programs should be developed that incorporate social intera ction and family involvement, particularly that of spouse involvement. These men may be best reached through motivation and support from their significant others. Thus, targeting men through women may be a successful strategy for recruitment. Implication s for Clinicians The role of clinicians may be most important in initiating weight loss with this population. Thus, it is important for physicians to assess the weight of their patients and explain the risks associated with their current weight status. The current physical activity levels for patients should be assessed as well as eating habits so appropriate recommendations and treatments may be suggested. These recommendations should be specific as to the amounts, type, and intensity of physical activity needed as well as for the servings and types of foods that need to be increased. In this sense doctors can prescribe physical activities and healthy foods that they want their patients to increase. In addition, clinicians must work with health practitioner s and health educators with referring patients to the appropriate resources within the community that will assist them with increasing physical activity and eating healthy. Working with employers on
141 establishing health screenings is also imperative when re aching out to those men who do not seek medical advice. Implications for Health Educators Health educators play an important role in assisting Baby Boomers with developing skills and knowledge regarding healthy portions, physical activity amounts, and str ess management techniques. Education must be provided on how to prepare healthy meals at home, how to read food labels and the amounts and the importance of increasing the intake of fruits and vegetables, fiber, protein, whole grains, and low fat foods. In addition, physical activity recommendations for weight loss specifically must be made clear as well as healthy goals for weight loss. Proper stress management through proper time management techniques, healthy outlets such as physical activity, appropriat e sleep, and relaxation techniques must also be taught. Further, health educators can help men set goals and specific objectives with regard to each Health educators can pr ovide training for these instruments as a way to break daily physical activity goals into multiple bouts throughout the day. They must also work to motivate individuals to get health screenings from clinicians as well as counsel physicians on effective rec ommendations for patients. Finally, they need to work with practitioners on establishing physical activity groups within the community and increase support for walking areas. Implications for Worksite Health Promotion The workplace environment can assist men with both healthier options as well as provided opportunities for activity. Men in this study identified not having healthy options at work as a barrier to healthy eating. Thus, health promoters must work with
142 employers to establish wellness programs that include healthy eating in the workplace. This must also include making healthy foods and beverages not only available but affordable for employees. In addition, physical activity opportunities need to be provided in the form of exercise groups, progr ams, or workout areas. As work is a preferred venue to exercise at, the added convenience of being able to exercise during the day may assist some men with overcoming the barrier of time. The present study pr ovided many implications that may assist men with aging successfully. First, understanding what a healthy weight is may help educate those individuals who are not aware of the potential health risks that are associated with being overweight. Men must be e ncouraged to routinely schedule check ups with their physicians that not only provide them with education on weight loss but to assess their current health risks. This will enable men to adopt healthier behaviors as part of their daily living and increase the quality and quantity of the years they have remaining. In addition, men will be able to work longer and remain productive allowing them to enjoy greater social security benefits and financial support upon retirement. Furthermore, prevention of chronic conditions such as diabetes and arthritis will enable them to remain independent reducing the need for ADLs and potentially improve mental and psychological health in the process. Recommendations for Future Research With the discrepancies between reported physical activity participation and the amounts necessary to achieve weight loss, it is important for future research to determine if men know the required amounts of moderate physical activity needed to lose weight. In addition, while motivators and barri ers to physical activity were
143 addressed it is unknown what barriers and motivators that these men have toward both moderate and vigorous activity. In addition, the barriers and motivators to muscular strength activities should also be determined. With high participation in walking programs, research on the success of walking programs for weight loss in this population is also needed. Understanding the determinants of participation in lifetime activities such as golf, tennis, and swimming may also aid in dev eloping weight loss programs given a greater variety of physical activities. In addition, determining the frequency of visits to a physician as well as the potential barriers and motivators to these visits will assist in developing strategies to increase p hysician interaction with less seen patients. Further studies should also include more in depth questions on the eating behaviors of Baby Boomers to accurately determine what foods they need to increase and decrease. In addition, future research should inc lude assessment of stress levels of these men as well as the stress management techniques that they employ to determine how physical activity and eating behaviors are influenced by stress. Finally, with the growing numbers of individuals who live with arth ritis, understanding how physical activity levels are influenced by this chronic condition can help with designing weight loss programs that include more appropriate physical activity recommendations. Conclusion In conclusion, this study was conducted to examine the weight status, physical activity patterns, and eating behaviors of male Baby Boomers. The findings suggest that while Baby Boomers are overweight or obese they feel that they are in good health. Obese men are not fully aware of how severe their weight problem is, but are still likely to be losing weight while overweight men are aware that they need to lose weight, but are quite often satisfied with their weight. In addition, this population does not participate
144 frequently enough in physical acti vity, or at an intensity sufficient enough to lose weight. They also experience a high frequency of overeating due to a lack of knowledge on portion sizes. Thus, health practitioners, educators, and clinicians play an important role in helping to educate t hese individuals on the severity of obesity and the proper weight loss strategies necessary to lose weight. With the growing numbers of overweight and obesity and the chronic conditions that they face, including morbidity and mortality, programs and interv entions must be developed that meet their specific needs.
145 APPENDIX A PARTICIPANT SURVEY This study is investigating the eating patterns, weight management, and physical activity practices of male Baby Boomers. Information from this st udy will be used to develop weight loss and weight management programs designed to meet the needs of male Baby Boomers. Please help us by completing this survey by answering all of the questions. Please circle or put a check next to your answer. Your info rmation will be kept confidential. Completing the survey is completely voluntary and you do not have to answer any of the questions that you do not want to. This survey will take 15 to 25 minutes to complete. Q1. What year were you born? _______________ Q2. What is your marital/relationship status? Single, not in a committed relationship Single, in a committed relationship Married, separated Married, living with spouse Q3 How would you describe your sexual orientation? Heterosexual (st raight) Homosexual (gay) Bisexual (sex with men and women) Q4. Do you have any children ? Yes (Go to Q 5) No (Go to Q 6) Q5. Please indicate if you have any children in your household that falls in any of the following age categories. Cho ose as many as apply 5 years of age or younger 6 years to 12 years 13 years to 18 years Q6. What is your current work status? Choose one. Work full time Work part time Unemployed Unable to work due to disability Q7. Do you rent o r own your home? Rent Own
146 Q8. What type of home do you live in? Apartment/condominium House Mobile home Q9. Would you classify the area where you live as rural? Yes No Q10. Were you born in the United States? Yes (Go to Q 12) No (Go to Q 11) Q11. Approximately how many years have you lived in the United States? ________ Q12. Which Racial/ethnic group best describes you? Black/African American Hispanic White/Caucasian Other Q13. What is the hi ghest level of education that you have achieved? Eight grade or less Did not finish high school High school graduate/GED A.A. degree or professional license B.A./B.S. degree Graduate or professional degree Q14. Approximately ho w much is your yearly income? Less than $19,999 $20,000 to $29,999 $30,000 to $39,999 $40,000 to $49,999 $50,000 to $59,999 $60,000 to $69,999 More than $70,000
147 EATING PATTERN This section tells us how you usually eat. Q 15. How would you describe your diet? Excellent Very good Good Fair Poor Q16. Do you usually eat breakfast? Yes No Q17. How often do you eat at fast food restaurants (McDonalds, Burger King, Everyday Almost every day A few days a week A few days a month Rarely or never Q18. Yes No Q19. Everyday Almost every day A few days a week A few days a month Rarely or never Q20. Are you the person who is primarily responsible for grocery shopping in your home? Yes No Q21. How often do you cook any of the meals in your home? Everyday Almost every day A few days a week A few days a month Rarely or never
148 Q22 Do you usually pack a lunch to take to work? Yes No Q23. How often do you drink sodas? Everyday Almost every day A few days a week A few days a month Rarely or never Q24. How often do you drink sweetened beverages such as Kool Aid, sweet tea, lemonade, or HiC? Everyday Almost every day A few days a week A few days a month Rarely or never Q25. Do you usually drink diet sodas? Ye s No Q26. Do you usually use sugar substitutes to sweeten your foods or drink (Equal, Sweet N Low, Splenda, etc.)? Yes No Q27. Do you usually read food labels when you shop? Yes No Q28 Do you understand everything you rea d on the food labels? Yes No
149 Q29. What information do you usually look for on food labels? Choose as many as apply. Calories Fat Cholesterol Sodium Carbohydrates Sugar Fiber Protein Vitamins & minerals Serving size Q30. How often do you overeat? Choose one. At every meal A least one meal a day A few times a week A few times a month A few times a year Never (Go to Q 32) Q31. What usually leads you to overeat? Choose as many as apply. Stress Loneliness Depression Anger Overwhelmed Boredom Tiredness Free food or food was just there Q32. What are the main reasons that prevent you from consistently eating a healthy diet? Choose as many as apply. It is not a priority for me Not Motivated I have a very busy life Healthy foods are expensive Healthy foods take too much time to prepare Healthy foods are not available at work Healthy foods do not taste good I do not want to give up some favorite foods I do not know how to cook I consistently eat a healthy diet
150 Q33. What would motivate you to consistently eat a healthy diet? Choose as many as apply. I want to lose weight I am diagnosed with a disease or ill ness Someone close is diagnosed with a disease To be a better role model for my kids To prevent getting certain diseases Restaurants offered more healthy foods Family members are willing to change Nothing I already eat healthy Q3 4. Indicate if you need to improve your diet by eating more of the following? Choose as many as apply I need to eat more fruits I need to eat more vegetables I need to eat more fiber I need to drink more water I need to eat more dai ry products I need to eat more low fat foods I need to eat more protein I need to eat more whole grains I need to choose healthier snacks Q35. Indicate if you need to improve your diet by eating less of the following? Choose as many a s apply I need to eat less food I need to eat less fried foods I need to eat less sugar I need to eat less salt and salty foods I need to drink less alcohol I need to eat less meat Q36. Please indicate if you are currently making significant positive changes in your diet. Choose one No, and I do not intend to in the next 6 months No, but I intend to in the next 6 months No, but I intend to in the next 30 days Yes, and I have been but for less than 6 months Yes, and I have been for more than 6 months
151 WEIGHT STATUS AND DIETING This section tells us about your weight, dieting behaviors, and body satisfaction. Q37. What is your height (without shoes)? (Example 5 feet 1 0 inches).____________ Q38. What is your current weight (in pounds)? (Example 185 pounds)._______________ Q39. What is your preferred (Example 185 pounds). __________ Q40. What is the current waist size of the dress pa nts that you wear (not counting baggy pants)? (Example 36 inches). ______________ Q41. How satisfied are you with your weight? Very satisfied Satisfied Somewhat satisfied Unsatisfied Very unsatisfied Q42. How would you describe your weight? Underweight Just right Slightly overweight Very overweight Extremely overweight Q43. How often do you t hink about how much you weigh? A few times a day Almost everyday A few times a month A few times a year N ever Q44. Please indicate if you are currently trying to lose weight. Choose one No, and I do not intend to in the next 6 months No, but I intend to in the next 6 months No, but I intend to in the next 30 days Yes, and I have been, but for less than 6 months Yes, and I have been for more than 6 months Q45. Has a doctor ever told you to lose weight? Yes No
152 Q4 6. What are you currently trying to do with your weight ? Trying to lose weight Trying to gain weight Trying to stay the same weight Not doing anything Q47. Have you tried to lose weight in the last 12 months ? Yes (Go to Q 48) No (Go to Q 52) Q48. Approximately how much weight did you lose the last time you tried? Less than 5 pounds 5 to 10 pounds 11 15 pounds 16 20 pounds More than 20 pounds Q49. Were you satisfied with that weight loss? Very satisfied Sati sfied Somewhat satisfied Unsatisfied Very unsatisfied Q50. How long did you stay on the weight loss program? Less than 1 week 1 week 2 to 3 weeks 4 to 6 weeks More than 6 weeks Q51. How long did you keep the weight off? Less than 1 month 1 to 3 months 4 to 6 months 7 months to 1 year More than 1 year
153 Q52. Where do you get most of your nutrition and dieting information? Choose as many as apply. TV Newspaper Magazine Wife, female fri ends & relatives Buddies Doctor Internet (general web search) Commercial weight loss website (e.g. weight watchers) Books Other (Specify)____________________ Q53. What weight loss strategies are you using or have you tried i n the past? Choose as many as apply. Eat less food Fast or skip meals Cut back on alcohol Cut back on fried foods Cut back on sweets and desserts Join a weight loss program Exercise more often Meal replacement drinks/bars (e.g Slim Fast) Diet pills or water pills I have never tried to lose weight Q54. What do you think are the main factors that prevent you from losing weight? C hoose as many as apply. Not a priority for me I am not motivated to lose weight N othing I have tried has worked Not sure if I can do it Have not found a plan that works for me Not disciplined, no will power I do not need to l ose weight or I am happy with my weight
154 Q55. What do you think are the main factors that would motivate you to lose weight? Choose as many as apply. To look better To feel stronger and fitter To be more productive at work If I am diag nosed with a disease or illness If someone close to me is diagnosed with a disease To prevent me from getting certain diseases If a doctor tells me to To be a better role model for my kids Being dissatisfied with my body Partner dissatisfied with my b ody Q56. What type of information do you think would help men your age who are trying to lose weight? Choose as many as apply Healthy recipes Portion control, serving sizes How to choose a weight loss program How to control stress How much they should eat How much exercise they need Online dieting Other (Specify)____________________ Q57. Would you consider having surgery to help you lose weight? (Example: gastric bypass, liposuction) Yes No Maybe PHYSICAL ACTI VITY This section tells us about your activity patterns. Q58. Do you have an injury, physical disability, or medical problem that prevents you from getting regular physical exercise ? Yes ( Go to Q 60) No ( Go to Q 59) Q59. How would you describe your current physical activity level? Very active Active Moderately active Not active Certified couch potato
155 Q60. How do you normally travel to work? Walk ( Go to Q 61) Bike ( Go to Q 61) Take the bus or other publ ic transportation ( Go to Q 62) Drive ( Go to Q 62) Work from home ( Go to Q 62) Q61. If you walk or bike, approximately how long does it take you to get to work? ______ minutes per day. Q62. Do you work in a physically demanding job that involves construction, digging, heavy lifting, etc? Yes No Q63. How often do you do planned moderate cardiovascular activity on a weekly basis (walking briskly, swimming, biking at a regular pace)? 5 to 7 times per week 3 to 4 times per week 1 to 2 times per week I do not exercise regularly Q64. On the days you do planned moderate cardiovascular exercise how long do you usually do so? Less than 30 minutes 30 to 45 minutes 46 minutes to 1 hour More than 1 hour Q 65. What is your primary cardiovascular activity? Choose as many as apply. Walking Running, jogging Biking Swimming Basketball Other ______________________________ Q66. How many times a week do you lift weights? 5 to 7 times pe r week 3 to 4 times per week 1 to 2 times per week I do not lift weights regularly
156 Q67. How often do you do flexibility exercises such as stretching or yoga? 5 to 7 times per week 3 to 4 times per week 1 to 2 times per week I do not stretch regularly Q68. Do you push yourself harder on the weekend by having longer bouts of exercise? Yes No Sometimes Q69. Does your neighborhood have adequate sidewalks for people to walk, run, or ride bikes? Yes No Q70. Wher e do you usually exercise? Choose as many as apply. At home At the gym At a nearby park At a community center Around the neighborhood At the YMCA At work At a stadium Q71. Do you currently participate in any of the following c ompetitive activities on a regular basis? Choose as many as apply. 5K, 10K run/walk Marathons Cycle team, Bike race Triathlon Tennis Golf Softball Coaching or refereeing youth sports
157 Q72. Approximately how many hours of T V do you watch every day? Less than 1 hour 1 3 hours More than 3 hours I do not watch TV regularly Q73. Approximately how many hours a day do you spend surfing the Internet for non work related purposes? Less than 1 hour 1 3 hours More than 3 hours I do not surf the Internet regularly Q74 Approximately how many hours a day do you spend on any of the following activities: online gambling, computer gaming, simulation games, video games, etc? Less than 1 hour 1 3 hours More than 3 hours I do not do any of the above Q75. Please indicate if you currently exercise. Choose one No, and I do not intend to in the next 6 months No, but I intend to in the next 6 months No, but I intend to in the next 30 days Yes, and I have been, but for less than 6 months Yes, and I have been for more than 6 months Q76. What do you think are the main reasons that prevent you from being physically active on a regular basis? Choose as many as apply. It is not a priority Get home too late Unsafe neighborhood Not motivated Get enough exercise at work Have health problems I would rather rest and relax than be active
158 Q77. What do you think would motivate you to be more physically active? Choose as many as apply. To lose weight Being diagnosed with a disease or illness Doctor tells me to Having someone to exercise with If my partner was physically a ctive If my friends were more physically active Having a membership to a gym To be a better role model More convenient places to exercise If I had transportation LIFESTYLE AND MEDICAL HISTORY This section tells us about your lifestyle and med ical history. Q78. How would you describe your health? Excellent Very good Good Fair Poor Q79. Do you have any type of health insurance? Yes No Q80. Do you smoke cigarettes? Yes No Q81. How would you d escribe your current alcohol usage? Very high High In the middle, neither high nor low Low I do not drink (Go to Q 83) Q82. In the last 30 days, have you ever had more than 5 drinks in one sitting? Yes No
159 Q83. Please indicate if you are taking any of the following. Choose as many as apply. Multivitamin (e.g. One a day) Vitamin C Vitamin E Fish oils Protein supplement Muscle building supplements Other _________________________ Q84. Please in dicate if you have been diagnosed with any of the following diseases or conditions? Choose as many as apply. Obesity Diabetes Heart disease High cholesterol Hypertension (high blood pressure) Stroke Prostate cancer Colon ca ncer HIV/AIDS Thank you for time and your support.
160 APPENDIX B INSTITUTIONAL REVIEW BOARD UFIRB 02 Social & Behavioral Research Protocol Submission Title of Protocol: Weight Loss Practices Among Male Baby Boomers and Perceptions and Needs f or Participation and Adherence to a Weight Loss Program Principal Investigator: Christopher K. Wirth UFID #: 9606 7890 Degree / Title: M.S.E.S.S. Department: Health Education and Behavior Mailing Address: Room 5, FLG PO Box 118210 Gainesville, F L 32611 Email Address & Telephone Number: Tel: 392 0583 x1283 E mail: cwirth@ ufl.edu Fax: 392 1909 Co Investigator(s): UFID#: Supervisor: Dr. Delores C.S. James UFID#: 1868 9210 Degree / Title: PhD, RD, LD, FASHA/Associate Professor Department: Health Education and Behavior Mailing Address: Room 5, FLG PO Box 118210 Gainesville, FL 32611 Email Address & Telephone Number: Tel: 392 0583 x1276 E mail : email@example.com Fax: 392 1909 Date of Proposed Research: February 1, 2008 to September 1, 2008 Source of Funding (A copy of the grant proposal must be submitted with this protocol if funding is involved): Unfunded
161 Scientific Purpose of the Study: Obesity levels are increasing among the Baby Boomer population and thus it is necessary for these individuals to lose and maintain a healthy weight. Current research suggests that men are less likely than women to do anything about their weight or to joi n a weight loss program. The primary aim of this investigation is to determine what male Baby Boomers do to achieve and maintain a healthy weight. A secondary aim of the investigation is to identify what elements of a weight loss program would be appealing to male Baby Boomers. A tertiary aim of the investigation is to identify strategies to motivate male Baby Boomers to exercise more. Describe the Research Methodology in Non Technical Language: ( Explain what will be done with or to the research partici pant. ) Twenty participants will be recruited to participate in a semi structured interview that will last approximately 1hour. Each participant will be asked a series of interview questions relating to weight management strategies, desirable components of a weight loss program, and motivational strategies to improve exercise levels. The interview will help develop recommendations for a weight loss program targeted at male Baby Boomers. [See Interview Attachment] Additionally, 350 participants will be rec ruited to complete a survey that will last approximately 25 minutes. The survey will ask questions about general demographics, as well current participation in regards to weight management, healthy eating, and exercise. The survey will help determine how w eight management, healthy eating, and exercise practices may differ among groups within the male Baby Boomer community. [See Survey Attachment] Describe Potential Benefits and Anticipated Risks: ( If risk of physical, psychological or economic harm may be involved, describe the steps taken to protect participant.) There is no more than minimal risk involved with the survey and interview portions of this study. The interview question participants will be ask about personal perceptions of healthy weight, indi vidual weight loss practices, and individual physical activity practice. Answering the questions is voluntary and the participants do not have to answer any of the interview questions that they do not want to. The individuals participating in the interview portion of the investigation will receive an incentive of a $15 Wal Mart card. The survey participants will be asked questions about weight management practices and will not receive any direct benefit for participation. Describe How Participant(s) Will Be Recruited, the Number and AGE of the Participants, and Proposed Compensation: Participants for the proposed investigation will be recruited from various community agencies and businesses in Alachua County. Participants will be male Baby Boomers born bet ween 1946 and 1964. 400 male Baby Boomers will be approached in an attempt to recruit 350 for the survey portion of the investigation. No compensation will be provided. 20 male Baby Boomers will be recruited for the interview portion of investigation and w ill receive $15 gift certificates to Wal Mart for participating in the interview.
162 Describe the Informed Consent Process. Include a Copy of the Informed Consent Document: Each interview participant will read and sign the Informed Consent Form (attached) b efore participation. Survey participants will provide consent by agreeing to complete the survey (script attached). Principal Investigator(s) Signature: Supervisor Signature: Department Chair/Center Director Signature: Date:
163 APPENDI X C INF ORMED CONSENT SCRIPT FOR SURVEY "Hi, my name is Chris Wirth and I am a PhD student from the Department of Health Education and Behavior at the University of Florida. I am studying the weight loss practices of male Baby Boomers. Specifically I am l ooking at what male Baby Boomers are doing to lose weight, what physically activities they are participating in, and what barriers and motivators they have towards weight management, healthy eating, and physical activity. I would appreciate it if you woul d agree to complete one of the surveys. It will take approximately 25 minutes to complete. I do not need your name so the information will be kept anonymous. Would you be willing to complete a survey?"
164 LIST OF REFERENCES Adams, M. (2005). U.S. weight l oss market worth $46.3 billion in 2004 Forecast to reach $61 billion by 2008. NaturalNews. Retrieved from http://www.naturalnews.com/z006133_weight_loss_dieters_food.html A dams, S.A., Der Ananian, C.A., DuBose, K.D., Kirtland, K.A., & Ainsworth, B.E. (2003). Physical activity levels among overweight and obese adults in South Carolina. Southern Medical Journal, 96 (6), 539 543. American Dietetic Association. (2009). Position of the American dietetic association: Weight management. Journal of the American Dietetic Association, 109 (2) 330 346. American Heart Association. (2006, November 8). American heart association urges new congress to tackle impending Baby Boomer health car e crisis. Retrieved August 2, 2007, from http://www.americanheart.org/presenter.jhtml?identifier=3043421 s Will Change Health Care. Retrieved from www.aha.org /aha/content/2007/pdf/070508 boomerreport.pdf Artinian, N.T. (2001). Perceived benefits and barriers of eating heart health y. MEDSURG Nursing, 10 (3) 129 138. Baradel, L.A., Gillespie, C., Kicklighter, J.R., Doucette, M.M., Penumetcha, M., & Blanck, H.M. (2009). Temporal changes in trying to lose weight and recommended weight loss strategies among overweight and obese American s, 1996 2003. Preventative Medicine, 49 158 164. Barnes, P. (2007). Physical activity among adults: United States, 2000 and 2005. Retrieved from National Center for Health Statistics (NCHS) website: http://www.cdc.gov/nchs/data/hestat/physicalactivity/physicalactivity.htm Bjorntorp, P. (2001). Do stress reactions cause abdominal obesity and comorbidities? Obesity Reviews, 2 (2), 73 86. Blair, S.N., Kampert, J.B., Ko hl III, H.W., Barlow, C.E., Macera, C.A., Paffenbarger, R.S., & Gibbons. (1996). Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all cause mortality in men and women. Journal of the American Medical Association, 2 76 (3), 205 210. Blair, S.N., Kohl III, H.W., Paffenbarger, R.S., Clark, D.G., Cooper, K.H., & Gibbons, L.W. (1989). Physical fitness and all cause mortality: A prospective study of healthy men and women. Journal of the American Medical Association, 262 (17 ), 2395 2401.
165 Blanchette, P.L. & Valcour, V.G. (1998). Health and aging among Baby B oomers. Generations, 22 (1), 76 80. Booth, M.L., Bauman, A., Owen, N., & Gore, C.J. (1997). Physical activity preferences, preferred sources of assistance, and perceived b arriers to increased activity among physically inactive Australians. Preventive Medicine, 26 131 137. Bouvier, L.F. & De Vita, C.J. (1991). The baby boom entering middle age. Population Bulletin, 46 (3), 1 34. Brown, S.A. (2005). Measuring perceived ben efits and perceived barriers for physical activity. American Journal of Health Behavior, 29 (2), 107 116. Brownson, R.C., Baker, E.A., Housemann, R.A., Brennan, L.K., & Bacak, S.J. (2001). Environmental and policy determinants of physical activity in the Un ited States. American Journal of Public Health, 91 (12), 1995 2003. Briefel, R.R., & Johnson, C.L. (2004). Secular trends in dietary intake in the United States. Annual Review of Nutrition, 24 401 431. Bryman, A. (2001). Social research methods. Oxford, NY: Oxford University Press. Buman, M.P., Yasova, L.D., & Giacobbi, P.R., Jr. (2010). Descriptive and narrative reports of barriers and motivators to physical activity in sedentary older adults. Psychology of Sport and Exercise, 11 223 230. Burk, L.E., Steenkiste, A., Music, E., & Styn, M.A. (2008). A descriptive study of past experiences with weight loss treatment. Journal of the American Dietetic Association, 108, 640 647. Burros, M. & Severson, K. (2005, January 13). U.S. diet guide puts emphasis on weight loss. The New York Times, pp. A1. Retrieved from http://proquest.umi.com.lp.hscl.ufl.edu/pqdlink?did=777912541&Fmt=7&clientId=2 0179&R QT=309&VName=PQD Carnethon, M.R., Gulati, M., & Greenland, P. (2005). Prevalence and cardiovascular disease correlates of low cardiorespiratory fitness in adolescents and adults. American Medical Association, 294 (23), 2981 2988. Centers for Disease Contr ol and Prevention (CDC). (1999). Neighborhood safety and the prevalence of physical inactivity selected states, 1996. MMWR Morbidity and Mortality Weekly Report, 48, 143 146. Centers for Disease Control and Prevention (CDC). (2007). National health and nutrition examination survey, 2007 2008 : Overview Retrieved from http://www.cdc.gov/nchs/data/nhanes/nhanes_07_08/overviewbrochure_0708.pdf
166 Centers for Disease Control and Prevention (CDC). (2008). About the BRFSS: Turning information into public health Retrieved from http://www.cdc.gov/brfss/about.htm Centers for Disease Control and Prevention (CDC). (2009). A bout the national health interview survey. Retrieved from http://www.cdc.gov/nchs/nhis/about_nhis.htm overweight or ob ese: A focus group study. Asia Pacific Journal of Clinical Nutrition, 18 (2), 257 264. Chang, V.W. & Christakis, N.A. (2003). Self perception of weight appropriateness in the United States. American Journal of Preventative Medicine, 24 (4), 332 339. Clelan d, R.L., Gross, W.C., Koss, L.D., Daynard, M., & Muoio, K.M. (2002). Weight loss advertising: An analysis of current trends Washington DC: Federal Trade Commission. Retrieved from http://www.ftc .gov/bcp/reports/weightloss.pdf Davis, C., Elliot, S., Dionne, M., & Mitchell, I. (1991). The relationship of personality factors and physical activity to body dissatisfaction in men. Personality and Individual Differences, 12 (7), 689 694. De Bourdeaudh uij, I., & Sallis, J. (2002). Relative contribution of psychosocial variables to the explanation of physical activity in three population based samples. Preventive Medicine, 34 (2), 279 288. Denscombe, M. (2003). The good research guide: For small scale soc ial research projects (2nd ed.) Philadelphia, PA: Open University Press. Determinant. (n.d.). In Merriam http://www.merriam webster. com/dictionary/determinant De Souza, P. & Ciclitira, K.E. (2005). Men and dieting: A qualitative analysis. Journal of Health Psychology, 10 (6), 793 804. Edlund, B.J., Lufkin, S.R., & Franklin, B. (2003). Lo ng term care planning for Baby B oomers: Address ing an uncertain future. Online Journal of Issues in Nursing, 8 (2), 88 98. Faul, F., Erdfelder, E., & Lang, A G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39 (2), 175 191. Fink, B. & Wild, K. (1995). Similarities in leisure interests effects of selection and socialization in friendships. Journal of Social Psychology, 135, 471 482. Flegal, K.M. (2005). Epidemiologic aspects of overweight an d obesity in the United States. Physiology & Behavior, 86 599 602.
167 Flegal, K.M., Carroll, M.D., Ogden, C.L., & Johnson (2002). Prevalence and trends in obesity among US adults, 1999 2000. Journal of the American Medical Association, 288 (14), 1723 1727. Flegal, K.M., Carroll, M.D., Ogden, C.L., & Curtin, L.R. (2010). Prevalence and trends in obesity among US adults, 1999 2008. Journal of the American Medical Association, 303 (3), 235 241. Frederick, D.A., Forbes, G.B., Grigorian, K.E., & Jarcho, J.M. (200 7). The UCLA body project I: Gender and ethnic differences in self objectification and body satisfaction among 2,206 undergraduates. Sex Roles, 57 317 327. Gillon, S. (2004). Boomer nation: The largest and richest generation ever, and how it changed Amer ica Free Press. Gorber, S.C., Tremblay, M., Moher, D., & Gorber, B. (2007). A comparison of direct vs. self report measures for assessing height, weight, and body mass index: a systematic review. Obesity Reviews, 8, 307 326. Gough, B. & Conner, M.T. (20 06). Barriers to healthy eating amongst men: A qualitative analysis. Social Science & Medicine, 62 387 395. Gregory, C., Blanck, H.M., Gillespie, C., Maynard, M.L., & Serdula, M.K. (2008). Perceived health risk of excess body weight among overweight and obese men and women: Differences by sex. Preventive Medicine, 47, 46 52. Grieve, F.G., Wann, D., Henson, C.T., & Ford, P. (2006). Healthy and unhealthy weight management practices in collegiate men and women. Journal of Sport Behavior, 29 (3), 229 241. Hag drup, N.A., Simoes, E.J., & Brownson, R.C. (1998). Fruit and vegetable consumption in Missouri: Knowledge, barriers and benefits. American Journal of Health Behavior, 22 (2), 90 100. Hamman, R.F., Wing, R.R., Edelstein, S.L., Lachin, J.M., Bray, G.A., Dela hanty, Rosett. (2006). Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care September, 29 (9), 2102 2107. doi: 10.2337/dc06 0560 Hankey, C.R., Leslie, W.S., & Lean, M.E.J. (2002). Why lose weight? Reasons for seeki ng weight loss by overweight but otherwise healthy men. International Journal of Obesity, 26( 6), 880 882. Hart, C.L., Hole, D.J., Lawlor, D.A., & Smith, G.D. (2007). How many cases of type 2 diabetes mellitus are due to being overweight in middle age? Evid ence from the Midspan prospective cohort studies using mention of diabetes mellitus on hospital discharge or death records. Diabetic Medicine, 24, 73 80.
168 Hellmich, N. (2009, November 17). Rising obesity will cost U.S. health care $344 billion a year. USA Today. Retrieved from http://www.usatoday.com/news/health/weightloss/2009 11 17 future obesity costs_N.htm Himes, C.L. (2001). Elderly Americans. Populati on Bulletin, 56 (4), 1 40. Hoeger, W. K. & Hoeger, S.A. (2010). Body Composition. Principles and labs for fitness and wellness (10th ed.) (p. 136). Belmont, CA: Wadsworth, Cengage Learning. Hoeger, W. K. & Hoeger, S.A. (2010). Physical fitness and wellness Principles and labs for fitness and wellness (10th ed.) (pp. 1 38). Belmont, CA: Wadsworth, Cengage Learning. Hoeger, W. K. & Hoeger, S.A. (2010). Weight management. Principles and labs for fitness and wellness (10th ed.) (pp. 147 192). Belmont, CA: Wads worth, Cengage Learning. Houston, D.K., Nicklas, B.J., & Zizza, C.A. (2009). Weighty concerns: The growing prevalence of obesity among older adults. Journal of the American Dietetic Association, 109 (11), 1886 1895. Hoyert, D.L., Heron, M.P., Murphy, S.L., & Kung, H C. (2006). Deaths: Final data for 2003 National Vital Statistics Reports, Centers for Disease Control and Prevention, 54(13). Retrieved from: http://www.cdc.gov/nchs/data/nvs r/nvsr54/nvsr54_13.pdf Institute of Medicine. (2002). Dietary reference intakes: energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academy Press. Retrieved August 8, 2007, from http://www.nap.edu/books/0309085373/html/ InsuranceNewsNet. Inc (2007, March 21). Baby Boomer obesity takes its toll on the health care economy. Retrieved April 24, 2007, from http://insurancenewsnet.com/article.asp?a=top_news&id=77454 Jackson, J.E., Doescher, M.P., Saver, B.G., & Hart, L.G. (2005). Trends in professional advice to lose weight among obese adults, 1994 to 2000. Journal of G eneral Internal Medicine, 20 814 818. Janzen, W. & Cousins, S. (1995). Marriage, women and physical activity. Journal of Women and Aging, 7 55 70. James, D.C.S. (2003). Gender differences in body mass index and weight loss strategies among African Amer icans. Journal of the American Dietetic Association, 103 (10), 1360 1362.
169 James, D.C.S. (2004). Factors influencing food choices, dietary intake, and nutrition related attitudes among African Americans: Application of a Culturally Sensitive Model. Ethnicit y & Health, 9 (4), 349 367. James, D.C.S. & Bonds, J.R. (2006). Obesity status and body satisfaction: Are there differences between African American college females at black and white universities? Health Educator, 38 (1), 1 8. Jehn, M.L., Patt, M.R., Appe l, L.J., & Miller, E.R. (2006). One year follow up of overweight and obese hypertensive adults following intensive lifestyle therapy. Journal of Human Nutrition and Dietetics, 19 349 354. Johnson Taylor, W.L., Fisher, R.A., Hubbard, V.S., Starke Reed, P. & Eggers, P.S. (2008). The change in weight perception of weight status among the overweight: comparison of NHANES III (1998 1994) and 1999 2004 NHANES. International Journal of Behavioral Nutrition and Physical Activity, 5 9 14. Kaiser, B.L., Brown, R .L., & Baumann, L.C. (2010). Perceived influence on physical activity and diet in low income adults from two rural counties. Nursing Research, 59 (1), 67 75. Kant, A.K., Graubard, B.I., & Schatzkin, A. (2004). Dietary patterns predict mortality in a nationa l cohort: The national health interview surveys, 1987 and 1992. The Journal of Nutrition, 134, 1793 1799. King, D.E., Mainous, A.G., Carnemolla, M., & Everette, C.J. (2009). Adherence to healthy lifestyle habits in US adults, 1988 2006. The American Journ al of Medicine, 122 (6), 528 534. Knickman, J.R. & Snell, E.K. (2002). The 2030 problem: caring for aging Baby B oomers. Health Services Research, 37 (4), 849 884. Kristal, A.R., Hedderson, M.M., Patterson, R.E., & Neuhauser, M.L. (2001). Predictors of self initiated, healthful dietary change. Journal of the American Dietetic Association, 101 (7), 762 766. Kruger, J., Galuska, D.A., Serdula, M.K., & Jones, D.A. (2004). Attempting to lose weight: Specific practices among U.S. adults. American Journal of Prevent ive Medicine, 26 (5), 402 406. Kuk, J.L, Ardern, C.L., Church, T.S., Hebert, J.R., Sui, X., & Blair, S.N. (2009). Ideal weight and weight satisfaction: Association with health practices. American Journal of Epidemiology, 170 456 463. Lappalainen, R., Sab a, A., Holm, L., Mykkanen, H., & Gibney, M.J. (1997). Difficulties in trying to eat healthier: Descriptive analysis of perceived barriers for healthy eating. European Journal of Clinical Nutrition, Suppl.2 51, S36 S40.
170 Lee, I M, Sesso, H.D., Oguma, Y., & American Journal of Epidemiology, 160, 636 641. Lee, I M., Sesso, H.D, & Paffenbarger Jr, R.S. (2000). Physical activity and coronary heart disease risk in men: Does the duration of exercise episodes predict risk ? American Heart Association. Leitzmann, M.F., Park, Y., Blair, A., Ballard Barbash, R., Mouw, T., Hollenback, A.R., & Schatzkin, A. (2007). Physical activity recommendations and decreased risk of mortality. Archives of Inter nal Medicine, 167 (22), 2453 2460. Leveille, S.G., Wee, C.C., & Iezzoni, L.I. (2005). Trends in obesity and arthritis among Baby Boomers and their predecessors, 1971 2002. American Journal of Public Health, 95( 9), 1607 1613. Levy, A.S. & Heaton, A.W. (1993 ). Weight control practices of U.S. adults trying to lose weight. Annals of Internal Medicine, 119 (7), 661 666. Linde, J.A., Jefferey R.W., Levy, R.L., Pronk, N.P., & Boyle, R.G. (2005). Weight loss goals and treatment outcomes among overweight men and wo men enrolled in a weight loss trial. International Journal of Obesity, 29 1002 1005. Littman, A.J., Kristal, A.R., & White, E. (2005). Effects of physical activity intensity, frequency, and activity type on 10 y weight change in middle aged men and women International Journal of Obesity, 29 524 533. Lloyd, H.M., Paisley, C.M., & Mela, D.J. (1995). Barriers to the adoption of reduced fat diet in a UK population. Journal of the American Dietetic Association, 95 (3), 316 322. Marcus, B.H. & Simkin, L.R. (1993). The stages of exercise behavior. The Journal of Sports Medicine and Physical Fitness, 33 (1), 83 88. Marketdata Enterprises. (2009, February 16). Diet market worth $58.6 billion in U.S. last year, but growth is flat, due to the recession. Retrieved from http://www.marketdataenterprises.com/pressreleases/DietMkt2009PressRelease.p df Markey, C.N. & Markey, P.M. (2005). Relations between body image and dietin g behaviors: An examination of gender differences. Sex Roles, 53 (7/8), 519 530. doi: 10.1007/s11199 005 7139 3 Masley, S.C., Weaver, W., Peri, G., & Phillips, S.E. (2008). Efficacy of lifestyle changes in modifying practical markers of wellness and aging. Alternative Therapies in Health & Medicine, 14 (2), 24 29.
171 McCabe, M.P. & Ricciardelli, L.A. (2004). Body image dissatisfaction among males across the lifespan: A review of past literature. Journal of Psychosomatic Research, 56 675 685. McPherson, K.E. & Turnbull, J.D. (2005). Body image satisfaction in Scottish men and Health, 4 (1), 3 12. Merrill, R.M. & Richardson, J.S. (2009). Validity of self reported height, weight, an d body mass index: findings from the National Health and Nutrition Examination Survey, 2001 2006. Preventing Chronic Disease, 6(4). Retrieved from: http://www.cdc.gov/pcd/issues/2009/oct/08_ 0229.htm McGuire, M.T., Wing, R.R., Klem, M.L., & Hill, J.O. (1999). Behavioral strategies of individuals who have maintained long term weight losses. Obesity Research 7 (4), 334 341. Meyer, J. (2001). Age: 2000 ( C2KBR/01 12 ). Retrieved from U.S. Census Bureau website: http://www.census.gov/prod/2001pubs/c2kbr01 12.pdf Mokdad, A.H., Marks, J.S., Stroup, D.F., & Gerberding, J.L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291 (10), 1238 1245. Mo rse, J.M., & Field, P.A. (1995). Qualitative research methods for health professionals (2nd ed.). Thousand Oaks, CA: Sage Publications. Muenning, P., Haomiao, J., Lee, R., & Lubetkin, E. (2008). I think therefore I am: Perceived ideal weight as a determin ant of health. American Journal of Public Health, 98 (3), 501 506. National Cancer Institute. (2005). Theory at a glance: A guide for health promotion practice. (2nd ed.). (Monograph) (NIH Publication No. 05 3896). Washington, DC: U.S. Department of Health and Human Services. NIH Conference. (1991). Gastrointestinal surgery for severe obesity. Consensus Development Panel. Annals of Internal Medicine, 115 (12) 956 961. Nothwehr, F., Snetselaar, L., & Wu, H. (2006). Weight management strategies reported by rural men and women in Iowa. Journal of Nutrition Education and Behavior, 38 (4), 249 253. (2007). Reasons for wanting to lose weight: Different strokes for different folks. Eating Behaviors, 8 132 135. Ogden, J. & Taylor, C. (2000). Dieting and cognitive style: The role of current and past dieting behaviour and cognitions. Journal of Health Psychology, 5(1), 17 24.
172 Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., & Flegal, K.M. (2006). Prevalence of overweight and obesity in the United States, 1999 2004. Journal of the American Medical Association, 295 (13), 1549 1555. Pate, R.R., Pratt, M., Blair, S.N., Haskell, W.L., Macera, C.A., Bouchard, C., et al (1995). Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Journal of the American Medical Association, 273 (5), 402 407. Parikh, N.I., Pencia, M.J., Wang, (2007). Increasing trends in incidence of overweight and obesity over 5 decades. American Journal of Medicine, 120 242 250. Pender, N.J. (1996). Health promotion in nursing practice (3rd ed.). Stamf ord, CT: Appleton & Lange. Portney, L.G., & Watkins, M.P. (2000). Foundations of clinical research: Applications to practice (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Prochaska, J.O. & DiClemente C.C. (1982). Transtheoretical therapy: Toward a mor e integrative model of change. Psychotherapy: Theory, Research, and Practice, 19 (3), 276 288. Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. In G.A. Marlatt & G.R. VandenBos (Eds.), Addictive behaviors: Readings on etiology, prevention, and treatment. Washington, D.C: American Psychological Association. Prochaska, J.O. & Marcus, B.H. (1994). The transtheorectical model: applications to exercise In R.K Dishman (Ed.), Advances in exercise adherence (pp. 161 180). Champaign, IL: Human Kinetics. Prochaska, J.O., Redding, C.A., & Evers, K.E. (2002). The transtheoretical model and stages of change. In K. Glanz, F.M. Lewis, & B.K. Rimer (Eds.), Health behavior and health education, 3rd ed. San Francisco: Jossey Bass. Prochaska, J.O. & Velicer, W.F. (1997). The transtheorectical model of health behavior change. American Journal of Health Promotion, 12 (1), 38 48. d by people of varying age and weight. Obesity Research, 8, 309 316. Reboussin, B.A., Rejeski, W.J., Martin, K.A., Callahan, K., Dunn, A.L., King, A.C., & Sallis, J.F. (2000). Correlates of satisfaction with body function and body appearance in middle an d older aged adults: The activity counseling trial (ACT). Psychology and Health, 15 (2), 239 254.
173 Riebe, D., Garber, C.E., Rossi, J.S., Greaney, M.L., Nigg, C.R., Lees, F.D., et al. (2005). Physical activity, physical function, and stages of change in olde r adults. American Journal of Health Behavior, 29 (1), 70 80. Robinson, A.H., Norman, G.J., Sallis, J.F., Calfas, K.J., Rock, C.L., & Patrick, K. (2008). Validating stage of change measures for physical activity and dietary behaviors for overweight women. International Journal of Obesity, 32 1137 1144. Rudman, W.J. (1989). Age and involvement in sport and physical activity. Sociology of Sport Journal, 6 228 246. and perc eived barriers towards weight loss. European Journal of Clinical Nutrition, 61 526 531. Sallis, J.F., Hovell, M.F., Hofstetter, C.R., Faucher, P., Elder, J.P., Blanchard, J., et al. (1989). A multivariate study of determinants of vigorous exercise in a co mmunity sample. Preventive Medicine, 18 20 34. Saris, W.H.M., Blair, S.N., van Baak, M.A., Eaton, S.B., Davies, P.S.W., Di Pietro, L. et al. (2003). How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st Stock Conf erence and consensus statement. Obesity Reviews, 4 (2), 101 114. Sarkin, J.A., Johnson, S.S., Prochaska, J.O., & Prochaska, J.M. (2001). Applying the Transtheoretical Model to regular moderate exercise in an overweight population: Validation of a stages of change measure. Preventive Medicine, 33 462 469. Schoeller, D.A., Shay, K., & Kushner, R.F. (1997). How much physical activity is needed to minimize weight gain in previously obese women? American Journal of Clinical Nutrition, 66 (3), 551 556. Sciamann a, C.N., Tate, D.F., Lang, W., & Wing, R.R. (2000). Who reports receiving advice to lose weight? Archives of Internal Medicine, 160 (15), 2334 2339. Sesso, H.D., Paffenbarger Jr. R.S., & Lee, I M. (2000). Physical activity and coronary heart disease in men : The Harvard alumni health study. Circulation, 102, 975 980. Sherwood, N.E., & Jeffery, R.W. (2000). The behavioral determinants of exercise: Implications for physical activity interventions. Annual Review of Nutrition, 20 21 44. Shoob, H.D., Croft, J. B., & Labarthe, D.R. (2007). Impact of Baby Boomers on hospitalizations for coronary heart disease and stroke in the United States. Preventive Medicine, 44 447 451.
174 concerns, motivators and barriers for healthful eating and regular exercise. Military Medicine, 170( 10), 841 845. Simon, H.B. (2002). New York, NY: Free Press. Smith, A.M. & Owen, N. (1992). Ass ociations of social status and health related beliefs with dietary fat and fiber densities. Preventive Medicine, 21 (6), 735 745. Sonstroem, R.J. (1988). Psychological models. In: Dishman, R, editor. Exercise adherence: Its impact on public health Champai gn, IL: Human Kinetics Strauss, W. & Howe, N. (1991). 1584 2069. New York: Harper Perennial Decrease Overweight and Obesity, US Government Printing Office. Thorpe, K.E. (2009). The future costs of obesity: National and state estimates of the impact of obesity on direct health care expenses A Collaborative Report from United Health Foundation, the American Public Health Association and Partnership f http://www.americashealthrankings.org/2009/report/Cost%20Obesity%20Report final.pdf Towers A.J., Flett, R.A., & Seebeck, R. (2005). Assessing potential barriers to exercise adoption in middle aged men: Over stressed, under controlled, or just too unwell? (1), 13 27. U.S. Census Bureau. (2006). Selected c haracteristics of Baby Boomers 42 to 60 years old in 2006 Washington, DC: Age and Special Populations Branch, U.S. Census Bureau. Retrieved from http://www.census.g ov/population/www/socdemo/age/2006%20Baby%20Boomers .pdf U.S. Department of Agriculture. (1998). USDA continuing survey of food intakes by individuals, 1994 1996. U.S. Department of Health and Human Services (1990). The health benefits of smoking cessati on: A report of the Surgeon General. DHHS Publication No. 90 8416). Retrieved from http://profiles.nlm.nih.gov/NN/B/B/C/T/_/nnbbct.pdf
175 U.S. Department of Health and Human Services. (199 6). Physical activity and health: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. U.S. Department o f Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults the evidence report (NIH Publication N o. 98 4083). Retrieved from http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf U.S. Department of Health and Human Services. (2000). Healthy people 2010: understanding and imp roving health. DHHS Publication No. 017 001 00543 6. Washington, DC, US Government Printing Office. U.S. Department of Health and Human Services. (2008). 2008 Physical activity guidelines for Americans (ODPHP Publication No. U0036). Retrieved from http://www.health.gov/paguidelines/pdf/paguide.pdf U.S. Department of Health and Human Services. (2010). for a healthy and fit nation Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General. U.S. Department of Health and Human Services and U.S. Department of Agriculture. (2005). Dietary Guidelines for Americans, 2005 Retrieved August 3, 2007, from http://www.health.gov/dietaryguidelines/dga2005/document/default.htm Health Education Quarterly, 19 (3), 315 330. Vaillant, G.E., & Mukamal, K (2001). Successful aging. American Journal of Psychiatry, 158 839 847. Villareal, D.T., Apovian, C.M., Kushner, R.F., & Klein, S. (2005). Obesity in older adults: Technical review and position statement of the American society for nutrition and NAASO, the obesity society. Obesity Research, 13 (11), 1849 1863. Verbrugge, L.M. (1985). Gender and health: An update on hypotheses and evidence. Journal of Health and Social Behavior, 26 156 182. Wasserstein, W. (2004). World Almanac & Book of Facts, 8 8. Wee C.C., Davis, R.B., & Phillips, R.S. (2005). Stage of readiness to control weight and adopt weight control behaviors in primary care. Journal of General Internal Medicine, 20 410 415.
176 Wellman, N.S., Kamp., B., Kirk Sanchez, N.J., & Johnson, P.M. (2007). Eat better & move more: A community based program designed to improve diets and increase physical activity among older Americans. American Journal of Public Health, 97 (4), 710 717. Weinsier, R.L., Hunter, G.R., Desmond, R.A., Byrne, N.M., Zuckerman, P.A. & Darnell, B.E. (2002). Free living activity energy expenditure in women successful and unsuccessful at maintaining a normal body weight. American Journal of Clinical Nutrition, 75 (3), 499 504. Wister, A.W. (2005). Baby Boomer health dynamics: How are w e aging? Toronto: Toronto Press Incorporated. Wolfe, B.L., & Smith J.E. (2002). Different strokes for different folks: Why overweight men do not seek weight loss treatment. Eating Disorders, 10 115 124. World Health Organization. (1995). WHO expert commit tee on physical status: The use and interpretation of anthropometry (WHO Technical Report Series; 854). Retrieved from http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf Yates, A., Edman, J., & Arugue te, M. (2004). Ethnic differences in BMI and body/self dissatisfaction among Whites, Asian subgroups, Pacific Islanders, and African Americans. Journal of Adolescent Health, 34 300 307. Yeaworth, R.C. (2002). Long term care and insurance. Journal of Geron tological Nursing, 28 (11), 45 51
177 BIOGRAPHICAL SKETCH Christopher Kevin Wirth was born in Laramie, Wyoming in 1979. During his youth and adolescence, he was actively involved with sports and by the time he graduated high school he had developed a strong pa ssion for coaching. He attended the University of Wyoming where he spent four years working as an equipment manager for the Wyoming football team and majoring in physical education teaching. In 2001, he was hired to teach physical education and health educ ation at Johnson Jr. High in nearby Cheyenne, WY. In 2002, Chris moved to Gainesville, Florida where he attended classes at the University of Florida while teaching classes for the Sport and Fitness program. In addition, he provided physical education to K 8 students at Millhopper Montessori School. In 2004 he received the Norma Leavitt Scholarship and was nominated for the Graduate Student Teacher of the Year. Later that spring, he graduated with a degree of Master of Exercise and Sport Sciences in the ar ea of Sport Pedagogy. Following graduation, Chris was accepted into the doctoral program at the University of Florida. In the fall of 2004, he began working on his Ph.D. in Health and Human Performance in the department of Health Education and Behavior. During his time in the doctoral student he taught undergraduate students in the areas of health education and foundations of health promotion. He was also able to spend two years teaching methods courses in the physical education teacher preparation progra m and spent time in the local school district observing student teachers. In August of 2008, Chris was hired by Methodist University in Fayetteville, North Carolina, to teach physical education and health education. Chris received his Ph.D. from the Univ ersity of Florida, in August of 2010. He plans to continue his career in
178 teacher preparation and will be expanding his research to also include adolescent weight issues. In the fall of 2010 he intends to take the Certified Health Education Specialist (CHES ) exam, pass the Praxis I and II exams to gain his teaching license in North Carolina, and establish an Ultimate Frisbee recreational league at Methodist University.