Abstract
Racial disparities in weight-related outcomes among males may be linked to differences in behavioral change efficacy; however, few studies have pursued this line of inquiry. The purpose of this study was to determine the degree to which self-efficacy associated with changing sugar-sweetened beverage (SSB) consumption intake varies by race among male first-year college students. A self-administered, cross-sectional survey was completed by a subsample of freshmen males (N = 203) at a medium-sized southern university. Key variables of interest were SSB intake and self-efficacy in reducing consumption of sugared beverages. African American and Whites had similar patterns of SSB intake (10.2 ± 2.8 vs. 10.1 ± 2.6); however, African Americans had lower proportions of individuals who were sure they could substitute sugared beverages with water (42.2% vs. 57.5%, p < .03). The results from logistic regression models suggest that self-efficacy to reduce SSB intake among males vary by race. African American males were less likely to assert confidence in their ability to change behaviors associated with SSB (odds ratio = 0.51; confidence interval [0.27, 0.95]) in the full model adjusting for weight-related variables including SSB consumption. The findings suggest that weight loss and weight prevention interventions targeting young African American males require components that can elevate self-efficacy of this group to facilitate behavioral modifications that reduce SSB consumption and their risk for obesity-related diseases.
Keywords
Introduction
African American men constitute a population with disproportionately high levels of illness, chronic disease, and premature mortality (Bruce et al., 2010; Griffith & Thorpe, 2016; Thorpe et al., 2013; Thorpe et al., 2014; Thorpe, Richard, Bowie, LaVeist, & Gaskin, 2013). The risks for poor health outcomes among this population have been amplified in the past few years as the prevalence of obesity among African American males has increased considerably (Ogden, Carroll, & Flegal, 2014; Thorpe et al., 2014). Published analyses from the National Health and Nutrition Examination Survey from 1999 to 2008 indicate that African American men had the largest change in prevalence of all groups in the study (Flegal, Carroll, Ogden, & Curtin, 2010). The proportion of African American men who were obese increased from 28.1% (1999-2000) to 37.3% (2007-2008; Flegal et al., 2010). Recent research exploring the relationship between excess weight and poor health among males has reported that racial disparities in overweight and obesity prevalence are increasing among younger members of this population (Ogden, Carroll, Kit, & Flegal, 2014; Skinner & Skelton, 2014). Scientists have begun to design race- and gender-specific weight loss and weight gain prevention interventions (George et al., 2012; Kassavou, Turner, & French, 2013; Whitt-Glover et al., 2014; Whitt-Glover & Kumanyika, 2009; Wong, Gilson, van Uffelen, & Brown, 2012), yet there is an urgent need for interventions targeting young African American males in emerging adulthood (18-25 years of age). It has been suggested that emerging adulthood is a critical developmental period for long-term health outcomes because behavioral patterns initiate and become established during this period (Nelson, Story, Larson, Neumark-Sztainer, & Lytle, 2008; Schwartz, Cote, & Arnett, 2005). African American males may be particularly vulnerable to weight gain during emerging adulthood as they have high levels of sugar consumption during this developmental period (Kumanyika, Grier, Lancaster, & Lassiter, 2011).
Sugar consumption has been linked to multiple metabolic conditions (e.g., obesity, diabetes, hypertension, chronic kidney disease) for which African American males have elevated risks for early onset, accelerated progression, and complications (Johnson et al., 2009; Malik, Popkin, Bray, Despres, & Hu, 2010; Malik, Popkin, Bray, Despres, Willett, et al., 2010; Nguyen, Choi, Lustig, & Hsu, 2009). The prevalence of hypertension among African American males during emerging adulthood doubles the corresponding prevalence among White males (Courtenay, 2000) and sugar-sweetened beverage (SSB) consumption may be a contributing factor to this disparity. Findings from a recent study reported that clinically significant reductions in systolic (1.8 mmHg) and diastolic (1.1 mmHg) blood pressure occurred when study participants reduced their intake of SSBs by one 12 ounce serving per day (Chen et al., 2010). Evidence suggesting that SSB intake contributes to elevated hypertension risk among African American males during emerging adulthood is bolstered by recent research indicating that this group has the highest level of SSB consumption of any race-, gender-, and age-specific groups in the United States (Kumanyika et al., 2011). Reducing SSB consumption among African American males during emerging adulthood could prevent or impede the progression of the onset of adverse metabolic outcomes.
Behavior change interventions can be important for reducing risks for high blood pressure, weight gain, and related conditions; however, only a few studies have examined their effectiveness among African American men (Griffith, Allen, Johnson-Lawrence, & Langford, 2014; Newton, Griffith, Kearney, & Bennett, 2014). The results from these studies are promising; however, the participants for these studies were middle-aged and older African American males. Emerging adulthood is a distinct period in the life course in which individuals are trying out different behaviors as they complete their education and training for future careers and gradually settle into adult roles (Arnett, 2000; Bowman, 1989). Instability is a feature of emerging adulthood and individuals may lack confidence to make changes to dietary patterns. This is particularly salient for African American males as their eating patterns can be influenced by contextual factors such as convenience, family structure, and stress (Allen, Griffith, & Gaines, 2013; Bruce, Sims, Miller, Elliott, & Ladipo, 2007; Griffith & Johnson, 2013; Griffith, Schulz, Johnson, & Herbert, 2009; Griffith, Wooley, & Allen, 2013).
Social cognitive theory has been deemed useful for understanding the person-context-behavior relationship and has been the theoretical foundation for multiple intervention studies designed to promote healthy eating or physical activity (Thomas, 2006). Self-efficacy, a key component of social cognitive theory, has been a central focus in the weight management literature. The basic premise is that individual beliefs about their ability to achieve personal goals choices have implications for behavior change outcomes (Bui, Kemp, & Howlett, 2011; Gamble, Parra, & Beech, 2009; Richman, Loughnan, Droulers, Steinbeck, & Caterson, 2001). Self-efficacy is commonly used in nutrition and physical activity interventions particularly with youth and young adults. A few studies have examined the association between self-efficacy and weight-related behaviors among college students (Butler, Black, Blue, & Gretebeck, 2004; Franko et al., 2008); however, no study to our knowledge investigated this relationship among African American men in general and African American male emerging adults explicitly. The purpose of this study was to examine differences in self-efficacy associated with changing SSB consumption intake among African American and White first-year college students.
Method
Participants
Data for this analysis were drawn from a surveillance study collecting nutrition and physical activity information from incoming freshmen during the Fall 2005 semester at a medium-sized, state university located in a large southern city. The study was approved by the University of Memphis Institutional Review Board. Eligible participants for this study were first-time, first-year students attending classes during the Fall 2005 semester. In an effort to enroll as many first-year students as possible, freshmen were recruited via three methods: (a) presentations conducted by research staff during ACAD (Academic support, Connection to the University resources, Achievements, and Destination points) classes and dorm meetings at the beginning of their initial semester; (b) manned information booths/tables at student orientation meetings and fairs; and (c) posted flyers in areas on campus frequented by freshmen (e.g., student activity center or student union). A research staff member provided additional information about the study to interested students, confirmed eligibility, and asked eligible students (first-time, first-year students) to sign the informed consent form and provide contact information, including permanent address.
Survey Questionnaire
Once informed consent was acquired, participants completed a self-administered survey at the recruitment sites. The survey was designed to assess the overall health of first-time, first-semester college students with an emphasis on obesity-related behaviors (i.e., nutrition, physical activity). The survey questionnaire consisted of items designed to measure self-perceptions of body image, body mass index (BMI), self-reported behavioral patterns, and confidence level regarding making healthy food choices. A substantial number of items on the survey were replicated from the Behavioral Risk Factor Surveillance System Questionnaire. The Behavioral Risk Factor Surveillance System, designed by the Centers for Disease Control and Prevention (CDC; 2000), monitors modifiable risk and health behaviors or conditions related to the leading causes of death and disability such as cardiovascular disease, cancer, diabetes, and injuries.
Study Variables
SSB consumption change efficacy was the outcome of interest for this study and was derived from an item asking about their confidence to “drink water instead of sweet drinks.” The response categories were “not sure,” “sort of sure,” and “very sure.” This measure was transformed into a dichotomous variable indicating that individuals were “very sure” (coded 1), they could replace sugared beverages with water, or “not sure” or “sort of sure” (coded 0), they could replace sugared beverages with water.
Body weight-related variables were also included in these analyses. BMI was a measure derived by dividing the self-reported weight (in pounds) by self-reported height (in inches) squared and multiplying the dividend by 703, which is the standard formula for calculating BMI for children and adolescents (CDC, 2014). BMI percentiles are typically generated for individuals under 19 years of age; however, this statistic was not calculated because the sample included individuals who were 20 years of age or older. The “concerns about weight” and “attempts to lose weight” measures were drawn from items on the McKnight Risk Factor Survey (Shisslak et al., 1999). The complete survey was originally designed to identify risk factors for eating disorders in adolescent girls; however, research reported that young men have concerns about their body weight and some seek to address body image concerns through attempts to lose weight (Pritchard, King, & Czajka-Narins, 1997; Slater & Tiggemann, 2014). The “concerns about weight” measure is composite of seven items asking respondents about the frequency of thoughts and actions associated with having trepidation about their weight. The “attempts to lose weight” variable is a composite measure of five items asking study participants about the methods and frequency of their effort to lose weight. The response categories for both of the McKnight components were “never” (coded 1), “sometimes” (coded 2), and “a lot” (coded 3).
It has been established that diet and exercise can influence health behavior change (Blair, Jacobs, & Powell, 1985) and variables representing calorie-dense food intake and physical activity were included in the analyses. The take-out food frequency score was a composite of responses to eight items beginning with the phrase, “How often do you eat the following foods from a restaurant . . . ” Each item referred to a fast food item and the quick service restaurant where it could be purchased. The response categories were “less than once a month” (coded 1); “once or twice a month” (coded 2); “once a week” (coded 3); and “more than once a week” (coded 4). The physical activity variable for this analysis was a dichotomous variable indicating whether or not participants met national recommendations for exercise. This variable was derived from responses to three questions asking the number of days over the past week that respondents: “Participated in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities”; “Participated in physical activity for at least 30 minutes that did not make you sweat and breathe hard”; and “Exercise to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting.” The responses to each of these questions ranged from “0 days” (coded 1) to “7 days” (coded 8). According to the Physical Activity Guidelines for Americans (U.S. Department of Health & Human Services, 2008), adults should engage in at least 150 minutes of moderate intensity, 75 minutes of vigorous intensity physical activity or an equivalent combination of the two types of aerobic exercise weekly. The guidelines also stated that physical activity should be bolstered with muscle-strengthening activity or at least moderate intensity for at least 2 days per week. Respondents who engaged in 20 minutes of vigorous activity for at least 4 days per week or 30 minutes of moderate intensity exercise for at least 5 days per week and had two or more days of strength training on a weekly basis were coded as 1, all others were coded 0. The SSB consumption frequency score was a composite measure of responses to 4 items asking participants about their consumption frequency of regular soda or sweetened tea, milkshakes or sweetened coffee drinks, Kool-Aid or lemonade, and chocolate or flavored milk. The responses to each item were “never” (coded 1), “1 to 3 times per month” (coded 2), “1 to 6 times per week” (coded 3), “1 to 2 times per day” (coded 4), and “3 or more times per day” (coded 5).
The remaining variables in the analysis were demographic measures such as age, self-reported race, and commuter status. Age was measured by a categorical variable asking participants to indicate whether they were younger than 18 years of age (coded 1), between 18 and 20 years of age (coded 2), or older than 21 years of age (coded 3). The age variable used in this analysis was derived from the original six-category variable because there were no respondents in the “26 to 30,” “31 to 35,” or “36 years and older” categories. Race/ethnicity was captured by an item asking respondents to identify themselves as White/Caucasian, Black/African American, Hispanic, Asian/Pacific Islander, or other. Only African American and White males were included in the study and the race variable was a dichotomous variable in which Whites were coded 0 and African Americans were coded 1. Commuter status was derived from an item asking participants if they lived on or off campus.
Statistical Analysis
Chi-square and analysis of variance tests were used to examine the mean and proportional differences by race for each of the variables in the analysis. Logistic regression models were specified to examine the association between race and SSB consumption change efficacy. The modeling strategy was employed in three steps to observe the effect of each group of variables on race and SSB consumption change efficacy. First, Model 1 included the demographic variables: race, age, and commuter status. Next, Model 2 included variables in Model 1 along with BMI, concerns about weight, and attempts to lose weight. Third, Model 3 included variables from the previous two models as well as the take-out food frequency score, whether or not individuals met physical activity guidelines, and the SSB consumption frequency score. p Values < .05 were considered statistically significant and all tests were two-sided. All analyses were conducted using STATA version 12.
Results
Table 1 depicts the distribution of sample characteristics among college men for the total sample and by race. Two-hundred and three males completed surveys and African Americans made up approximately 41% (n = 83) of the analytic sample. Over half of the sample (51.2%, n = 104) expressed confidence they could replace SSBs with water; however, African American males in the sample were significantly less likely than Whites (42.1% vs. 57.5%) to be very sure if they replace SSBs with water. The results in Table 1 indicate racial differences in age, as African American males were more likely to be younger than 18 years of age (28.9% vs. 10.0%) in the sample compared with White males. African American and White males had similar values across the remaining variables in the analysis. The majority of first semester first-year students lived on campus. The mean BMI for the total sample of males was 24.9 (SD = 5.8). The males in this study also had a mean take-out food consumption score of 10.6 (SD = 4.1) and 46% of the sample met physical activity guidelines. The average scores on the concerns about weight and attempts to lose weight indicators were 7.54 (SD = 2.4) and 11.17 (SD = 3.1), respectively. The mean sugared beverage consumption score was 10.13 (SD = 2.7).
Distribution of Sample Characteristics Among 203 White and African American Males.
Note. BMI = body mass index; SSB = sugar-sweetened beverage.
The models examining the association between race and SSB consumption change efficacy are presented in Table 2. In Model 1, adjusting for demographic variables, African American males had lower odds of expressing confidence in their ability to substitute SSBs with water (odds ratio = 0.54, confidence interval [0.29, 0.99]) than White males. BMI, concerns about weight, and attempts to lose weight variables were added in Model 2; however, African American males continued to be less likely than White males to be very sure they could replace sugared beverages with water. The take-out consumption frequency score, met physical activity guidelines, and SSB consumption frequency score variables were added in the full model and the race difference in the odds of being very sure one could replace sugared beverages with water continued to persist. African American males were nearly half as likely than White males (odds ratio = 0.51, confidence interval: [0.27, 0.95]) to express confidence in their ability to substitute SSBs with water.
Association of Sugar-Sweetened Beverage Consumption Change Efficacy.
Note. BMI = body mass index; SSB = sugar-sweetened beverage; CI = confidence interval; OR = odds ratio. All variables included in the analysis are listed in the table.
The reference category contains individuals younger than 18 years of age.
Discussion
There is an urgent need for interventions for young African American males to lower their risks for chronic disease onset and accelerated progression; however, there is a dearth of information about the individual, cultural, and social factors influencing health behaviors among this group. SSB consumption is an especially important target for behavioral interventions among this population because sugared beverage consumption was reported to be most common among young adults, men, and African Americans (Kumar et al., 2014). Reducing SSB consumption has been identified as a weight management and chronic disease prevention strategy (Johnson et al., 2009; Kumanyika et al., 2011; Kumar et al., 2014); however, replacing consumption of sugared beverages with water and other healthier drinking options could be salient for African American males to reduce their elevated risks for obesity and chronic diseases. Behavior change is difficult; however, no studies to our knowledge have assessed the perceived degree of difficulty making lifestyle modifications among at risk populations like African American males. The current study used data drawn from a sample of African American and White male first-year college students to assess racial disparities in SSB behavioral modification efficacy.
African American men in the study had significantly lower odds of expressing confidence in their ability to substitute SSB with water than White males in the fully adjusted model. The pursuit of research questions exploring lower confidence among African American males to make behavioral changes presents an interesting avenue for theoretical development. Social cognitive theory (Bandura, 2004) posits that self-efficacy affects health behavior directly and indirectly through its impact on goals, outcome expectations, and perceived facilitators and impediments. But Bandura also posits that self-efficacy and health behaviors are shaped by situational and environmental factors. Research has shown that African American and White males emerge from and exist in different cultural, economic, political, and social environments that can lead to differences in how individuals perceive their levels of personal control (Bruce & Thornton, 2004). Males from disadvantaged backgrounds tend to have fewer experiences in which positive behaviors resulted in equally positive outcomes, thereby muting expectations about results from lifestyle changes. Advertising may also disproportionately affect African American males’ SSB consumption and self-efficacy given the overabundance of advertising exposure these males experience (Bailey, 2006). Future research should seek to disentangle intrapersonal characteristics such as self-efficacy from peer norms regarding SSB and water consumption, access to and cost of SSB and water on and off campus, the perceived value of purchasing SSBs and bottled water, and other environmental factors that may affect self-efficacy and actual SSB consumption.
Self-efficacy is an important factor for behavior change and it is often presumed to be part of behavioral interventions (Glanz, Rimer, & Lewis, 2002). There has been some evidence in the social psychological literature to suggest that self-efficacy can vary by race and gender (Buchanan & Selmon, 2008). But, no research to our knowledge has explicitly examined racial differences in the degree to which males believe they can positively change their health behaviors. The results from this study raise some interesting research questions about self-efficacy and its implications for behavioral modification and intervention development strategies focused on African American and other minority males. However, there are other findings worth noting. The results presented in this study indicated that African American and White males had similar SSB consumption frequency scores which differ from those highlighted in recent reports such as Kumanyika et al. (2011). It is likely these discrepancies are due to study design and measurement differences. Kumanyika et al. (2011) reported data from National Health and Nutrition Examination Survey, which were collected using 24-hour recall, and gathered information on a myriad of SSBs including sports and energy drinks. The data analyzed for this study used 30-day recall and did not collect information about sports and energy drink usage. Kumar et al. (2014) notes that these differences can contribute to different SSB consumption estimates between studies.
The findings from this study are important because they highlight future avenues of inquiry; however, there are some limitations of note. Some important variables were not available to be included in the analysis. Socioeconomic status is a variable that has direct and indirect implications for racial disparities in outcomes like self-efficacy (Bruce & Thornton, 2004). The analytic models are estimated using data drawn from a sample of African American and White male first-year college students attending a single university in the South in 2005; therefore, the results are not generalizable to African American or White males not in college, those later in their collegiate careers or those attending college in other regions of the country. The generalizability of the results is also limited given the age distribution of African Americans in the sample. The factors leading to the sizeable segment of African American males under 18 years of age in the study are unknown; however, it is noteworthy that this atypical age distribution could confound or bias results. The age of the data is also potential limitation because the number and type of SSBs available for consumption have changed considerably over the past decade. Similarly, data collection preceded the emergence of research highlighting marketing practices by soft drink companies targeting young African American males (Grier & Kumanyika, 2008, 2010; Kumanyika et al., 2011). It is also important to note that the models in this study were estimated using cross-sectional data, which does not allow for the specification of temporal events or determination of causal inferences. The small sample size limits the number of independent variables included in regression analysis, thereby limiting the number of factors considered and potentially its robustness. All of the usual limitations associated with self-report data apply (Bruce et al., 2007).
Conclusion
This study underscores the importance of self-efficacy and how it can vary by race among young men. Additional studies are needed to determine the manner in which social, psychological, and behavioral factors can affect health behavior self-efficacy of males as well as those assessing the degree to which patterns of association vary across race, ethnicity, age, and socioeconomic status. Results from this line of research lay the foundation for the inclusion of components that can bolster the effectiveness of behavioral interventions targeting African American males that can reduce risks for unhealthy weight gain, obesity, premature morbidity, disability, and mortality among this group.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.