NST 166 Unit 3 Study Guide

Explain how obesity is measured and limitations of those measures

obesity is measured using Body Mass Index (BMI)

• uses height and weight to classify weight status

• useful for population screening

limitations:

• does NOT directly measure body fat

• does NOT distinguish between fat mass and lean muscle mass

• does NOT show where fat is distributed in the body (visceral fat is more strongly related to metabolic risk)

describe obesity as a multifactorial condition

Obesity is a multifactorial condition, meaning it is not caused by one thing and it is not simply a matter of individual willpower.

• other factors include:

  • Biology and genetics

  • Hormones and metabolism

  • Medications

  • Stress and sleep

  • Mental health

  • food access

explain energy balance in real-world terms

the relationship between energy coming in through food/beverages and going out through metabolism, physical activity, and normal body functions.

In real-world terms, it is not just a simple math equation because people do not make food and activity decisions in a vacuum.

• the environment often shapes what is easy, affordable, normal, and realistic.

identify determinants beyond individual behavior

Determinants beyond individual behavior include:

• Food environment

• Marketing and advertising

• Food prices

• Portion sizes

• Ultra-processed food availability

• Sugar-sweetened beverage availability

• Food insecurity

• stress

• sleep

• transportation access

Be able to define marketing and describe what the “exchange” is.

Marketing is a strategy used to influence consumer behavior. In commercial marketing, the goal is usually to convince consumers to choose a product.

The exchange is what the consumer gives up and what they receive in return.

• commercial marketing: money for a product

• social marketing: giving up time, effort, convenience, comfort, or an existing habit in exchange for a health or social benefit.

How are different groups (especially children) targeted?

Different groups are targeted through segmentation and tailored messages. Marketers think about age, location, values, attitudes, lifestyle, readiness for behavior change, and behavior patterns.

Children are especially targeted through:

• Bright colors

• Cartoon characters

• Toys

What is secondhand exposure?

Secondhand exposure is when someone is exposed to marketing even though they are not the direct intended target.

• ex) a caregiver and a marketing aimed at children

What is Pester factor and how does it influence caregiver behavior?

The pester factor is when children repeatedly ask or pressure caregivers to buy a product they saw advertised.

• It influences caregiver behavior because caregivers may eventually buy the product

What is the difference between commercial marketing and social marketing? Understand the main goals and strategy of each approach.

Commercial marketing satisfies the needs and wants of consumers and convinces consumers to choose a product.

Social marketing aims to change the attitudes and behaviors of consumers.

examples:

• Commercial marketing: convincing consumers to buy soda.

• Social marketing: encouraging consumers to drink water or reduce sugar-sweetened beverage intake.

Understand how marketing can shape food choices and ultimately health and nutrition status.

Marketing shapes food choices by changing what people see, want, remember, and consider normal.

• can increase the acceptability

Why is it important to identify a target group within a marketing campaign?

It is important to identify a target group because the message, strategy, and delivery need to fit the population being served.

Different groups have different values, beliefs, barriers, motivations, cultural backgrounds, and levels of readiness for behavior change.

What is marketing segmentation and what classes of variables are typically used?

marketing segmentation:

dividing a broad population into smaller groups based on shared characteristics

1. Demographic segmentation

2. Geographical segmentation

3. Psychographic segmentation, which includes personal values, attitudes, opinions, personality, lifestyle, and level of readiness for behavior change

4. Behavioristic segmentation, based on criteria such as frequency and occasion, benefits sought, and attitude toward a product

Know the 4 P’s of Marketing

The 4 P’s are:

1. Product — what is being offered

2. Price — perceived costs, including time, effort, stigma, and financial cost

3. Place — where and how the service or product is accessed

4. Promotion — how information is communicated

What types of behavior does marketing aim to change? Which is the easiest to change? The most difficult?

Marketing can aim to change:

1. Cognitive change — a change in knowledge or awareness

2. Action change — a change in a specific, one-time behavior

3. Behavior change — a change in ongoing patterns of behavior over time

4. Value change — a change in underlying beliefs, attitudes, or priorities

The easiest is usually cognitive change, because it only requires changing awareness or knowledge.

The most difficult is value change, because it requires changing deeper beliefs, attitudes, or priorities.

What role does the government play in food marketing, and what can they do to protect consumers? Think of the examples we discussed in class.

The government can regulate, limit, or shape food marketing to protect consumers, especially children.

Government responsibility can include:

• Prohibit marketing of unhealthy foods in schools

• Limit marketing of unhealthy foods on television

• Establish and enforce high standards for food marketing to children

• Support sustained, multidisciplinary research on marketing impacts on food choices of children

• Ensure public funds do not subsidize products contributing to poor health

Be able to describe what added sugar is and where they are found?

Added sugars are sugars and syrups added during processing, preparation, or at the table.

Examples include:

• Table sugar

• Brown sugar

• High-fructose corn syrup

What counts as SSB?

Sugar-sweetened beverages are any liquids that are sweetened with various forms of added sugars.

Examples of SSBs include:

• Regular soda

• Fruit drinks with added sugar

• Sports drinks

• Energy drinks

• Sweetened teas

How do SSBs contribute to energy surplus? Why are SSBs not satiating?

SSBs contribute to energy surplus because they add calories quickly without making people feel full in the same way solid foods do.

They are not very satiating because liquid calories are consumed quickly, require less chewing, and do not produce the same fullness response as foods with fiber, protein, or complex structure.

What health outcomes are associated with frequent intake of SSB?

Frequent intake of SSBs is associated with:

• Weight gain

• Obesity

• Type 2 diabetes

• Cardiovascular disease risk

• Dental caries

**they provide added sugar and calories w/ little nutritional value

How is fructose metabolized differently than glucose?

Glucose: can be used by many tissues in the body and is more tightly regulated by insulin and normal energy-control pathways.

Fructose: goes more directly to the liver + can be converted into fat when consumed in high amounts

What does it mean that fructose “bypasses regulation”?

Fructose “bypasses regulation” means that it does not go through the same tightly controlled metabolic checkpoints as glucose.

• fat production in the liver

• increased triglycerides

• metabolic risk

How does SSB consumption vary globally?

SSB consumption varies globally based on availability, affordability, marketing, urbanization, and the strength of beverage industry presence.

• In the El Susto documentary context, Mexico was described as one of the top soda-consuming countries, with very high per-person soda intake.

What is the relationship between SSB intake and obesity at the population level?

At the population level, higher SSB intake is associated with higher obesity risk because SSBs add calories without much satiety.

• The relationship is not only individual behavior. It reflects affordability, marketing, industry strategies, and food environments.

How does affordability influence consumption?

Affordability influences consumption because when SSBs are cheap, people are more likely to buy and consume them regularly.

What is a behavioral nudge?

Behavioral nudging refers to intentional changes in the environment designed to influence behavior without restricting options or significantly changing economic incentives.

Identify examples of nudges (e.g., default pricing, placement, defaults, labeling).

Examples of nudges include:

• Product placement at checkout

• Placing sugary drinks at eye level

• Making water the default beverage

• Calorie labeling

• Warning labels

• Smaller default portion sizes

• Default pricing or promotions that make certain products more appealing

How do nudges shape SSB consumption?

Nudges shape SSB consumption by changing what is easiest, most visible, most normal, or most automatic.

What is the difference between System 1 and System 2 thinking?

System 1 thinking is fast, automatic, intuitive, and requires little effort. It is driven by habits, cues, and emotions.

System 2 thinking is slow, deliberate, analytical, and requires effort and attention. It is used for complex decision-making.

Which system most commonly drives eating behavior and why?

System 1 most commonly drives eating behavior because food decisions are often fast, automatic, cue-driven, emotional, and habitual.

Describe how environmental factors (availability, affordability, marketing) shape SSB intake.

Environmental factors shape SSB intake by making sugary drinks easy, cheap, visible, and normal.

• Availability: SSBs are widely available in stores, restaurants, schools, vending machines, and checkout areas.

• Affordability: If sugary drinks are inexpensive, people are more likely to buy them regularly.

• Marketing: Ads, branding, sponsorships, and promotions increase preference and demand.

• Placement: Products placed at checkout or eye level become automatic choices.

What are pouring rights contracts?

agreements between beverage companies and institutions, such as universities or schools, that give a company the exclusive right to sell or market its beverages in that setting.

• ex) a university may have a contract with Pepsi or Coca-Cola that shapes what drinks are available in vending machines, dining areas, events, and campus stores

How do they shape the food and beverage environment?

by determining which beverages are available, promoted, and normalized in an institution.

They can affect:

• Vending machine options

• Campus dining options

They make certain products more visible and accessible.

How do they act as a structural nudge?

they shape the default beverage environment before an individual makes a choice.

• ex) one company controls most beverage access on campus, then students are nudged toward the products that company provides

What is a soda tax?

an excise tax on sugary drinks

• a flat rate per ounce of SSBs

How does a soda tax influence behavior differently than environmental changes?

A soda tax influences behavior through price.

expensive soda vs. removing soda from checkout

What evidence exists on soda taxes and consumption?

El Susto: In the Mexico example, after the soda tax, people drank less sugary drinks, about 7% less in the first year, and water intake increased.

El Susto: You should be able to talk about the major events, political and industry strategies, and cultural beliefs from this film.

El susto refers to a folk belief that a severe shock, fright, or traumatic event can trigger illness, including diabetes.

• If people believe diabetes is caused by emotional trauma or fright, they may be less likely to focus only on sugary drinks, processed foods, or metabolic risk

• the beverage industry used around $1 billion per year for eight years to grow and protect its market

• After Mexico implemented a soda tax, sugary drink intake decreased by about 7% in the first year, while water consumption increased.

What does maternal health include?

goals such as:

• increasing early and adequate prenatal care

• reducing low birth weight and preterm births

• increasing breastfeeding initiation and duration

• improving infant nutrition and feeding practices

• reducing maternal anemia and nutrient deficiencies

Why is it important for both mother and infant outcomes?

• because the health of the mother directly shapes infant outcomes.

• Maternal health also matters for the mother’s own survival and long-term health, including risk of complications during pregnancy, delivery, and postpartum.

What are the three main indicators of maternal and child health?

• Infant Mortality Rate

• Low Birth Weight

• Maternal Mortality Rate

Why are these useful at the population level?

because they reflect the overall functioning of health systems, nutrition, prenatal care, social conditions, and access to basic resources.

• Do they have adequate care? nutrition? support?

What factors influence fertility rates globally?

Key drivers of fertility include:

• Opportunity costs for women

• High costs of living and children

• Shift in values

• Effective family planning

• Delayed family formation

• Urbanization

• Work-life balance

How do access to care and child survival shape fertility decisions

• Safety and survival: High risk of child mortality means families often choose to have more children. Low risk means families often choose to have fewer children.

• Access to reproductive care: Increased access to reproductive healthcare leads to planned, fewer births. Decreased access leads to unplanned, higher fertility.

• Health system effects: Strong health systems improve child survival and lower fertility. Weak health systems increase infant and child mortality, limit maternal care, and increase fertility.

What are the leading causes in the U.S. vs globally?

In the U.S., the five leading causes of infant death in 2022 were:

1. Birth defects

2. Preterm birth and low birth weight

3. Sudden infant death syndrome

4. Unintentional injuries, such as car crashes

5. Maternal pregnancy complications

Globally, the causes of infant mortality include:

1. Infectious diseases, including pneumonia, diarrhea, and malaria

2. Prematurity-related causes

3. Intrapartum events, such as birth asphyxia, trauma, or prolonged labor

4. Congenital anomalies, or birth defects

Why are many of these causes preventable?

because they are tied to access to prenatal care, skilled birth attendance, clean water, sanitation, vaccination, infection prevention, nutrition, emergency care, and early screening.

What are the main causes?

Diarrheal disease is often caused by:

• Unsafe water

• Poor sanitation

• Lack of hygiene

• Rotavirus

It is a leading cause of mortality in children under 5, causing approximately 444,000 to 525,000 deaths annually. Over 99% of childhood diarrheal deaths occur in low- and middle-income countries.

What are key prevention strategies?

Key prevention strategies include:

• Improving sanitation

• Improving water sources

• Safe water storage at home

• vaccines

What is low birth weight?

Low birth weight is a birth weight of 5.5 pounds, or 2500 grams, or less.

Very low birth weight is less than 1500 grams, or about 3 pounds, 4 ounces.

What are the main causes and risk factors?

Main causes of low birth weight include:

• Poor growth in utero, often brought on by restrictions in nutrients, oxygen, or placental function

• Premature birth

Risk factors:

• mom’s high blood pressure/diabetes/poor nutrition

Why is it a major concern for long-term health?

Low birth weight is a major concern because low birth weight infants are about 20 times more likely to die than heavier infants

• Increased illness in infancy

• Slower physical growth

• Delayed cognitive development

• Greater risk of chronic diseases later in life

What strategies help prevent low birth weight?

Strategies include:

• Improve maternal health before pregnancy

• Adequate nutrition, including balanced diet and micronutrients like iron and folic acid

• Healthy weight prior to pregnancy

• Regular check-ups to monitor growth and complications

what are the main causes?

Main causes of maternal mortality include:

• Hemorrhage

• Eclampsia or hypertensive disorders

• Sepsis and infection

• Obstructed labor

• Unsafe abortion

• Complications from existing conditions

• Anemia and malnutrition

• Lack of timely emergency obstetric care

How do direct vs indirect causes differ?

Direct causes are complications directly related to pregnancy, childbirth, or the postpartum period.

• ex) hemorrhage, eclampsia, sepsis, obstructed labor, and unsafe abortion.

Indirect causes are existing or underlying health conditions made worse by pregnancy.

• ex) anemia, malaria, heart disease, diabetes, HIV, or other chronic conditions.

Three Delays Model:

What are the three delays?

1) Delay deciding to seek care

2) Delay reaching care

3) Delay receiving quality care

How does each delay impact maternal outcomes

Delay 1: deciding to seek care
This can happen because of cost, social norms, lack of recognition of danger signs, fear, or low decision-making power.

Delay 2: reaching care
This can happen because of distance, poor roads, lack of transportation, or geography.

Delay 3: receiving quality care
This can happen because of staff shortages, lack of supplies, lack of blood, lack of surgical capacity, or poor-quality treatment.

What strategies address each of the three delays?

Strategies for Delay 1: deciding to seek care

• Health education

• Recognizing danger signs

• Empowering women and families

• Reducing stigma

• Community outreach

• Improving trust in the health system

Strategies for Delay 2: reaching care

• Transportation systems

• Referral systems

• Ambulance access

• Better roads

• Maternity waiting homes

• Local clinics closer to communities

Strategies for Delay 3: receiving quality care

• Skilled birth attendants

• Emergency obstetric care

• Blood supply

• Medications

• Surgical capacity

• Trained staff

• Adequate supplies

• Respectful maternity care

what is healthy aging?

Healthy aging means maintaining health, function, independence, and quality of life as people get older.

• shaped across lifespan

What components define it (physical, mental, social)?

Physical health: maintaining strength, mobility, bone health, muscle mass, immune function, and the ability to perform daily activities.

Mental health: maintaining cognition, emotional well-being, memory, and reduced risk of depression, anxiety, and dementia.

Social health: maintaining social connection, independence, community participation, and support systems.

How do nutrition needs change across life stages?

Nutrition needs change because growth, development, metabolism, hormones, body composition, and activity levels change across the lifespan.

• childhood: needs growth/brain development/growth

• adulthood: needs focus more on maintaining health

• older adulthood: calorie needs decrease b/c metabolism and activity levels decline

Why is adolescence a critical period?

Adolescence is a critical period because it is a time of rapid physical growth, cognitive development, puberty, increasing independence, and development of long-term health behaviors.

Calcium intake is especially important (for bone health)

What is internal food regulation?

Internal food regulation refers to eating based on internal body signals, such as hunger, fullness, satiety, and energy needs.

• early childhood (more likely to respond to hunger and fullness cues)

What is external food regulation?

External food regulation refers to eating based on outside cues rather than internal hunger and fullness.

• older people (adulthood)

• external cues examples:

  • food availability

  • portion size

  • marketing

  • stress

How do they interact over time? How does this affect our eating patterns change over time?

eating patterns shift from being mostly internally regulated to being increasingly shaped by external cues.

Understand the various influences that shape eating behaviors and how it is connected to models we discussed in class.

Eating behaviors are shaped by individual, social, environmental, and policy-level factors.

Social Cognitive Theory: eating behavior is shaped by the interaction between person, behavior, and environment. For example, a student’s knowledge, campus food environment, and eating habits influence each other.

Integrated Behavioral Model: eating is shaped by attitudes, norms, self-efficacy, skills, habits, and environmental constraints. This is especially useful for adolescents because peers and social norms matter.

Transtheoretical Model: eating behavior change depends on readiness to change. A person may be in precontemplation, contemplation, preparation, action, or maintenance.

Social Ecological Model: eating is shaped across levels: individual, interpersonal, organizational, community, and policy.

What makes Adolescence a critical life stage?

because it includes rapid growth, puberty, brain development, increasing independence, and formation of lifelong health behaviors.

also a stage when adolescents are heavily influenced by peers

What are common dietary patterns among adolescents?

Common adolescent dietary patterns include:

• Low fruit and vegetable intake

• Low whole grain intake

• High sugar-sweetened beverage intake

• High fast food intake

increasing independence + strong external influences

Why is calcium intake important during this stage? How does this impact our health later in life?

Calcium is important during adolescence because this is a critical period for bone growth and peak bone mass development.

• may not build optimal bone density

• can increase risk of osteoporosis

What types of school and community interventions support healthy eating in this age group?

School and community interventions include:

• Healthy school meals

• Nutrition education

• School garden programs

• Farm-to-school programs

Why are multi-level approaches most effective?

Multi-level approaches are most effective because adolescent eating is not shaped by knowledge alone.

• shaped by individual preferences, caregivers, food availability, marketing, policy, cost, etc.

What demographic shifts are occurring in the U.S.?

an increasing older adult population because people are living longer

Why are people living longer?

People are living longer because of improvements in:

• Medical care

• Public health

• Vaccination

• Sanitation

Older people need nutrient needs increase but calorie needs decrease.

They have less “room” for empty calories because they need more nutrition per calorie.

• older adults need nutrient-dense foods

What is sarcopenia?

the age-related loss of muscle mass, strength, and function.

• it increases risk of falls, fractures, disability, loss of independence, hospitalization, and poor quality of life.

Why is protein important in older adults?

Protein is important because it helps maintain muscle mass, muscle strength, immune function, wound healing, and physical function.

• higher risk of sarcopenia

What are common risk factors for malnutrition in older adults? Think of the DETERMINE method

• Disease

• Eating Poorly

• Tooth loss or mouth pain

• Economic hardship

• Reduced social contact

• Multiple medicines

• Involuntary weight loss or gain

• Needs assistance in self-care

• Elder years above age 80

Why is malnutrition often underrecognized?

Malnutrition is often underrecognized because it can be mistaken for normal aging.

• can also be hidden b/c older adults may live alone

What programs support older adult nutrition (e.g., SNAP, OAA programs)?

Programs include:

• SNAP

• Older Americans Nutrition Program

• Congregate meals

• Home-delivered meals, such as Meals on Wheels

• Senior Farmers’ Market Nutrition Program

• Commodity Supplemental Food Program

• Local food banks and senior centers

• Healthcare and community-based nutrition screening programs

What is health equity?

Health equity is the attainment of the highest level of health for all people.

• requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities

How is equity different from equality? From liberation?

Equality: everyone on the same box. means everyone is treated the same and receives the same resources.

• does not account for different starting positions or needs

Equity: giving people what they need to see over the fence. means everyone tailoring resources to individual needs so people have a better opportunity to reach the same outcome

Liberation: removing the fence. is more structural. means removing the barrier or fixing the system so unequal access is no longer a problem.

What is the difference between health disparities and health inequities?

Health disparities are differences in comparable health outcomes.

Health inequities are differences in comparable health outcomes that are rooted in unfairness or injustice.

What structural factors contribute to health inequities?

Structural factors include:

• Unequal access to quality care

• Differences in insurance coverage

• Differences in provider availability

• Under-resourced hospitals and clinics

• Segregation of care systems

What are the different levels (structural, institutional, interpersonal, internalized)? How do they interact?

Structural racism: broad societal patterns that create unequal access to education, housing, healthcare, and economic opportunities.

Institutional racism: racism within systems and organizations, such as healthcare, education, and legal systems, where policies and practices result in unequal outcomes.

Personally mediated/interpersonal racism: acts of prejudice and discrimination between individuals. This can be intentional or unintentional, conscious or unconscious.

Internalized racism: when individuals from marginalized groups accept negative messages about their own abilities or worth.

They interact because what happens at the structural level influences institutions, which shapes interpersonal treatment, which can then shape internalized beliefs and health behavior.

What are the differences between private insurance and public programs?

Private insurance is typically obtained through employment or purchased individually. It includes managed care plans such as HMOs, PPOs, POS plans, and EPOs. These vary by network, flexibility, referrals, and cost.

Public insurance programs include Medicare and Medicaid. They are government programs designed to provide coverage to specific populations, such as older adults, people with disabilities, and low-income individuals.

What is Medicare? Who does it serve?

AGE/DISABILITY, NOT INCOME

Medicare is a federally run entitlement program through which people 65 years of age or older and people in certain other eligible categories receive health insurance.

It serves:

• people 65 years of age or older

• younger individuals with long-term disabilities who qualify

• Some people with specific medical conditions or government employment histories

What is Medicaid? Who does it serve?

LOW INCOME

Medicaid is a federally aided, state-administered entitlement program that provides medical benefits for certain low-income persons in need of health and medical care.

• Eligible low-income individuals

• Certain pregnant women and children with low incomes

• Older adults

• Blind individuals

• People with disabilities

• Some families with dependent children

In California, Medicaid is called Medi-Cal.

What is implicit bias?

Implicit biases are unconscious associations that lead to a negative perception of another person based on factors such as race or gender.

How has racism and biases resulted in a mistrust in healthcare

Racism and bias have resulted in mistrust because communities have experienced historical and ongoing inequities in medical treatment, unethical research practices, discrimination, dismissal, and unequal care.

ex) The Tuskegee syphilis study (Black men were misled and not treated appropriately)

cultural competence starts with self-awareness

Cultural competence starts with understanding your own background and biases.

• if we do not understand how our own beliefs affect how we view others, we cannot move forward in becoming culturally competent

What is ethnocentrism vs cultural relativism?

Ethnocentrism is considering the beliefs, values, customs, and viewpoints of your group to be superior.

Cultural relativism is the idea that a person’s beliefs, values, and principles should be understood within their own cultural context.

what is cultural competence?

the ability to understand, communicate with, and effectively interact with people across cultures, acknowledging and respecting differences.

Why is cultural competence important in community nutrition?

culturally competent care helps providers design interventions that fit people’s real lives instead of replacing or dismissing cultural practices.

Campinha-Bacote Model

What are the five components (ASKED)?

The Campinha-Bacote Cultural Competence Model includes five interdependent constructs that spell ASKED:

1. Awareness — becoming aware of your beliefs, values, and biases and comparing them to cultures different from your own.

2. Skill — providing culturally meaningful interventions.

3. Knowledge — exploring different cultures and understanding generalities.

4. Encounter — direct and indirect experiences with individuals from diverse backgrounds.

5. Desire — motivation to engage in cross-cultural encounters and stimulate competence.

Why is cultural competence a continuous process?

Populations change.

It is not a one-time achievement.

It is shaped by ongoing experiences, reflection, learning, and encounters with different cultures.

Cultural Competence Continuum

What are the stages from destructiveness → proficiency?

1. Cultural destructiveness: attitudes, practices, and policies are destructive to other cultures.

2. Cultural incapacity: paternalistic attitude toward the “unfortunates”; no capacity to help.

3. Cultural blindness: belief that culture makes no difference; everyone is treated the same; dominant culture approaches are applied to everyone.

4. Cultural precompetence: weaknesses in serving culturally diverse populations are realized and some attempts are made to accommodate.

5. Cultural competence: differences are accepted and respected, self-evaluations are continuous, cultural skills are acquired, and adaptations are made.

6. Cultural proficiency: activities add to the knowledge base, research is conducted, new approaches are developed, and organizational cultural competence is encouraged.