Community-Based Designed Pilot Cooking and Texting Intervention on Health-Related Quality of Life among College Students
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1. Introduction
Young adults’ (ages 18–35) lifestyle habits and behaviors are inscribed from their youth environment and parental influence. As they leave their childhood homes and attend college, many young adults experience newfound living independence. Paralleling these changes are deviations in diet, activity, stress, and other lifestyle situations and behaviors. Due to several confounding factors acting in a small window of one’s lifespan, young adults are known to have unhealthy lifestyles and the highest prevalence of mental health disorders among the age groups [1].
The transition to college is typically associated with unfamiliar levels of pressure and responsibility and consequently poorer mental health. In 2021, the prevalence of any mental health illness (AMI) was found to be the highest in young adults (33.7%) when compared to younger and older age groups [2]. Impaired mental health not only contributes to poor quality of life but also impacts physical abilities, resulting in a greater risk of developing chronic disease [3]. A major contributor to poor mental health status among college students is stress and dealing with fatigue and anxiety due to the stressors of university academic and social life [4]. While a vast majority of students report having access to services that help them with their physical and mental health, adverse effects on mental status are still prevalent [5]. Furthermore, young adults face difficulties post-graduation, such as struggles with functioning at work and work absences, if mental health issues are ignored [6].
Food insecurity likely contributes to the stress induced by college and subsequent poor mental health. Many undergraduates suffer from high rates of food insecurity. In fact, the rates of food insecurity among college students are double the rate for U.S households (35% to 42% versus 14%) [7,8]. Food insecurity has multifaceted effects on college students, adversely impacting their health-related quality of life. The literature reveals food-insecure students report significantly higher perceived stress; poor sleep quality; disordered eating behaviors [9]; consuming significantly fewer servings of fruits, vegetables, and legumes daily; and unfavorable academic experiences, such as trouble focusing in class, failing courses [10], and a low GPA [9]. Yet, college students often face the burden of food insecurity alone, leading to feelings of negative self-worth surrounding their food security statuses [11].
Food insecurity further exacerbates poor diet quality among college students. In a sample of over 1000 college students, 97% of participants did not meet fruit and vegetable recommendations and consumed 100 calories above the added sugar recommendation [12]. Studies specifically comparing food-secure to food-insecure college students consistently find that students with food insecurity report eating significantly fewer fruits and vegetables and more processed foods compared to their food-secure counterparts [10,13,14,15]. Additionally, food-insecure students unintentionally suffer from greater eating disturbances, as food-insecure students often report skipping meals entirely to afford academic-related expenses, such as rent and tuition [11]. Moreover, food-insecure students provide contradicting statements regarding their perception of a ‘normal college lifestyle’, with some perceiving food insecurity and unhealthy eating patterns as normal [10].
High rates of food insecurity paired with poor dietary habits, and health-related quality of life, put young adults at a greater risk for chronic disease [1,16]. Nevertheless, research has shown that with better diet quality, college students are less likely to report anxiety and depression, which underscores the importance of addressing modifiable risk factors associated with chronic disease and mental health [17]. Unfortunately, conflicting perceptions of food security status contribute to college students’ poor mental health, causing confusion, shame, stigma, and fear regarding food decisions. Shame and stigma often prevent students from exploiting external resources for acquiring healthy food to combat poor diet quality, such as SNAP benefits, or campus resources, such as food pantries [11]. Despite facing higher rates of food insecurity than other subpopulations [11], the determinants of food insecurity and interventions aimed at improving food security among college students are understudied.
To improve the food security and health behaviors of young adults, programming needs to be culturally relevant. A way to improve the feasibility, sustainability, and buy-in of behavior change is to involve stakeholders in the process and progression of designing, implementing, and evaluating programs. Community-based participatory research (CBPR) applies core principles that, as explained by Simona and colleagues, “(a) foster joint ownership in the identification of health priorities, the development and evaluation of research strategies and their design, and the dissemination of findings; (b) a keen recognition and appreciation for the importance of stakeholder-driven priorities, research, and solutions; (c) building capacity of both stakeholders and researchers to engage in research collaboratively; and (d) recognizing that conducting the research is not the endpoint but continues on with a commitment to dissemination, spread, adoption and sustainability [4,18]”.
Researchers have conducted interventions within the college student population using CBPR, which led to improvements in diet quality and mealtime behavior regulation, physical activity, and alcohol consumption [19], but mental health and food security have not been explored. When looking for guidance on evidence-based programming to influence behavior change for these variables, theories of behavior change, such as Social Cognitive Theory (SCT), can be implemented. SCT highlights the importance of cognitive, behavioral, and environmental factors. Other community health interventions have proven feasible and successful at improving a multitude of behaviors among varying demographic groups when programming is developed utilizing methods such as cooking demonstrations, nutrition education [20,21], and text message campaigns [22,23].
The timing of young adulthood provides a key opportunity to enhance the health and longevity of our next generations of leaders and employees. Overall, young adults are at greater risk of developing AMIs, and, as a population with a history of poor diet quality and high rates of food insecurity, intervention strategies designed to improve health-related quality of life of young adults are warranted. The current research aimed to test the feasibility of a pilot health program, developed using CBPR, for improving the health-related quality of life (HRQOL), food security, and diet quality of college students. It was hypothesized that after participating in the program, college students would report an improvement in HRQOL, specifically in the mental health domain, food security, and diet quality.
3. Results
The baseline survey was emailed to 13,398 undergraduates, and 809 students responded. After removing those with missing or incomplete data, it was observed that 124 students indicated an interest in enrolling in the College Cooking Connection. Of those 124 students, 65 participated in one or more of the four cooking classes and completed pre-post assessments. The overall sample of participants in this study (N = 65) consisted of individuals who were predominantly female (71.2%), white (80.3%), identified as heterosexual (60.6%), were approximately 20 years in age, and rated their health as “good” (42.4%) (Table 2). Years in school were relatively equally spread across undergraduate rankings (freshman through senior).
From baseline to post-program (approximately 16 weeks), there was a significant improvement in “days/month when mental health was not good” (M = 11.57 ± 8.51 to M = 10.11 ± 8.38 days/month, p p p p 2 = 1.92, p = 0.17 (95% CI: −3.47, 18.85). See Table 3 for the results.
Additionally, a subsample of participants (n = 23, 36.9%) was identified as food insecure at baseline (corresponding to a food security score of 2 or higher). In this subsample, there was a significant change in food security status from baseline to post-intervention (McNemar x2 = 9.00, p Table 4).
Diet quality changes from baseline to post-intervention were assessed for those students whose sHEI total scores were below the 50th percentile (n = 29; average score: 48.92). sHEI total score and component scores (fruit, vegetable, added sugar, sodium, and whole grains) were assessed for change and effect size. The variables total sHEI score, total fruits, and total vegetables all significantly improved in the subsample group (all p’s Table 5).
A subsample of students (46%, n = 30) reported their experiences with the text message component of the program. Based on the results, 23.3% of the subsample reported the text messages to be valuable/very valuable, with the majority (63.3%) reporting that the text messages were “somewhat valuable”. Forty percent of people reported attending events or visiting resources shared through the text messages, and 83.3% reported being more aware of the resources available on their campus after receiving the texts. Open-ended feedback included linking PowerPoint slides from the nutrition lessons, highlighting a recipe of the week, including more information about food, sharing student fundraisers, and making the messages “less ominous”.
4. Discussion
The current study aimed to establish the feasibility of using the College Cooking Connection to improve health-related quality of life, food security status, and dietary quality among college student participants. Following the intervention, the participants’ days per month of perceived poor mental health, diet quality, and food security improved in a subsample of students who began the program at a time when they were food insecure. These results showcase that it is feasible to improve modifiable risk factors of chronic disease through a nutrition/cooking and texting program conducted on college campuses.
Research has captured the rise in and/or worsening of mental health challenges among young adults, particularly throughout the transition to college [30]. In our study, it was shown that mentally healthy days improved from baseline to post-program implementation among our full cohort. This is especially important considering the lasting effects of the coronavirus disease 2019 (COVID-19) pandemic and the impact it has had on college students’ mental health [31]. Research has shown that COVID-19 worsens college students’ mental health in various ways [32]; however, as the current study shows, college health programming and resources can the reduce risk of mental health disorders. Soria and Horgos [33] showed that during the pandemic, college students who reported that they had a greater sense of belonging and felt valued at their colleges were less likely to report symptoms of depression or anxiety. They also found that college students who reported food insecurity had increased odds of both depression and generalized anxiety [33]. These findings, taken together, underscore the importance of the college environment and understanding how it can be utilized to support the best health outcomes for this population.
Similarly, several studies on food insecurity have been conducted on young adults, particularly in the college setting, sharing similar sentiments of unhealthy life consequences indicating the need for policies, interventions, and programming to alleviate the burden. Unfortunately, there are limited studies concerning the effect of evidence-based programming on reducing food insecurity among young adults. Of the few studies conducted, Torrey and colleagues utilized a “Food Scholarship Program” in which students received bi-monthly pre-packed food totes with preparation directions and recipe cards. As a result, student vegetable HEI scores significantly improved, and significant micronutrient intake improvements were observed, but the prevalence of food insecurity (low or very low) at baseline did not significantly change post-intervention [34]. In contrast, Ahmed and colleagues ran a student-led intervention, “Playing with Our Food”, in which student leaders shared food research and played educational games with participants to raise awareness of and reduce stigma regarding food insecurity and related campus programs. Although this study did not directly assess the frequency changes in food insecurity among participants, it did reveal that students felt more inclined to utilize campus food programs (i.e., campus food pantries) and felt open to changes related to food and food programming due to the intervention [34].
Not only does food insecurity impact mental health, but it also impacts nutritional status. In an analysis of EAT 2010–2018 data, Larson and colleagues identified nutrition-related behaviors more likely to be displayed among young adult individuals who were screened and assessed as being food insecure, including regarding poor diet quality, limited healthy foods at home, skipping breakfast, consumption of fast food, and binge eating [35]. Historically, dietary patterns among young adults have included higher amounts of fats and processed foods along with limited intake of fruits and vegetables [36], whole grains, and low-fat dairy. Despite some previous trends in dietary quality indicating improvements in component scores (i.e., greater high-quality carbohydrate intake) [37], there continues to be a lower quality overall for over half of youth and adolescents [38] supporting the need for dietary and behavioral-based interventions among younger populations.
Among a subsample group of students in the current study who had dietary quality scores below the 50th percentile, total dietary quality, total fruit score, and total vegetable score all significantly improved following the intervention. Like food security status changes, though sHEI scores improved, this improvement still maintained a dietary quality scoring below 50%, indicating that dietary intake was still less than recommended. These findings are similar to others indicating young adults have the worst dietary quality among the age groups [39].
Improvements in fruit and vegetable consumption are noteworthy for this population. As food insecurity is known to influence related conditions such as obesity and related chronic conditions, a modest increase in fruit and vegetable consumption is clinically meaningful. A previous meta-analysis of prospective cohort studies indicated all-cause mortality and cardiovascular risk decreased with an increase in servings of fruit and vegetables [40]. A similar meta-analysis of young adult dietary interventions identified that there was a higher proportion of studies that did not find significant changes in dietary quality after interventions with these populations. Though the authors suggest that this age group may be associated with the greatest difficulty in changing dietary habits, in our full cohort, we did find that the intervention was successful in significantly changing dietary quality [39].
As mentioned, the transition to a university or college setting can generate a strong shift in eating patterns [39] and preparations [41]. Consumption of meals and beverages on a college campus has been associated with worse dietary quality scores [42]. Inversely, home meal preparation and overall cooking skills have been associated with greater dietary quality and have been suggested to be incorporated into intervention programming for this population [43]. Intervention studies on dietary quality changes among young adult college students have also indicated positive outcomes on mental health and give evidence that a healthy diet can lessen symptoms of depression [44].
4.1. Limitations
Our study is not without limitations. The student participants self-selected to participate through university-wide recruitment and were not randomly selected. Therefore, the individuals who participated in this study may have ultimately been interested in nutrition, well-being, and health. Additionally, due to the nature of an electronic survey and the assessment of behavioral items, inherent bias should additionally be noted due to the nature of the self-reported data. Specifically, regarding the HRQOL variables, while they captured the participants’ perceptions of days of poor mental health, they did not capture what was contributing to poor mental health. In future studies on this population, researchers may want to include a more robust measure of mental health such as the Warwick–Edinburgh Mental Wellbeing Scale [45]. Likewise, generalizability to other college and university populations is limited, as our cohort was a small, homogeneous sample drawn from two university communities and lacked a control comparison group. While our demographics are not representative of the larger population of the United States or the overall demographics of college students; they are representative of the demographics of the two universities where the study was conducted [46]. Future research should include a larger sample and a control group to deduce if the improvements observed were due to the intervention.
As we intended to implement minimal inclusion criteria to obtain feedback from a wide audience, this may have led to a lack of information collected from those most at risk of structural vulnerabilities. Due to our purposive sampling, we are unable to determine external validity, and our study may not have robust representation. Likewise, due to the nature of this program, namely, including two intervention components (cooking classes and text messaging), we are unable to differentiate the intervention component impacts individually. In future implementations of this program, researchers could consider recruiting separate cohorts for each intervention component to identify which approaches elicit a favorable response. Finally, as these data were collected as part of a larger study, future work should consider more robust mixed-methods questioning of food environmental influences.
4.2. Implications for Research and Practice
This study both supports previous findings in the literature and provides further insight into at-risk groups of young adults. Despite its limitations, the current study captured the unique and positive outcomes of a college health promotion intervention. These findings provide further insight into the power of health-related interventions for young adults, particularly among those with poor diet quality or food insecurity. Future studies may consider a longer intervention program with intentional recruitment efforts toward including students who are at risk for poor dietary intake (i.e., lower dietary quality scores or screening for food insecurity).
Since research shows that students are better protected against poor mental health when feeling supported and valued by their university, providing programming for students that cultivates a sense of belonging may be particularly beneficial, especially for groups at greater risk of poor mental health (i.e., females, food-insecure students, and sexual minority students). This is especially important post-COVID-19 and -social distancing, which resulted in feelings of isolation and increased stress/anxiety. The most effective programs for improving health and promoting belonging on college campuses will be ones designed in partnership with students.
Efforts for expanding reach to all college students, rather than a self-selected few, may be found through nutrition and well-being programs or opportunities embedded within college curricula. Previous work has utilized core courses that are part of each student’s basic degree hours to implement well-being classes. Providing a full-term (i.e., semester or quarter) college course promoting healthful lifestyle behaviors may be a beneficial avenue for combining the components of evidence-based interventions. In the meta-analysis by Ashton and colleagues, the effectiveness of Behavior Change Techniques was assessed based on the Behavior Change Techniques Taxonomy [47]. The authors found that some of the more effective intervention techniques included (1) habit formation, (2) assessing the salience of consequences, (3) adding objects to the environment, and (4) action planning [39].
With improving food security rates among emerging adults, several position pieces have been published regarding the advancement of food security status by several pioneers in the field. Expanding our knowledge of food security rates and risks, assessing college environments, adapting or developing programs, implementing change, and assessing the impact of these programs [48,49], in addition to the expansion of governmentally funded programs for this widely left-out group, further research, and support for health equity across campuses and universities and for marginalized students, particularly via taking an individualized approach per campus [49], would greatly benefit this field.
5. Conclusions
Following a pilot intervention conducted on a college campus aimed at improving health-related quality of life for emerging adults, the participants’ mental health improved, along with their diet quality. Food security status did not change for the full sample, though in a subsample group of food-insecure students, students who reported low food security at baseline significantly improved their food security statuses following the intervention. Likewise, among individuals below the 50th percentile for diet quality at baseline, their diet quality significantly improved. Generalizability should be considered when expanding these results to other emerging adult populations.
Continued approaches should be formed, adapted, or expanded in an effort to improve health among our next generation of workers. College and university environments should continue to focus on mental health, diet, and food security among their constituents, particularly for those at risk. Providing knowledge and learning experiences for these individuals should not come without the care of their health, well-being, and longevity.
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