Throughout my undergraduate training I became increasingly aware of a clinical practice issue that although has little implications now can have significant future consequences. While on clinical placement I was surprised by the amount of patients I had met that had hypertension or diabetes as a result of adopting poor health behaviours. Diseases that are largely preventable are appearing more frequently as comorbidities of being overweight or obese in the health care setting (Guh, Zhang, Bansback, Amarsi, Birmingham, & Anis, 2009). This made me question which age group is both susceptible to weight gain and are beginning to develop their own health behaviours. As a result, I developed an interest into the weight gain associated with tertiary students and their surrounding environment. An initial literature search supported my assumptions that tertiary students are susceptible to factors that contribute to both weight gain and developing negative health behaviours. Using the PECOT model (Whitehead, 2013) to refine my search allowed me to develop a search question that would direct my literature review. In this literature review I was able to deliver evidence that verified that first year tertiary students gained weight as a result of the new university environment and that typically weight problems in late adolescence are a predictor for adulthood obesity. My recommendations included that education needs to be delivered to students before coming to university on the importance of adopting positive health behaviours and further more a study needs to be conducted on New Zealand tertiary students. These recommendations will ensure new tertiary students will understand the importance of adopting positive health behaviours and that through a New Zealand study we will gain a better understanding into the causes specific to our country with the potential to implement strategies addressing those causes.
Clinical Practice Issue
The growing prevalence of overweight and obesity is not only a global health concern; it is also a health concern for New Zealand. New Zealand has had one of the largest increases in the rate of obesity in the last few decades, placing New Zealand in third place for the highest overweight and obesity rates on an international scale (Ng, et al., 2014). The World Health Organisation (2015) defines being overweight as having a Body Mass Index (BMI) equal to or greater than 25 and being obese as having a BMI that is equal to or greater than 30. 31% of New Zealanders are obese with a further 35% being classed as overweight (Ministry of Health, 2015). These high percentages have caused overweight and obesity to be the leading risk factor to a person’s health representing 9% of illness, disability and premature deaths in the New Zealand health care system (Ministry of Health, 2015).
Strategies need to be focused around prevention of weight gain rather than promoting weight loss as it has been proven that successful weight loss is typically regained within several years (De Vous, Hanck, Neisingh, Prak, Groen, & Faas, 2015). To prevent overweight and obesity, a better understanding of the high-risk periods and susceptibility for weight gain is needed (Vella-Zarb & Elgar, 2010). Students entering their first year of tertiary study have been identified as a high-risk group for weight gain. It is during this time that there are many social influences acting on the students to change their eating, drinking and physical activity behaviours (De Vous et al., 2015). In 2011 a health behaviour survey of New Zealand tertiary students revealed that 26.6% of the student population among the eight universities have a BMI that is 25 or greater (Kypri, Samaranayaka, Connor, Langely, & Maclennan, 2011).
Upon transitioning into first year tertiary study, students begin to establish their independence and start to adopt new health behaviour patterns that are lasting (Nelson, Story, larson, Neumark-Sztainer, & Lytle, 2008). The health behaviour patterns developed are often associated with promoting weight gain contributing to unhealthy future consequences (Finlayson, Cecil, Higgs, Hill, & Hetherington, 2012). These health behaviours are guided not only by the student’s own attitudes and beliefs; they are also influenced by the “perceived norm” of the environment they are immersed in (Rimal & Real, 2003). Often the transition to tertiary study comes along with many lifestyle changes. Students experience moving away from home, taking on a more advanced workload, an increased exposure to more social eating and drinking, easier access to fast food and generally a reduced sleeping pattern (Finlayson et al., 2012). The students newly found independence in the university environment allows the students to become susceptible to these weight gain related risks, which have the ability to promote negative health behaviours (Nelson et al., 2008).
It has been revealed that the average weight gain in the first year of tertiary study is between 0.73kg to 3.99kg (Vella-Zarb & Elgar, 2009). The weight gain may not seem significant, however weight gain and weight problems in late adolescence years are considered to be a high predictor for overweight and obesity in adulthood (Vella-Zarb & Elgar, 2010). Although New Zealand students have been studied very little in comparison to the world, the weight gain among first year university students is still very relevant to New Zealand. With 26.6% of tertiary students in New Zealand being classed as overweight or obese, the weight gain is a clinical practice issue that needs to be further explored.
Search Question Identified
A practice issue that is raised is that first year university students are susceptible to weight gain. Further exploration of this issue has been achieved by asking more questions. Is the University environment an obesogenic environment? What are the factors that contribute to the weight gain? And are there long-term health consequences from gaining weight in the late adolescence years? Research identifies that the weight gained in first year university students is greater than those of the same age not studying (Vadeboncoeur, Townsend, & Foster, 2015) and that the transition into the first year of university is associated with factors that promote weight gain (Vella-Zarb & Elgar, 2009). The aim of this literature review is to explore how the transition into tertiary study contributes to weight gain and further develop an insight into what are the factors that are associated with weight gain in the first year environment. Through using inclusion and exclusion criteria I was able to refine my question. Literature included in the research would be both international and national journal articles, first year university students, factors that promote weight gain in university and the influences of adopting health behaviours and literature from 2008-present. Excluded criteria from this review included research that involved other university years, a comparison group as this was not the main focus of the research question and a time frame as this was not applicable to the final research question. More articles were able to be included in the inclusion criteria than exclusion criteria, as the literature search came back initially with a limited number of articles.
As a result of using the PECOT model the search question developed into ‘What factors are associated with the transition into the new university environment that can influence negative health behaviours causing weight gain amongst first year university students who have moved away from home?’
The “freshman 5” has been nothing but a myth and word of mouth until now in which Vella-Zarb and Elgar (2009) established in their study that first year tertiary students can gain weight between 0.73kg and 3.99kg over eight months. Boyce and Kuijer (2014) maintains that although the weight gain is small, students in first year gain weight at rates that are significantly higher than young adults who do not attend university. Numerous factors have been found to be associated with weight gain include a decrease in physical activity, high caloric food and alcohol consumption, a high baseline BMI, living in a hall of residence and high levels of perceived stress (Vella-Zarb & Elgar, 2009). Recent reports from LaCaille et al. (2011) suggest that it is factors such as high caloric food consumption and decreased physical activity that contribute most to weight gain and these behaviours are a result of moving away from home, having high levels of perceived stress and having to form new social connections. The transition into the university environment can often be associated with drastic changes in both the surroundings and resources (Wengreen & Moncur, 2009) and if the students do not adjust adequately they risk adopting negative health behaviours such as poor eating habits and a decrease in physical activity levels to cope with the change (Crombie, Ilich, Dutton, Panton, & Abood, 2009).
Moving away from home and into a hall of residence is one factor that can contribute to weight gain by influencing negative eating behaviours. The transition into a Hall Residence as suggested by Vella-Zarb and Elgar (2010) is accompanied by a change in the food environment allowing new habits to be formed. Nelson et al. (2009) further supports this and concludes that the meals are served in a dining hall as an all you can eat buffet style with large portions, which frequently encourage over consumption and the choice of unhealthy food items. The residential halls common areas are only equipped with microwaves (LaCaille, Dauner , Krambeer, & Pedersen, 2011) which limit the snacks and meal replacements to convenience meals such as microwavable pastas, frozen meals and soups (Nelson, Kocos, Lytle, & Perry, 2009) all which have little nutritional value. In conjunction with the residential hall environment is the excessive consumption of alcohol with 70% of students living in a residential hall binge drinking (McEwan, 2009). Binge drinking has become a tradition developing into its own custom that is well established in the first year university environment (McEwan, 2009). LaCaille et al. (2011) states that alcohol consumption both directly and indirectly contributes to weight gain for the calories it adds to the student’s energy intake and the associated unhealthy eating behaviour that is coexists with it. Eating behaviours such as over consumption, choosing high caloric foods and the altered eating patterns associated with alcohol consumption and buffet style eating all contribute to weight gain and are influenced by the hall of residence environment (Nelson et al. 2009).
Often the transition into the new university environment is associated with a higher, more advanced workload (Finlayson et al. 2012). As a result of trying to manage this new workload Wichianson et al. (2009) contends that students can experience high levels of stress during this period. This is supported by Vella-Zarb and Elgar (2010) who states that the transition into the university environment can be stressful and the stress can contribute to students adopting unhealthy behaviours. Studies outlined by Nelson et al. (2009) suggest that a decrease in physical activity and an increase in food consumption are influenced by the lack of time and high-perceived stress, which are a direct result of the increased and more advanced workload. LaCaille (2011) found that due to the demands of the university workload, students often had little time for physical activity. As a consequence of the lack of time and poor time management Nelson et al (2010) reports that students chose to prioritise completing class work, quick and easy meals and sleeping instead of completing some sort of physical activity and eating a nutritional meal. Recent studies have addressed that physical activity decreases and food consumption increases while students are studying and feeling “stressed out” (Nelson et al., 2009; Vella-Zarb & Elgar 2010). Crombie et al., 2009 claims that stress related eating is associated with weight gain among first year university students. Stressed students will tend to choose cheap, quick, unhealthy convenience foods as it will allow more time for them to study (LaCaille et al., 2011). Leaving little time for consumption of nutritional meals and physical activity are the consequences of students prioritising work completion over their health.
A recent survey by Kypri et al. (2011) has stated that 77.2% of tertiary students don’t follow the recommended fruit and vegetable dietary guidelines and 16% don’t follow the recommended physical activity guidelines. LaCaille et al. (2011) addresses that an understanding of these factors and their contribution to these eating and physical activity behaviours which can ultimately lead to weight gain need to be obtained. As a result of the factors in the university environment students have a larger energy intake than output resulting in possible weight gain.
Implications for Practice
Literature has indicated that an increase in the prevalence of overweight and obesity has been observed to be the highest in 18-29 year olds and further more in students who are transitioning into the first year of tertiary study (Crombie et al., 2011). Not only is this period associated with overweight and obesity it is also a critical time in which the students are adopting health behaviour patterns that are lasting (Nelson et al., 2008). Studies have revealed that the metabolic and physiological changes, which are associated with overweight in adolescence, are mostly likely to follow into adulthood (Wang, Chyen, Lee, & Lowry, 2008). Being overweight or obese in adulthood is related to an increased susceptibility to comorbidities such as type two diabetes, cardiovascular diseases and even some cancers all of which can further lead to morbidity or premature mortality (Guh et al., 2009). In New Zealand 9% of illness, disability and premature deaths are a direct result of being overweight or obese and its related comorbidities (Ministry of Health, 2015). Small changes made to improve nutrition and physical activity of first year tertiary students has the potential to reduce adulthood overweight and obesity (Hills, Byrne, Lindstrom, & Hill, 2013) and its related comorbidities in the ward setting.
Recommendations and Rationale
Rationale – It is evident from the literature that the predominant behaviours promoting weight gain in the first year of university is the decreased physical activity levels and increased food consumption. Educating the students before they arrive in the university environment will allow students to be prepared for the changes they are about to face. Education should include information about the importance of exercise and nutritional food intake in regards to stress management, overconsumption and self-control and lastly the unhealthy habits of alcohol consumption. By educating the students about all of these factors and their consequences before starting university could allow the students to adopt positive health behaviours rather than negative health behaviours.
Rationale – Predominantly all studies except one has been conducted over seas, in particular Unites States of America. It is still very relevant to New Zealand with statistics showing that a large percentage of New Zealand tertiary students being over weight or obese. It is known by word of mouth that there is weight gain in the first year of University, however to gain a better understanding of where the weight gain begins and more specifically how much is gained and what causes the weight gain, a study needs to be completed. This will allow us to discover what the causes are specific to New Zealand and implement prevention strategies where needed to prevent the weight gain and further more prevent overweight and obesity amongst tertiary students.
Literature has provided evidence supporting that first year tertiary students are susceptible to weight gain due to a variety of factors in the university environment. Living in a hall of residence, having a higher more advanced academic workload and excessive alcohol consumption have been identified as the main factors which contribute to weight gain amongst the tertiary students. These factors contribute to weight gain by influencing students to adopt negative health behaviours such as unhealthy eating habits and decreasing physical activity. If education is given to these students before entering university, the students are most likely going to take the needed measures to avoid adopting these negative health behaviours and their consequences. Students will then be more prepared for the transition into university and will be able to use coping methods that will help them both stay healthy and succeed. By preventing the adoption of negative health behaviours and ultimately weight gain in first year university students, we are taking steps in preventing the likelihood of those same students becoming overweight or obese in their adulthood life.
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