HEALTH KICK: PROMOTING HEALTHY EATING IN YOUTH SPORT USING AN

ACCEPTANCE AND COMMITMENT THERAPY BASED INTERVENTION

Jenna M. Marx

A Dissertation

Submitted to the Graduate College of Bowling Green

State University in partial fulfillment of
the requirements for the degree of

DOCTOR OF PHILOSOPHY

August 2017

Committee:

Dara R. Musher-Eizenman
Committee Chair

Lynn A. Darby
Graduate Faculty Representative

Dryw O. Dworsky

William H. O’Brien




ProQuest Number: 10645595




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 ii

ABSTRACT

Dara R. Musher-Eizenman, Advisor

Prior research has called into question the health benefit of participating in youth

athletics for children. This two-part study identified the need for, developed and

implemented, and assessed an ACT-based healthy eating intervention for parents of youth

athletes ages 8-14. Participants of Study I (N = 29) responded to twelve Ecological

Momentary Assessment (EMA) prompts, and indicated that youth athletes consumed

significantly more fast food on game days than practice days (t(21) = 3.4, p = 0.002) or

non-sport days (t(24) = 4.4, p < 0.001). Based on these results, fast food consumption on

game days was targeted most centrally during the Study II intervention.

Participants of Study II (N = 31) attended an individual 1-hour ACT-based

healthy eating intervention that included psychoeducation and experiential components

incorporating defusion, values, and committed action. Theory of Planned Behavior

measures were given before and immediately following the workshop, and at two month

follow-up. Behavioral intention and perceived behavioral control to provide homemade

meals and snacks on game days significantly increased from pre-workshop to immediate

follow up (t(30) = 4.1, p < 0.001; t(30) = 2.2, p = 0.038), and was maintained at two-

month follow up (t(24) = 3.3, p = 0.003; t(24) = 2.1, p = 0.05). Subjective norms about

other’s views increased from pre-workshop levels to two-month follow up (t(24) = 2.3, p

= 0.029), and attitudes shifted more positively immediately following the workshop

(t(30) = 4.7, p < 0.001). Analysis using the SPSS PROCESS macro found significant

effects of attitudes on intention (b = 0.8, SE = 0.3, p = 0.0097). Intention did not

 iii

significantly predict fast food consumption on game days (b = -0.1, SE = 0.1, p > 0.05),

but subjective norms had a significant direct effect on fast food consumption (b = 0.3, SE

= 0.1, p = .0207). Indirect effects on fast food consumption through intention were not

significant, thus the model does not support mediation. Consumption of fast food

decreased somewhat from Study I to Study II (t(26) = 1.6, p = 0.123), but this change was

not significant. Implications and future directions are discussed.

 iv

This dissertation is dedicated to my loving parents, Paul I. Marx and Peggie A.

Marx, whose unwavering support instilled in me the confidence to pursue my dreams.

Thank you for teaching me how to learn, how to laugh, and how to love.
 v

ACKNOWLEDGEMENTS

First and foremost, I would like to acknowledge and thank my advisor, Dara

Musher-Eizenman, for helping me to develop the skills needed to weather the storm that

is academic research. Your passion for fostering student development, excitement for

exploring uncharted academic territory, and knowledge of all things statistical make you

a wonderful mentor. If, one day, my mentees have half the complimentary things to say

about me as I could say of you, I will consider it a great success.

In addition, I would like to thank my committee members, Lynn Darby, Dryw

Dworsky, and William O’Brien for their thoughtful comments during proposal and

defense meetings that served to improve the quality of this project.

I would also like to thank my family and friends around the world for their

support during my tenure in graduate school. Cards and Skype calls from afar made a

huge difference in my life as a graduate student; thank you. I am also fortunate to have

the support of an exceptional cohort of colleagues and friends, whose presence was

invaluable to maintaining my mental and physical health during this process.

Finally, I would like to thank my future husband, Tyler Clark, for both everything

you did and for everything you did not even know you did to support me during this

process. I could not have done this without you.

 vi

TABLE OF CONTENTS

Page

INTRODUCTION…………………………………………………………………….…..1

Research Questions and Hypotheses…………………………………………….10

Study I…………………………………………………………...……….10

Research Question 1……………………………………………..10

Hypothesis 1……………………………………………………...11

Study II…………………………………………………………………...11

Research Question 2……………………………………………..11

Hypothesis 2……………………………………………………...11

Research Question 3……………………………………………..11

Hypothesis 3……………………………………………………..11

Research Question 4……………………………………………..11

Hypothesis 4……………………………………………………..11

METHOD….………………………………………………………………...………..…12

Participants………………………………………………………………………12

Study I……………………………………………………………………12

Study II…………………………………………………………………...13

Measures…………………………………………………………………………13

Study I and Study II……………………………………………………...13

Demographic Information………………………………………..13

Ecological Momentary Assessment……………………………...13

 vii

Food Frequency Questionnaires…………………………………14

Study II Only……………………………………………………………..14

Theory of Planned Behavior Variables…………………………..14

Behavioral Intention………………………………...……15

Subjective Norms………………………………...………15

Attitudes…………………………………………….……15

Perceived Behavioral Control ………...…………………15

Fidelity………………………………………………...…16

Procedure……………………………………………………………...…………16

Study I……………………………………………………………………16

Study II…………………………………………………………………...17

RESULTS………………………………………………………………………………..19

Demographics………………………………………………………………...….19

Analyses………………………………………………………………………….21

Reliability Analyses……………………………………………..……….21

Study I………………………………………………………………...….22

Research Question 1……………………………………………..22

Study II………………………………………………………………..….23

Research Question 2……………………………………………..23

Research Question 3……………………………………………..25

Research Question 4………………………………………….….27

DISCUSSION……………………………………………………………………….…...29

REFERENCES….…………………………………………………………...…...…..….38
 viii

Appendix A: Study I Recruitment Letter. ...…………….………...………….............…52

Appendix B. Study I Consent Form….………..………….…...........……...……...….…54

Appendix C. Study II Recruitment Letter, Soccer.…………...........…........………...….56

Appendix D. Study II Consent Form, Soccer.…….…...….....……...........……..….…...58

Appendix E: Study II Recruitment Letter, Basketball…….……..…….............…....….60

Appendix F: Study II Consent Form, Basketball. ………….............................…….….62

Appendix G: Demographic Variables Assessed.……..…....………...................…….…64

Appendix H: EMA Measures.……… …………….……….....…………..........……..…65

Appendix I: Food Frequency Questionnaire…..………………..….....………...........…66

Appendix J: Pre- and Post- Workshop, and Follow-Up Measures for Study II…...........67

Appendix K: Fidelity Questions. ...…………………….………….....………...........….71

Appendix L: Workshop Protocol….………………...…………….....………............…72

 ix

LIST OF TABLES

Table Page

1 Demographics of participants ……………………………...…………......….….20

2 Cronbach’s Alpha and Mean (SD) of Theory of Planned Behavior measures…..21

3 Mean (SD) of child consumption frequencies for each day designation based on

EMA report……………………………………………………………………....23

4 Mean (SD) of child consumption frequencies based on food frequency

questionnaire report……………………………………………………………...23
 x

LIST OF FIGURES

Figure Page

1 Theoretical relationship between TPB variables…………...…………........….….5

2 Observed direct and indirect relationships between TPB variables.……………..25

3 Participant reported TPB levels over time.……………………………………....26

HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 1

INTRODUCTION

A report from the Sport and Fitness Industry Association (SFIA) estimated that

21.5 million children between the ages of 6 and 17 participate in at least one youth sport

(Kelley & Carchia, 2013). The authors also reported data collected by Sabo and Veliz,

(2008), which put the estimate at 28.7 million children, or approximately 72% of the

39.82 million students age 8 to 17 in 2011. Though these estimates vary, it is clear that

the majority of children in the United States are involved in youth athletics.

As summarized by the position statement of the American Alliance for Health,

Physical Education, Recreation and Dance, participation in youth sports has possible

physical, psychological, academic, and social benefits (Blom, Bronk, Coakley, Lauer, &

Sawyer, 2013). The authors highlight gains in skills across these areas, including

development of social and conflict resolution skills, problem solving and emotion

regulation, and increased cognitive functioning and school performance (Blom et al.,

2013). Additionally, the physical benefits of youth sport participation include increases in

stamina, strength, flexibility, coordination, and cardiorespiratory functioning (Blom et al.,

2013). Based on this review, it is clear that athletic participation is expected to have many

benefits. Perhaps surprisingly, then, literature on the health benefits of youth athletics is

mixed. Cross-sectional research has demonstrated that participation in a team sport

predicts lower Body Mass Index (BMI; Shea, Shaver Heeney, Goy, & Randall Simpson,

2010), yet other research has found no effect of youth sport on weight status (Nelson et

al., 2011). The impact of sports participation on weight is important to consider because

although youth sports participation is highly prevalent, so is childhood obesity. In fact,

childhood obesity rates tripled between 1980 and 2002, and recent estimates show that
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 2

nearly 17% of the nation’s population of children ages 2-19 is obese (Centers for Disease

Control and Prevention, 2015a; Galson, 2008). Though Body Mass Index, a height to

weight ratio, is most often used to determine weight status for adults, children’s weight

status is determined using BMI percentile, which better accounts for gender and age

(Centers for Disease Control and Prevention, 2015b). Children under the 5th percentile

are considered underweight; from the 5th to less than the 85th percentile are considered

healthy weight; from the 85th percentile to less than the 95th percentile are considered

overweight; and in the 95th percentile or greater are considered obese (Centers for

Disease Control and Prevention, 2015b). A rise in sedentary behavior, combined with

increased availability of high-calorie, low-nutrient foods and beverages, as well as an

increase in consumption and snacking rates, have all been implicated in the rise of

childhood overweight and obesity (Jahns, Siega-Riz, & Popkin, 2001; Popkin & Duffey,

2010; Schwartz & Brownell, 2007).

Children who are engaged in youth sport are more physically active than their

non-athlete peers (Nelson et al., 2011), and add about 30 minutes of moderate to vigorous

activity to their total level of activity on sport-days as compared to non-sport days

(Wickel & Eisenmann, 2007). This increase in activity is a benefit from an obesity

prevention and health promotion standpoint (Galson, 2008). However, concerns have

been raised over the intensity level of energy expenditure in youth athletics, with critics

asserting that youth sport is less physically demanding than many people assume (see:

Bergeron, 2007; Wickel & Eisenmann, 2007). So, though youth athletes are more active

than their non-athlete peers, the amount of benefit they receive from being physically

active has been called into question.

HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 3

An additional health concern related to participation in youth athletics is caloric

consumption. Although one study found that overall, young athletes have better eating

habits than non-athletes; for example, “sport-involved youth generally ate breakfast more

frequently and had higher mean protein, calcium, iron, and zinc intakes than their non-

sport-involved peers” (Croll et al., 2006, pg. 714), other studies have found more

concerning trends. For example, although researchers found that youth athletes consume

more milk, fruit, and vegetables than their non-athlete peers, they have also found that

youth athletes are likely to drink more sugar-sweetened beverages, and consume more

fast food and more calories overall than their non-athlete peers, leading the authors to

question the health benefits of youth athletics (Nelson et al., 2011). Other researchers

have made similar claims; Kelly and colleagues (2008) found that concessions stands at

sporting venues and swimming pools sold mostly unhealthy foods. They suggested that

these concessions lead children to receive inconsistent health messages, “with healthy

lifestyles being promoted through sports participation, but unhealthy dietary choices

being provided” (Kelly, Chapman, King, Hardy, & Farrell, 2008, pg. 226; see also: Kelly

et al., 2010). Further, few youth sport organizations have a written policy on healthy

eating; written policies tend to be correlated with increased healthy food intake in

afterschool activities (Ajja, Beets, Huberty, Kaczynski, & Ward, 2012).

Nutrition is important for young athletes, not only for performance, but also to

ensure healthy growth and development. Foods that contain whole grains, fruits,

vegetables, and milk, as well as adequate protein to support growth, are recommended for

young athletes (Burke, 2007; Meyer, O’Connor, & Shirreffs, 2007). Despite the messages

of advertisers, research suggests that it is unnecessary for youth athletes to consume post-
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 4

workout snacks (Rosenbloom, 2012; Wagner, 2009). Some research suggests that total

fluid volume intake is more important than content for this age group (Rowland, 2011).

However, a recent meta-analysis suggests that it is unnecessary and inadvisable for

children to drink energy or sports drinks during or after a workout, but that consumption

of water is important to prevent dehydration (Schneider & Benjamin, 2011). Indeed, the

authors state that “rigorous review and analysis of the literature reveal that caffeine and

other stimulant substances contained in energy drinks have no place in the diet of

children and adolescents. Furthermore, frequent or excessive intake of caloric sports

drinks can substantially increase the risk for overweight or obesity in children and

adolescents” (Schneider & Benjamin, 2011, pg. 1182). Therefore, although participating

in youth athletics provide many benefits, it also may bring health risks due to the

frequency of consumption of high caloric foods and beverages.

Past research suggests that coaches, parents, and children receive little training in

nutrition, weight management, or physical needs of youth athletes (Harris & Foltz, 1999;

Muhammad, Omar, Shah, Muthupalaniappen, & Arshad, 2008; Torres-McGehee et al.,

2012; Venter & Harris, 2009). Coaches, parents, and athletes are also subject to a wealth

of advertising promoting products that claim to be integral to success (Bragg,

Yanamadala, Roberto, Harris, & Brownell, 2013; Emond, Sargent, & Gilbert-Diamond,

2015; Wilson & Sparks, 1996), social norms that promote unhealthy eating practices (e.g.

team pasta dinners; Gould, Collins, Lauer, & Chung, 2007; Senécal, Loughead, &

Bloom, 2008), and unique time and convenience demands fostered by hectic game and

practice schedules (Harwood & Knight, 2009; Legg, Wells, & Barile, 2015). The

combination of these factors facilitates unhealthy eating patterns for youth athletes, and
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 5

creates an environment ripe for intervention.

One way to conceptualize the factors contributing to a youth athlete’s

consumption of unhealthy and unnecessary foods and beverages is through the Theory of

Planned Behavior (TPB). Ajzen (1991) proposed that behavior is best predicted by an

individual’s intention, which is a function of attitudes, subjective norms, perceived

behavioral control, and the interaction of these variables (See Figure 1).

Figure 1: Theoretical relationship between TPB variables.

Several studies have leant support for the use of the TPB with dietary variables. A

recent meta-analysis investigating the role of the TPB in dietary patterns found that

intention was most strongly related to attitudes, followed by perceived behavioral control
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 6

and subjective norms, and that the relationship between intention and behavior was

stronger than the relationship between perceived behavioral control and behavior

(McDermott et al., 2015). Another literature review and meta-analysis exploring the role

of TPB in children’s eating behaviors found that the TPB was most often used to assess

healthy eating and sugary snack and beverage consumption, and found similar

relationships between attitudes and intentions and intentions and behavior (Riebl et al.,

2015; see also: Murnaghan et al., 2010). This review also highlighted three interventions

that used the framework of TPB to successfully improve eating behaviors, particularly

with the use of implementation intentions, which are statements in if-then format that

specify when and how a behavioral goal will be enacted (Gratton, Povey, & Clark-Carter,

2007; Karimi-Shahanjarini, Rashidian, Omidvar, & Majdzadeh, 2013; Tsorbatzoudis,

2005; Wieber, Thürmer, & Gollwitzer, 2015). A separate review of interventions

targeting adolescent and young adult eating behavior using the Theory of Planned

Behavior (10 studies) and Theory of Reasoned Action (essentially, the TPB without

perceived behavioral control; one study) found that nine of eleven studies created dietary

behavior change attributable to the intervention (Hackman & Knowlden, 2014). Clearly,

the TPB has demonstrated efficacy in changing dietary behavior among children.

Although intention, attitude, and perceived behavioral control have been used to

predict healthy behaviors (Conner, Norman, & Bell, 2002), a recent study assessing

sedentary behavior found social norms to be the strongest predictor of unhealthy

behavior, suggesting that perhaps the aspects of the model work differently for healthy

and unhealthy behaviors (Prapavessis, Gaston, & DeJesus, 2015). A study by Dunn,

Mohr, Wilson, & Wittert (2011) found that the TPB predicted fast food consumption, and
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 7

that immediate needs (e.g. convenience) override concern for long-term health risks in

predicting this behavior.

Another factor that has been implicated in unhealthy behavior is the role of social

norms. A recent review of the influence of social norms on eating behavior asserted that

social norms impact both food choice and portion size, particularly if an individual shares

an identity with the norm referent group and the appropriate behavior is unclear (Higgs,

2015). This is particularly important in the world of youth athletics, where group

cohesion tends to be strong (Eys, Lougheed, Bray, & Carron, 2009). A separate review of

socially facilitated eating explained the mechanisms behind this process; relevant to the

present research is the mechanism of disinhibition, which normalizes or provides

permission for the chosen food and portion (Herman, 2015). Therefore, social norms are

one factor that influences unhealthy eating and habits.

Fortunately, social norms can work not only to facilitate unhealthy eating and

habits, but also healthy eating and habits. A recent meta-analysis examining the role of

eating norms on behavior found that both high- and low-intake eating norms impacted

consumption, food choice and quantity of food consumed (Robinson, Thomas, Aveyard,

& Higgs, 2014), highlighting the importance of including norms in intervention research.

Social norms have been found to consistently predict healthy eating and physical activity

independent of social support (Ball, Jeffery, Abbott, McNaughton, & Crawford, 2010).

Another study examined the role of social forces in healthy eating, and found that

perceived social support moderated the relationship between perceived behavioral control

and intention, and between attitude and intention to eat healthy (Povey, Conner, Sparks,

James, & Shepherd, 2000). The study also found that subjective norms (i.e. how we think
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 8

valued others expect us to behave) increased intention to eat healthy, but descriptive

norms (i.e. how we think others are behaving) had no effect. These results suggest that

interventions focusing on the increasing social support or perceptions thereof, and

addressing social norms may impact healthy eating behavior.

Although TPB is valuable as a basic model, research suggests that it does not

fully account for human behavior and must be considered in the context of other

important factors. For example, recent research has combined the Theory of Planned

Behavior with other theories and models to predict health related behaviors. One

approach combined the TPB with self-determination theory and the health action process

approach to predict consumption of fruit and vegetables, breakfast, and snacks (Girelli,

Hagger, Mallia, & Lucidi, 2016). Another study found that high stress levels decreased

the effects of subjective norms and perceived behavioral control on intention for healthy

and unhealthy eating intentions (Louis, Chan, & Greenbaum, 2009). These examples and

other similar research suggest that although several studies have impacted behavior by

directly affecting TPB processes– that is, changing attitudes, subjective norms, and

perceived behavioral control – there may be other ways to achieve these goals.

For example, mindfulness has been found to act as a moderator between intention

and behavior in the TPB model, and thus is a useful component in interventions

(Chatzisarantis & Hagger, 2007). Acceptance-based approaches have been demonstrated

to be useful for weight loss (Niemeier, Leahey, Reed, Brown, & Wing, 2012; Tapper et

al., 2009), particularly when internal experiences are powerful determinants of behavior

(Forman & Butryn, 2015), and when the food is readily available (Forman et al., 2007).

These approaches are thought to be effective because of the focus on building awareness
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 9

of one’s behavior, tolerance of distress created by internal experiences, and clarifying

values to motivate behavior (Forman, Butryn, Hoffman, & Herbert, 2009).

Acceptance and Commitment Therapy (ACT) is a third-wave cognitive-

behavioral therapy that aims to help people align their behavior with their values (Harris,

2009; Hayes, Strosahl, & Wilson, 2012). ACT uses six interconnected core processes—

mindfulness (i.e. present moment awareness), defusion (i.e. detachment from thoughts),

acceptance (i.e. openness to experience), self-as-context (i.e. the observing self), values

(i.e. what really matters), and committed action (i.e. behavior consistent with values)— to

increase psychological flexibility (Harris, 2009; Hayes et al., 2012). Psychological

flexibility is defined as “the ability to be in the present moment with full awareness and

openness to our experience, and to take action guided by our values” (Harris, 2009; pg.

12). Rather than changing internal experiences (i.e. thoughts and emotions), ACT

proposes that individuals can pursue a valued life while at the same time recognizing and

accepting their internal experiences. For example, a youth sport parent who values health

may select to bring orange slices for their child’s team, even though the parent may be

experiencing unpleasant emotions (e.g. guilt, anxiety) and thoughts (e.g. “My child will

be upset that I didn’t bring brownies. I hate making my child upset. I’m a terrible

parent.”). This parent is able to be aware of these internal experiences (mindfulness),

observe these thoughts (defusion), and experience these emotions (acceptance) as

separate from him/herself (self-as-context), and at the same time be aware of his/her

values (values) and behave in a way consistent with those values (committed action).

Therefore, an intervention based on ACT principles is focused on behavioral outcomes

based on what an individual values. These outcomes are specific goals—they can be
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 10

crossed off a to-do list— whereas the values are the guiding principle behind the action,

and are never “achieved,” but rather guide behavior in a particular way.

A number of research studies have demonstrated the effectiveness of this

approach in many health-related areas, including chronic pain (Hayes et al., 1999),

substance use disorders (Lee, An, Levin, & Twohig, 2015), and anxiety, depression,

addiction, and somatic health problems (A-Tjak et al., 2015), and smoking cessation

(Gifford et al., 2004; for additional research support for ACT, see Hooper & Larsson,

2015). Both conceptual and empirical support exists for using ACT to manage weight

(Forman et al., 2013, 2009; Katterman, Goldstein, Butryn, Forman, & Lowe, 2014; Lillis

& Kendra, 2014; Niemeier et al., 2012). To the author’s knowledge, no study has

assessed the impact of an ACT intervention on TPB variables and behavioral outcomes.

This research paper presents two studies that identified the need for, developed

and implemented, and assessed an ACT-based healthy eating intervention for youth

athletes ages 8-14. Given the important role that parents play in their child’s eating

(Costanzo & Woody, 1985), as has been done in past research, the intervention was

conducted with parents (see: Andrews, Silk, & Eneli, 2010).

Research Questions and Hypotheses

These studies explored the following research questions and tested the following

hypotheses:

Study I.

Research question 1. What are the eating patterns of youth athletes on different

types of sport days (game and practice) compared to non-sport days?

HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 11

Hypothesis 1. Consistent with prior research, it was expected that youth athletes

would engage in more unhealthy eating behaviors overall on sport days (game and

practice) compared to non-sport days.

Study II.

Research question 2. How do Theory of Planned Behavior constructs of

perceived behavioral control, subjective norms, attitudes, and intentions contribute to

parental feeding practices for youth athletes?

Hypothesis 2. TPB constructs were expected to have a moderate positive

relationship with parental feeding practices.

Research question 3. Does a brief one-hour ACT-based intervention with parents

have short- or long-term effects on perceived behavioral control, subjective norms,

attitudes, and intentions?

Hypothesis 3. It was expected that the intervention would have a significant effect

on TPB constructed in both the short (immediate) and longer (two month follow-up)

terms.

Research question 4. Can a brief one-hour ACT-based intervention with parents

improve eating habits for youth athletes?

Hypothesis 4. It was expected that the intervention would lead to healthier eating

behaviors for youth athletes (i.e. decreased consumption of sugar sweetened beverages,

sweets, and fast/fried foods).

HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 12

METHOD

Participants

Study I. Participants of this study included parents (N = 29) of youth travel soccer

players ages 8-14 years on single-gender teams. Travel teams were specifically targeted

upon recommendation from a participating soccer league due to the increased consistency

of participating members in these teams over recreation league play. This organization

noted that because travel teams run year-round, require a larger time commitment, and

are more competitive in nature than recreation league play, they typically draw from a

more stable base of participants.

Participants of this study were recruited in several ways. Youth soccer

organizations in northwest Ohio were contacted by the researcher to obtain permission to

recruit from their participants. Organizations that consented then directly distributed

recruitment materials to their families, and those interested in participating contacted the

researcher directly. Additionally, the researcher and research assistants recruited from

these organizations in-person during weekly practices, providing the opportunity for

parents to ask questions and arrange to participate. Further, university-wide campus

announcements about the study were distributed weekly via email. Finally, snowball

recruitment was attempted by the researcher asking all participants to share the

information about the study with other parents that might be interested in participating

(See Appendices A and B for recruitment materials).

All potential participants received letters describing the nature of the study,

requirements for participation, and risks and benefits of participating. Participants were

then asked to provide electronic informed consent to participate in the study. Participants
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 13

of Study I had the option to enter into a raffle for one of ten $25 [Link] gift cards.

One parent per child athlete was allowed to participate, and parents were instructed to

always respond about the same child. The Bowling Green State University Human

Subjects Review Board (HSRB) reviewed and approved all procedures prior to

recruitment.

Study II. Study II utilized the same recruitment procedures described above. Due

to a low response rate from youth travel soccer teams, recruitment was expanded to

include travel basketball teams. Thus, participants of this study (N = 31) included parents

of youth travel soccer and basketball players ages 8-14 years on single-gender teams.

Additionally, in an attempt to improve response rate, all participants who completed

Study II received $25 [Link] gift cards rather than entering a raffle. Although

multiple and various efforts were made to increase participation, the researchers were

unfortunately unable to recruit enough participants to utilize both a control and an

intervention group. Changes in recruitment procedures were reviewed and approved by

the Bowling Green State University Human Subjects Review Board (HSRB) prior to

recruitment (See Appendices C, D, E, and F for recruitment materials).

Measures

Study I and Study II. The following measures were used during both studies.

Demographic information. Demographic information about the participants and

their children were collected following consent procedures for Study I and Study II (See

Appendix G).

Ecological momentary assessment. EMA, or in-the-moment data collection

(Dunton & Atienza, 2009; Shiffman, Stone, & Hufford, 2008; Smyth & Stone, 2003), has
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 14

been supported in the literature to yield higher response rates and shorter latency of

response than traditional paper-and-pencil methods for food craving and intake

(Berkman, Giuliani, & Pruitt, 2014). EMA was used with parents in both Part I and Part

II to assess children’s eating behavior on sport (i.e. game and practice) and non-sport

days (See Appendix H).

Food frequency questionnaires. Food frequency questionnaires based on past

research (Kiefner-Burmeister, Hoffmann, Meers, Koball, & Musher-Eizenman, 2014)

were used to assess consumption behavior during collection of demographic information

and at follow-up for Study I (2 weeks after final EMA) and Study II (2 months after one-

hour workshop). Parents reported how often their child consumed a variety of food and

drink items over the past seven days using a 6-point Likert-style scale ranging from

“none” (1) to “more than once daily” (6). Items used in Study I and Study II were: sports

drinks, fast foods, candy/sweets, granola/sport/protein bars, vegetables, and fruit (See

Appendix I).

Study II only. In addition to those measures described above, participants of

Study II also completed the following measures immediately prior to and immediately

following the one-hour workshop, as well as at two months after the workshop (See

Appendix J).

Theory of Planned Behavior variables. Measures of behavioral intention,

subjective norms, attitudes, and perceived behavioral control in this study were based on

measures used in past research by Chatzisarantis and Hagger (2005). Other researchers

have also used these constructs to investigate youth sport dropout (Jeffery, Eys, Schinke,

& Lewko, 2008), assessment of parental intention to attend youth soccer games,
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 15

(Kaplanidou & Gibson, 2012), and cheating and social norms (Shields, Bredemeier,

LaVoi, & Power, 2005).

Behavioral intention. Behavioral intention was measured on a 7-point Likert-style

scale from “strongly disagree” (1) to “strongly agree” (7), and included six items

beginning with the following stems, “I intend to…,” “I plan to…,” “I am determined

to…,” “I can…,” “I will try to…,” and “I expect to…”, and ending with the target

behavior identified through Study I (i.e. providing homemade meals and snacks for my

child on game days).

Subjective norms. Subjective norms were measured on the same 7-point scale, and

included six items beginning with the following stems: “Others who are important to me

pressure me to…,” “Other people whose opinion I value would approve of my…,”

“Others I care about would want me to…,” “Other people who I admire would notice if

I…,” “Others who I respect would judge me if I did not…,” and “Others who are

significant in my life would care if I…” and ending with the target behavior, providing

healthy meals and snacks for my child on game days.

Attitudes. Attitudes in this study were measured using six adjective pairs on a 7-

point scale, in which the target behavior is stated (i.e. Providing healthy meals and snacks

for my child on game days is) and followed by a choice of the following adjective pairs:

good/bad, healthy/unhealthy, easy/difficult, practical/impractical, affordable/expensive,

and important/unimportant.

Perceived behavioral control. Perceived behavioral control was measured on a 7-

point Likert-style scale with five stems, “I feel in complete control over whether I…,” “It

is mostly up to me whether or not I will…,” “I have the power to…,” “I have the ability
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 16

to…,” and “I am completely in charge of…,” followed by the target behavior, and a sixth

item asking “How much control do you believe you have over…” measured on a scale

from “no control” (1) to “complete control” (7). For example, one item read: I feel in

complete control over whether I provide healthy meals and snacks for my child on game

days.

Fidelity. To ensure that each participant in Study II received the same information

as other participants during the one-hour informational workshop, participants completed

a short fidelity questionnaire following the workshop to assess for both content and

process (See Appendix K). Additionally, a graduate research assistant familiar with the

area of study attended the first five workshops, matched the protocol with the information

provided to participants, and provided in the moment feedback to the lead researcher to

ensure that the workshop was presented in its entirety.

Procedure

Study I. Upon providing informed consent to participate in the study, providing

demographic data, and responding to a food frequency questionnaire, parents were asked

to provide cell phone numbers to facilitate the Ecological Momentary Assessment (EMA)

procedures used in this study. Through use of EMA, parents were contacted 12 times

throughout the spring season and asked to respond to a series of questions about their

child’s eating behavior that day (See Appendix H). EMA occurred on a mix of non-sport

days, practice days, and game days. Parents were not informed ahead of time when these

assessments would take place; rather, they received text messages at 7 P.M. asking them

to complete the EMA survey for that day, and received a reminder at 9 P.M. to complete

the survey if they had not already done so. Though some research has found that parent
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 17

and child reports of child consumption are generally concordant (Persson Osowski,

Fjellström, Olsson, & Göranzon, 2012), other research has found significant

discrepancies in these reports (Thorn, DeLellis, Chandler, & Boyd, 2013). Therefore,

parents were informed that they could ask their child about their consumption that day to

improve accuracy of reporting. The purpose of this inquiry in Study I was to describe the

eating patterns of youth athletes, and identify any specific unhealthy behaviors (e.g. high

consumption of sweets) or risk factors (e.g. game days) that were targeted in the

informational workshop in Study II. Two weeks following the conclusion of the final

EMA, participants in Study I completed a follow-up food frequency questionnaire.

Study II. Participants in Study II underwent the same consent procedure

described above, and also provided demographic data, cell phone numbers, and

completed a food frequency questionnaire. Parents then scheduled an individual, one-

hour workshop with the lead researcher. Workshops were held at times and locations

convenient to participants, ranging from on the university campus to field- or courtside

during a soccer or basketball practice.

Each workshop began with participants completing several measures (See

Appendix J). Then, the interactive one-on-one workshop was conducted. This workshop

had several components. Following introductions, the primary researcher reviewed the

informed consent and confidentiality policies for participating in research, and provided

psychoeducation on the purpose of the workshop, as related to existing literature and

findings from Study I. This psychoeducation was aimed at impacting participants’

attitudes towards fast food consumption and intent to feed their children healthier diets.

Then, the researcher and participant discussed barriers to feeding youth athletes
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 18

healthfully, which included a discussion of subjective social norms and challenges to

acting contrary to these implicit behavioral rules. Social norms were framed as thoughts

that had become rules for behavior, and participants were led in a defusion exercise

(Harris, 2009) to increase flexibility around those thoughts. Next, participants and the

researcher discussed the role of values, and the impact that these can have in guiding

one’s behavior and evaluating thoughts through committed action (Miller, C’de Baca,

Matthews, & Wilbourne, 2001). Then, to improve perceived behavioral control,

participants were instructed in the creation of implementation intentions to concretely

identify one or two behavior changes they would like to make to feed their children more

healthfully, and thus engage in committed action (Wieber et al., 2015). Following the

creation of implementation intentions, participants were encouraged to stay committed to

the research project through the follow-up survey. Full text of the workshop script, which

was used as a guide and anchor for the lead researcher, but was not read word for word to

participants, is available in Appendix L. Parents completed post-test measures and

fidelity questions immediately following the workshop.

During the next eight weeks, parents received a series of 12 EMA text messages

and were asked to respond to a series of questions about their child’s eating behavior that

day (See Appendix H). As in Study I, parents were not informed in advance of when

these assessments would take place. Two weeks following the final EMA, parents were

asked to complete the TPB measures and food frequency questionnaire one final time

(See Appendices I and J).

HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 19

RESULTS

Demographics

Participants in these studies (Study I: N = 29; Study II: N = 31) were mostly

Caucasian, full-time employed, married women reporting about a male child. Median

income of the sample was $104,000 (Range: $42-255,000) for Study I and $97,500 for

Study II (Range: $17-175,000). Although the slight majority (51.7%) of parents in Study

I fell within a healthy weight range (BMI range 18.5-24.9), many (44.8%) fell within the

overweight (BMI 25-29.9) or obese (BMI ≥ 30) range (Centers for Disease Control and

Prevention, 2012). The majority of parents in Study II fell within the overweight/obese

range (54.8%; 38.7% healthy). The majority of children fell within a healthy weight

percentile for both Study I (75.9%; 20.7% overweight/obese) and Study II (54.8%, 29.1%

overweight/obese). See Table 1 for further demographic information. Across studies,

sports teams had an average of 11.3 games, held 16 mandatory practices, and held 8

optional practices, indicating 35.3 sport days. Teams had an average of 3.5 non-sport

days per week, for a total of 28 non-sport days. These data indicate that athletes are

involved in travel sports 63% of days during the season.

HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 20

Table 1. Demographics of participants.

Study I Study II
(N=29) (N=31)
Age, years M(SD) M(SD) M(SD)
Parent 43.1 (3.7) 40.4 (4.6)
Child 11.1 (2.1) 10.4 (1.9)
Gender % (N) % (N)
Parent
Father 24.1 (7) 12.9 (4)
Mother 75.9 (22) 87.1 (27)
Child
Boy 75.9 (22) 77.4 (24)
Girl 24.1 (7) 16.1 (5)
Race/Ethnicity
Parent
Caucasian, Non- 90.3 (28)
Hispanic/Latino
African American/
Black
Other 9.7 (3)
Child
Caucasian, Non- 93.5 (29)
Hispanic/Latino
African American/ 3.2 (1)
Black
Other 3.2 (1)
Body Mass Index/Percentile Range
Parent
Underweight 3.2 (1)
(BMI < 18.5)
Healthy Weight (18.5 51.7 (15) 38.7 (12)
to 24.9)
Overweight 24.1 (7) 25.8 (8)
(25 to 29.9)
Obese 20.7 (6) 29.0 (9)
(30 and above)
Child
Underweight 6.5 (2)
(<5th Percentile)
Healthy Weight (5th- 75.9 (22) 54.8 (17)
85th Percentile)
Overweight 6.9 (2) 19.4 (6)
(86-95th Percentile)
Obese 13.8 (4) 9.7 (3)
(>95th Percentile)
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 21

Marital Status
Married 96.6 (28) 71.0 (22)
Divorced/Separated 12.9 (4)
Single 3.4 (1) 12.9 (4)
Employment Status
Full-Time 58.6 (17) 74.2 (23)
Part-Time 24.1 (7) 16.1 (5)
Homemaker 17.2 (5) 6.5 (2)
Other 3.2 (1)
Children In Home
1 3.4 (1) 3.2 (1)
2 51.7 (2) 58.1 (18)
3 27.6 (8) 32.3 (10)
4 17.2 (5) 6.5 (2)
Note: Some percentages may not add up to 100 due to missing data.

Analyses

All analyses were conducted using the Statistical Package for Social Sciences

version 22 (SPSS 22) and the PROCESS macro (Hayes, 2013). Statistical significance

was set to a value of p < 0.05.

Reliability Analysis. Cronbach’s alpha reliability statistics were calculated for

each measure using data collected just prior to the workshop. Based on these results, one

item was removed from the norms measure (item 3), and one item was removed from the

attitudes measure (item 5), to improve the reliability of these scales. Reliability ranged

from moderate to high (See Table 2 for alpha values).

Table 2. Cronbach’s Alpha and Mean (SD) of Theory of Planned Behavior measures.

Cronbach’s Pre-Workshop Post-Workshop Follow-Up

Alpha (N=31) (N=31) (N=25)
Behavioral 0.921 5.8 (1.0) 6.5 (0.6) 6.4 (0.6)
Intention
Subjective Norms 0.693 (0.611) 3.9 (1.1) 4.2 (1.3) 4.3 (0.9)
Attitudes 0.641 (0.579) 5.8 (0.7) 6.3 (0.5) 5.7 (1.1)
Perceived 0.874 5.9 (0.9) 6.3 (0.7) 6.0 (0.6)
Behavioral Control
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 22

Note: Reliability calculated using Pre-Workshop values. Alpha values prior to removal of
items are written in parentheses. Behavioral Intention, Subjective Norms, Attitudes, and
Perceived Behavioral Control response options ranged from Strongly Disagree (1) to
Strongly Agree (7).

Study I.

Research question 1. What are the eating patterns of youth athletes on different

types of sport days (game and practice) compared to non-sport days? One-way analysis

of variance (ANOVA) using EMA data indicated that youth athletes consumption

patterns differed depending on day designation (i.e. practice, game, non-sport) for fast

food (F(2) = 8.6, p = 0.001), but not for consumption of sports drinks, sweets,

sport/energy bars, fruit, or vegetables. Paired samples t-tests indicated that youth athletes

consumed significantly more fast food on game days than practice days (t(21) = 3.4, p =

0.002) and on game days than non-sport days (t(24) = 4.4, p < 0.001). Specifically,

parents reported that their child consumes fast food on almost 70% of game days,

compared to about 30% on practice and non-sport days. Based on these results, fast food

consumption on game days was targeted most centrally during the Study II intervention.

Please see Table 3 for descriptive statistics related to these analyses. Paired sample t-tests

comparing consumption prior to and following conclusion of EMA collection based on

food frequency questionnaires indicated significant increase in fast food consumption

(t(25) = 2.5, p = 0.018) and decrease in consumption of sweets (t(25) = 4.7, p < 0.001)

across the eight weeks of Study I. See Table 4 for descriptive statistics related to these

analyses.
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 23

Table 3. Mean (SD) of child consumption frequencies for each day designation based on
EMA report.
Practice Game Non-Sport
Study I Study II Study I Study II Study I Study II
(N=48) (N=69) (N=62) (N=56) (N=123) (N=147)
Sports 0.21 0.14 0.37 0.39 0.23 0.17
drinks (0.38) (0.26) (0.34) (0.34) (0.28) (0.21)
Fast food 0.27 0.20 0.68 0.53 0.34 0.24
(0.41) (0.30) (0.37) (0.37) (0.34) (0.24)
Sweets 0.50 0.49 0.56 0.56 0.55 0.49
(0.44) (0.42) (0.43) (0.38) (0.34) (0.31)
Bars 0.36 0.22 0.17 0.11 0.13 0.10
(0.42) (0.36) (0.27) (0.26) (0.24) (0.26)
Fruit 0.86 0.85 0.79 0.87 0.97 0.78
(0.33) (0.34) (0.39) (0.30) (0.11) (0.30)
Vegetables 0.63 0.80 0.74 0.68 0.71 0.76
(0.41) (0.36) (0.38) (0.42) (0.25) (0.33)
Note: Mean frequencies also indicate percentage of type of day that a child consumed
the item, i.e. children consumed sports drinks on 21% of practice days in Study I. N’s
indicate number of responses per day designation in each study.

Table 4. Mean (SD) of child consumption frequencies based on food frequency

questionnaire report.

Study I Study II
Pre-Season Post-Season Pre-Workshop Post-Season
Sports drinks 2.4 (1.0) 2.5 (1.0) 2.5 (1.2) 2.4 (1.0)
Fast food 1.73 (0.7) 2.04 (0.8) 2.0 (0.7) 2.0 (0.7)
Sweets 4.0 (1.0) 3.5 (1.1) 3.4 (1.2) 3.6 (0.9)
Bars 2.6 (1.6) 2.3 (1.2) 2.9 (1.5) 1.9 (1.2)
Fruit 4.8 (0.9) 4.8 (1.0) 4.7 (1.3) 4.8 (1.3)
Vegetables 4.5 (1.2) 4.3 (1.2) 4.5 (1.4) 4.6 (1.6)
Note: Higher means indicate more frequent consumption. Response scale from “none”
(1) to “more than once daily” (6).

Study II.

Research question 2. How do Theory of Planned Behavior constructs of

perceived behavioral control, subjective norms, attitudes, and intention contribute to

parental feeding practices for youth athletes? The relationship between perceived

behavioral control, subjective norms, attitudes, intention, and parental feeding practices
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 24

(i.e. consumption of fast food on game days) was explored using Model 4 of the SPSS

PROCESS macro (Field, 2013; Hayes, 2013). Attitudes about providing healthy meals

and snacks on game days significantly predicted intention to engage in this behavior (b =

0.8, SE = 0.3, p = 0.0097), but subjective norms (b = 0.1, SE = 0.1, p > 0.05) and

perceived behavioral control (b = 0.2, SE = 0.2, p > 0.05) did not significantly predict

intention to provide healthy meals and snacks on game days. Intention did not

significantly predict fast food consumption on game days (b = -0.1, SE = 0.1, p > 0.05).

Perceived behavioral control and attitudes did not have significant direct effects

on fast food consumption on game days (b = -0.1, SE = 0.1, p > 0.05; b = -0.3, SE = 0.2,

p > 0.05), but subjective norms did have a significant direct effect on fast food

consumption on game days (b = 0.3, SE = 0.1, p = 0.0207).

Indirect effects on fast food consumption through intention were not significant

for perceived behavioral control (b= -0.1, CI [-0.2, 0.0]), subjective norms (b= -

0.0, CI [-0.1, 0.0], or attitudes (b= -0.1, CI [-0.4, 0.1]). Thus the model does not

support mediation of consumption of fast food on game days through intention. See Table

2 for descriptive statistics of these variables, and Figure 2 for a visual representation of

these relationships.
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 25

Figure 2. Observed direct and indirect relationships between TPB variables.

Note: * p<0.05, ** p<0.01; Values in parentheses indicate indirect effects. Attitudes had a
significant effect on intention, and subjective norms had a significant direct effect on fast
food consumption on game days.

Research question 3. Does a brief one-hour ACT-based intervention with parents

have short and/or long term effects on perceived behavioral control, subjective norms,

attitudes, and intentions? One-way ANOVAs indicated significant differences between

scores pre-workshop, immediately following the workshop, and at two-month follow up

for behavioral intention (F(2) = 10.8, p < 0.001), subjective norms (F(2) = 3.5, p =

0.038), attitudes (F(2) = 4.5, p = 0.016), and perceived behavioral control (F(2) = 4.5, p =

0.017). Participant report of behavioral intention and perceived behavioral control

significantly increased from pre-workshop to immediate follow-up (t(30) = 4.1, p <

0.001; t(30) = 2.2, p = 0.038), and this increase was maintained at two-month follow-up

(t(24) = 3.3, p = 0.003; t(24) = 2.1, p = 0.05). Participant report of subjective norms

increased from pre-workshop levels to two-month follow up (t(24) = 2.3, p = 0.029), and

participant report of attitudes increased immediately follow the workshop (t(30) = 4.7, p
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 26

< 0.001), and then fell to pre-workshop levels at two-month follow up (t(24) = 2.4, p =

0.023). See Table 2 for descriptive statistics for these variables, and Figure 3 for a visual

depiction of the outcomes.

Figure 3. Participant reported TPB levels over time.

6.5

Behavioral Intention
5.5

Perceived Behavioral
5 Control

Attitudes
4.5

Subjective Norms
4

3.5

3
Pre-Workshop Post-Workshop 2-Month Follow-Up

Note: Behavioral Intention and Perceived Behavioral Control significantly increased from
Pre-Workshop to Post-Workshop, and this increase was maintained at 2-Month Follow-
Up. Attitudes significantly increased from Pre-Workshop to Post-Workshop, but this
increase was not maintained at 2-Month Follow-Up. Subjective Norms increased from
Pre-Workshop to 2-Month Follow-Up.

Although all participants were given the chance to provide anonymous feedback

on the workshop, only two provided feedback. One participant stated, “Thank you for the

awareness and insight to this valuable part of my child athletes lives. A few small
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 27

changes have already gone a long way,” and the other wrote, “It would have been great to

have been offered recipes to help provide healthy options.” Anecdotally, participants

seemed engaged during the intervention, were open to trying the various strategies, and

indicated they found the information useful. Participant reported fidelity was between 92

and 100 percent overall for implementation of the intervention.

Research question 4. Can a brief one-hour ACT-based intervention with parents

improve eating habits for youth athletes? Consistent with Study I, one-way ANOVA

using EMA data indicated differences in youth athlete consumption dependent on day

designation. For Study II, these differences were found for fast food (F(2) = 9.2, p =

0.001) and sports drinks (F(2) = 7.4, p = 0.002), but not for sweets, sport/granola bars,

fruit, or vegetables. Follow-up with paired samples t-tests indicated that children

consumed more sports drinks on game days than on practice days (t(18)= 2.6, p = 0.016)

and more on game days than on non-sport days (t(20) = 3.4, p = 0.003). Similarly, and

consistent with Study I, children also consumed more fast food on game days than

practice days (t(18) = 3.8, p = 0.001) and on game days than on non-sport days (t(20) =

3.3, p = 0.004). See Table 3 for descriptive statistics of these variables.

Paired samples t-tests comparing food frequency questionnaire data from the

beginning of Study I and prior to the workshop in Study II found no significant

differences in consumption prior to either study (all p’s > 0.05). Similarly, analysis of

food frequency questionnaire data at the end of Study I and at follow-up for Study II also

found no significant differences in consumption (all p’s > 0.05). Comparison of pre-

workshop and follow-up data from food frequency questionnaires in Study II found that
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 28

consumption significantly decreased across the study for sport/protein/granola bars (t(24)

= 2.8, p = 0.010). See Table 4 for descriptive statistics related to these analyses.

Because no differences were found between participants in Study I and Study II

on the initial food frequency questionnaire, and because no concurrent control group was

available, comparisons between these groups were made to assess for intervention

effects. Paired samples t-tests were used to compare child’s consumption as reported by

EMA on each particular day designation (i.e. sports drinks on game days across time),

and consumption of each item overall (i.e. sports drinks on all days across time) in Study

I with Study II. Consumption of fruit on non-sport days significantly decreased from

Study I to Study II (t(25) = 3.0, p = 0.007). Overall consumption of fast food decreased

somewhat from Study I to Study II (t(26) = 1.6, p = 0.123); however, this difference was

not significant.
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 29

DISCUSSION

This paper presents the results of two studies that identified a need for, developed

and implemented, and assessed an ACT-based healthy eating intervention for parents of

youth athletes. Study I found that consumption of fast food was particularly high for

youth athletes on game days, supporting earlier research that calls into question the health

benefit of participating in youth athletics (Nelson et al., 2011), and identifying the target

behavior for intervention in Study II. Although the present intervention did not

significantly impact consumption of fast food on game days, consumption did decrease

somewhat across studies from 68% of game days in Study I to 53% of game days in

Study II. Consumption of fast food also decreased, although not significantly, on practice

days and non-sport days from Study I to Study II. Additionally, consumption of

sport/protein/granola bars did decrease for participants of Study II from pre-workshop to

follow-up. Together, these results suggest that parents in Study II may have made slightly

healthier choices for their children, perhaps indicating the potential that a targeted ACT-

based intervention could have on eating patterns. However, because some of these results

are based on analyses using a non-concurrent comparison group, further research is

needed to determine how to best impact youth athletes’ eating habits.

There are several possible explanations for why the intervention was not effective

in achieving the target decrease in fast food consumption. The present study may have

provided an insufficient dose of the intervention to produce a significant effect; therefore,

future studies should explore the effects of increased dosage, possibly including weekly

reminders or additional sessions. Additionally, it is possible that the process of the

intervention would be more effective if amended. For example, perhaps the intervention
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 30

would be more effective if delivered in a group format, specifically in a team format

supported by the leaders of the youth sports organization. Recent research has

demonstrated that change in social norms is the mechanism of change in group

intervention (Cruwys, Haslam, Fox, & McMahon, 2015), and that social norms play a

major role in eating behavior (Cruwys, Bevelander, & Hermans, 2015). Therefore, a

group or organizational level intervention would likely impact the existing social norms

and food culture in youth sport, providing one pathway to increase intentions to feed

children healthfully.

Further, it is possible that the content of the intervention, although well received

by participants, did not meet their individual needs. Due to self-selection into the

intervention, parents may have already had relatively healthy feeding practices for their

children, as evidenced by high levels of consumption of fruit and vegetables, making it

difficult to detect improvements in feeding patterns. Past research has suggested that

parent involvement in children’s selection of fast food leads to selection of less energy

dense choices (Wellard et al., 2014), so it is possible that children’s eating habits did

become more healthy, but that the measures used to assess improvement were not

sensitive enough to detect these differences. This possibility is supported by the observed

decrease in sport/protein/granola bars for Study II participants that may indicate that

parents were in fact providing their children with more homemade meals and snacks, but

that this change was not reflected in fast food consumption.

Also, the intervention included three of the six core processes of ACT (i.e.,

defusion, values, and committed action), so it is possible that the inclusion of the

remaining three processes (i.e. mindfulness, self-as-context, acceptance) may increase

HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 31

effectiveness. A recent meta-analysis of the components of ACT identified significant

positive effect sizes for acceptance, defusion, mindfulness, and values, as well as the

combination of multiple mindfulness components and of values with mindfulness when

compared with a control (Levin, Hildebrandt, Lillis, & Hayes, 2012). Therefore, though

all six ACT processes are interrelated, perhaps a more specific focus on each of these

core processes would better contribute to behavioral change. Additionally, measures

related to ACT-specific processes and outcomes, such as mindfulness (e.g., MAAS;

Brown & Ryan, 2003) and psychological flexibility (e.g., AAQ-II; Bond et al., 2011),

may be useful in identifying key intervention components and mechanisms of change.

Future studies are encouraged to broaden the scope of the intervention and assess the

impact of this broadening on psychological flexibility and behavioral outcomes.

An unexpected finding was that consumption of fruit on non-sport days decreased

significantly from Study I to Study II based on EMA data. Although fruit was not a target

of the intervention, it is important to note and examine this finding for several reasons.

First, because there were no differences found in initial feeding practices based on the

food frequency questionnaire, and in absence of another explanation, this result indicates

the possibility that the brief ACT-based intervention impacted children’s eating habits.

However, no differences were found at the end of each study in fruit consumption, so any

possible effects were short-lived. Second, however, this finding may highlight problems

with conducting Study I and Study II in different seasons. It is possible that decreased

fruit consumption was due to factors other than the intervention, such as the lower

availability of fruit in Fall, when Study II was conducted, as opposed to Spring, when

Study I was conducted. This highlights the importance of including a concurrent control
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 32

group in future research. Third, this finding may indicate a missed opportunity to focus

not only on decreasing unhealthy intake but also on increasing healthy eating habits or

maintaining those already present. Future studies should monitor both healthy and

unhealthy eating habits to most comprehensively monitor intervention effects.

Although the intervention did not have a significant effect on consumption of fast

food on game days, it was successful in decreasing consumption of sport/protein/granola

bars. Additionally, the intervention significantly increased behavioral intention and

perceived behavioral control immediately following the workshop and maintained this

increase at two month follow-up. Past research has cited perceived behavioral control and

intention as the best predictors of behavior (McDermott et al., 2015; Riebl et al., 2015);

and as such the increase in behavioral intention and control is promising in the context of

past literature.

However, although the present study influenced TPB components, it did not find

that TPB factors significantly predicted behavior, similar to prior literature

(Chatzisarantis & Hagger, 2005). Fishbein and Ajzen (2005) assert that interventions

based on the TPB generally focus on increasing individual intention to perform a

behavior they previously had little or no intention to perform, while interventions based

on Cognitive Behavioral Therapy focus more on helping an individual enact changes

based on a previously held intention. This is because the TPB is primarily a motivational

theory rather than a volitional theory (Chatzisarantis & Hagger, 2005). Based on this

literature, an intervention combining the TPB and ACT, a third wave Cognitive

Behavioral Therapy, might be uniquely suited to bridge this gap between intention and

behavior. The results of the present study suggest that future research could illuminate
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 33

further the relationship between the TPB variables and identify mechanisms to influence

behavior.

Subjective norms and attitudes about providing homemade meals and snacks on

game days were also impacted by the intervention. Subjective norms increased at two

month follow-up, indicating that participants felt that others in their life would approve of

and otherwise support their efforts to provide homemade meals and snacks. Attitudes

increased immediately after the workshop, meaning that participants thought providing

homemade meals and snacks was good, healthy, easy, practical, affordable, and important

significantly more than before the workshop. Interestingly, when analyzing the full TPB

model, attitudes were significantly related to intention, and subjective norms directly

predicted consumption of fast food on game days. Although the TPB has been

successfully used in prior research to improve eating habits when combined with

implementation intentions (Gratton et al., 2007; Karimi-Shahanjarini et al., 2013;

Tsorbatzoudis, 2005), some research suggests that the model may work differently for

unhealthy habits (Dunn et al., 2011; Prapavessis et al., 2015). Literature suggests that

unhealthy habits may be partiularly susceptible to social norms (Herman, 2015; Higgs,

2015), so it is unsurprising that subjective norms directly predicted fast food consumption

in the present study. This result, in combination with past research, suggests that

consumption of unhealthy foods may be more dependent on environmental and social

cues than on individual intentions, attitudes, and control. Unhealthy eating behavior

appears to be unplanned and heavily impacted by social norms, and perhaps additional

forces. These may include pressure from the youth athletes themselves, other parents, or

sponsors. Therefore, unhealthy eating behavior may be difficult to affect with individual
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 34

level interventions. Future research could explore the utility of interventions aimed

directly at modifying social norms and environmental cues; for example, by creating a

policy against unhealthy eating practices in a youth sport organization, providing healthy

options during tournaments and travel play, or regulating advertising and sponsorship

opportunities in youth sport.

Modification of parental eating behavior may also be an avenue to impact

children’s eating habits. A recent study of healthy eating found that parental influence

through descriptive norms (i.e. their own eating behavior) of fruit and vegetable

consumption was more important than what they told their child, highlighting the

importance of modeling particularly for healthy foods (Pedersen, Grønhøj, & Thøgersen,

2015). A separate study of 10-13 year olds found that subjective norms, attitudes, and

perceived behavioral control significantly predicted intention, which in turn significantly

predicted eating behavior (Hewitt & Stephens, 2007). Although parental feeding practices

did not impact this relationship, children’s perceptions of parental attitudes and wishes

towards healthy eating were related to children’s intake (Hewitt & Stephens, 2007).

These studies may highlight additional mechanisms of change that should be explored in

future research. For example, researchers could examine the influence of a parent guided

movement to feed youth athletes healthier diets, including parents providing healthy

meals and snacks during games or tournaments, or the influence of conducting

interventions on parent’s own food choices and eating habits would have on their child’s

eating. Parental involvement may be particularly useful as a mechanism in youth sport, as

many parents volunteer as coaches or referees, and all parents are involved at a basic

level for registration and transportation (Legg et al., 2015). Capitalizing on already
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 35

established organizational involvement may be another avenue towards engaging and

motivating parents towards healthy feeding.

Although this study provides valuable new insights into the eating habits of youth

athletes and the potential of an ACT intervention to improve these habits, there are

several limitations of the present research. Due to challenges in recruitment leading to a

small sample size, a concurrent control group was not used to assess for intervention

effects, and random assignment was not applied to participants. Rather, consumption

patterns of Study II participants were compared to Study I participants. It is possible that

differences in feeding patterns observed in these groups were due to temporal/seasonal or

other outside factors, and not related to the intervention.

Although future studies are encouraged to enroll larger numbers of participants

and randomize them into control and intervention conditions, it is worth emphasizing the

challenges inherent in recruiting this group of participants. As noted earlier, despite

intensive recruitment efforts for both studies that were multi-modal and supported by the

organizations, participation was low. Parents may lack insight into what their children are

actually consuming on a daily basis, and may not know what a healthy diet consists of for

the child. Even with this information, parents may not have considered these eating

patterns in comparison to ideal healthy eating patterns.

Another possibility is that participants did not share the researcher’s view that

their child’s eating habits were unhealthy because high levels of fast food consumption

have become normalized in youth sport culture. This is consistent with the result that

perception of social norms are a driving factor behind feeding children fast food. Social

norms may have also hindered in-person recruitment efforts and on-site intervention
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 36

attendance; perhaps parents experienced unpleasant emotions (e.g. shame,

embarrassment) when having to admit in front of others that they might need help feeding

their child a healthy diet. Finally, parents in general have significant and often competing

demands on their time and money (and this may be especially true of parents whose

children compete on travel sports teams), and thus are a difficult group with which to

conduct research. It is possible that parents values led them to allocate any available time

they may have had to attend the workshop to accomplishing other important daily tasks.

Additionally, the small sample size in the present study may limit the

generalizability of the findings to other populations, particularly those including

participants of more diverse backgrounds and lower SES. However, youth athletes

generally hail from higher SES families (Johnston, Delva, & O’Malley, 2007), so the

findings may generalize better to other youth athletes than to youth in general. The high

SES of the present sample also suggests that the choice to feed children fast food is

driven by factors other than cost, such as convenience and social norms. Therefore, the

format of this intervention may be particularly appropriate for the target population; as it

can be generally understood that parents whose children participate in youth athletics

have the financial means to choose healthier options, addressing cognitive and social

barriers may be key to impacting behavior.

Although the use of EMA with parents to assess children’s behavior was intended

to measure behavior in real time, and thus avoid some of the limitations of self-report

data (e.g., recall errors), it is possible that social or psychological pressures (e.g.

expectancy effects) influenced parental responding. Future studies assessing eating habits

should include a direct and observable measure of child’s behavior. For example, a study
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 37

could observe and record all the foods and drinks a child consumes during all-day

tournaments across the season, or during an intensive sports camp. Although collecting

data on directly observable behavior is ideal, the use of EMA in the present study

facilitated the collection of multiple data points across time at no cost to the researchers

and very little time demand from participants, and is therefore considered a strength of

the study.

Prior research has used TPB ratings collected from parents in regard to children’s

eating (Andrews et al., 2010), but the outcome in this study was parental behavior, not

child behavior, as is the outcome of the present study. To the author’s knowledge,

parental report of TPB has not previously been used to predict a child’s behavior.

However, because parents and other significant adults in a child’s life have a great deal of

control over that child’s eating (Costanzo & Woody, 1985), collecting TPB data from the

children themselves may not completely capture the forces driving their behavior,

particularly for younger children. However, it may supplement the information provided

by parents, so future research could consider collecting and analyzing data from parent-

child dyads.

In sum, this research presents evidence that youth sport participation is related to

high levels of consumption of fast food, and that a brief ACT-based intervention with

parents may have the possibility of improving youth athlete eating habits. Future research

in this area may illuminate both mechanisms driving these unhealthy habits and inform

design of effective healthy eating promotion programs and policies in youth sport.
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 38

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HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 52

APPENDIX A: STUDY I RECRUITMENT LETTER

Department of Psychology

Dear Soccer Club Parent:

As a graduate student in the Psychology Department at Bowling Green State University, I

am conducting a study on the eating habits of youth athletes. Therefore, I am recruiting
parents of children participating on teams with the Soccer Club (SC) to participate.
Parents may respond for only one child; however, an additional parent may participate if
more than one child is engaged with SC. The SC Board has approved this research,
however, your participation is completely voluntary and your decision to participate or
not will in no way affect your status with the club.

If you agree to participate, I ask that you visit the link below to an online survey. You
will first be asked to indicate your consent to participate, and then asked a short series of
demographic questions. You will be asked to provide your cellular phone number and
email address, with which the researchers will contact you twelve times during the
upcoming spring season with a series of seven short questions you can answer directly by
replying to the message or clicking the link contained therein. It is estimated that each
response will take less than three minutes.

All responses to these surveys are anonymous, and will be kept secure on a password-
protected computer. Individual responses will not be shared with the SC, however, a
summary of the results will be presented to the Board. Responses to open-ended
questions may be quoted or paraphrased in scientific writing, and will be reported
anonymously. Risk of participation is no greater than that experienced in daily life.

To thank you for your participation, you will have the option to enter your email address
into a raffle for a $25 [Link] gift card. There will be ten total prizes, so your
individual chances of winning will be approximately 1/6. Each response to the text
message and/or email survey will result in an additional entry into the drawing. You may
also provide your email address to receive a summary of the results of the study.

Please visit the following website if you are interested in participating:

[Link]

If you have questions about this study, please contact the Principal Investigator, Jenna
Marx, M.S., at (419) 327- 4306 or jmmarx@[Link]. You may also contact the project
advisor, Dr. Dara Musher-Eizenman, at (419) 372-2948 or mushere@[Link].
 HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 53

Additionally, you may contact the Chair of the Human Subjects Review Board, at (419)
372-7716 or hsrb@[Link], with questions about participant rights.

Thank you very much,

Jenna M. Marx, M.S.
Bowling Green State University

PLEASE KEEP THIS PAGE FOR YOUR RECORDS

BGSU HSRB - APPROVED FOR USE

IRBNet ID # _702203
EFFECTIVE __01/26/2015
EXPIRES __01/19/2016

206 Psychology Building 419-372-2301 [Link]/departments/psych

Bowling Green, Ohio 43403-0232 fax 419-372-6013
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 54

APPENDIX B: STUDY I CONSENT FORM

Department of Psychology

When you visit the online survey, this page will appear before you begin. If you
agree to participate, you will be asked to click a checkbox indicating consent.

I have been asked to participate in this research study on the eating habits of youth
athletes. I have been told what will occur during this study, including that I will be
contacted multiple times via text message and/or email and asked about my child’s eating
habits. I have been told that the risk of participation is no greater than that experienced in
daily life. This study will help psychologists understand the nutritional environment
youth athletes experience and contribute to education programs and policies to better
meet their nutritional needs.

Data from this study will mostly be reported as anonymous group data, and will
confidential. However, I consent that the researcher may quote or paraphrase my
responses in scientific writing. If this occurs, I have been informed that no identifying
information will be connected with the response. Data from this study will be stored on
the password protected computer of the primary researcher. After the study, please
remember to clear your internet browser and page history to protect your confidentiality.

My participation in this study is completely voluntary and I can stop participating at any
time. By signing this form, I am giving consent to participate in this study. Deciding to
participate or not will not impact my relationship with the Soccer Club or Bowling Green
State University in any way. I have the option to enter a raffle with a 1/6 chance of
winning a $25 [Link] gift card. Each response to the text message and/or email
survey will result in an additional entry into the drawing.

If I have comments, questions, or concerns about the study, I may contact the Principal
Investigator, Jenna Marx, M.S., at (419) 327- 4306 or jmmarx@[Link]. I may also
contact the project advisor, Dr. Dara Musher-Eizenman, at (419) 372-2948 or
mushere@[Link]. Additionally, I may contact the chair of the Human Subjects Review
Board, Bowling Green State University, at (419) 372-7716 or at hsrb@[Link] with any
comments, questions, or concerns about this study.

By clicking the box below, I agree to voluntarily participate in this research study. I agree
that the purpose of the study has been explained to me, that I understand that I will be
asked a number of multiple choice and short-answer questions, and that I will answer the
questions presented truthfully and to the best of my ability.
 HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 55

☐ I ag ree to participate in this research study.

BGSU HSRB - APPROVED FOR USE

IRBNet ID # _702203
EFFECTIVE __01/26/2015
EXPIRES __01/19/2016

PLEASE KEEP THIS COPY FOR YOUR RECORDS

206 Psychology Building 419-372-2301 [Link]/departments/psych
Bowling Green, Ohio 43403-0232 fax 419-372-6013
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 56

APPENDIX C: STUDY II RECRUITMENT LETTER, SOCCER

Department of Psychology

Dear Soccer Club Parent:

As a graduate student in the Psychology Department at Bowling Green State University, I

am conducting a second study on the eating habits of youth athletes ages 8-14. All soccer
club parents are eligible to participate regardless of whether or not you participated
in the first study. Therefore, I am recruiting parents of children participating on teams
with your soccer club to participate. Each parent may respond for only one child;
multiple parents in the household may participate if more than one child is engaged with
the soccer club. The soccer club board has approved this research, however, your
participation is completely voluntary and your decision to participate or not will in no
way affect your status with the club.

If you agree to participate, I ask that you follow the link below to sign the attached
consent form to indicate your consent to participate and provide general demographic
data. You will then attend one 30-minute workshop, where you will be asked to respond
to several surveys prior to and following the workshop, which will take approximately 30
minutes, for a total of 1 hour. You will also be asked to provide your email and cellular
phone number, with which the researchers will contact you twelve times during the
upcoming fall season with a series of short questions you can answer directly by clicking
the link provided. It is estimated that each response will take less than three minutes. At
the end of the season, you will be contacted via email and asked to complete a final
survey. Due to high demand, you may be asked to attend the workshop at the end of the
season. If this occurs, we ask that you complete a short survey and a series of questions
during the fall season prior to attending the workshop.

All responses to these surveys are anonymous, and will be kept secure on a password-
protected computer. Individual responses will not be shared with the soccer club;
however, a summary of the results will be presented to the Board. Responses to open-
ended questions may be quoted or paraphrased in scientific writing, and will be reported
anonymously. Risk of participation is no greater than that experienced in daily life.

To thank you for your participation, you will receive a $15 [Link] gift card for
attending the workshop, and another $10 if you complete the follow up survey. You may
also provide your email address to receive a summary of the results of the study.

Please visit the following website if you are interested in participating:

[Link]
 HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 57

If you have questions about this study, please contact the project advisor, Dr. Dara
Musher-Eizenman, at (419) 372-2948 or mushere@[Link]. Additionally, you may
contact the Chair of the Human Subjects Review Board, at (419) 372-7716 or
hsrb@[Link], with questions about participant rights.

Thank you very much,

Jenna M. Marx, M.S.
Bowling Green State University

PLEASE KEEP THIS PAGE FOR YOUR RECORDS

BGSU HSRB - APPROVED FOR USE

IRBNet ID # _702203
EFFECTIVE __09/10/2015
EXPIRES __01/19/2016

206 Psychology Building 419-372-2301 [Link]/departments/psych

Bowling Green, Ohio 43403-0232 fax 419-372-6013
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 58

APPENDIX D: STUDY II CONSENT FORM, SOCCER

Department of Psychology

When you visit the online survey, this page will appear before you begin. If you
agree to participate, you will be asked to click a checkbox indicating consent.

I have been asked to participate in this research study on the eating habits of youth
athletes. I have been told what will occur during this study, including that I will be
contacted multiple times via text message and/or email and asked about my child’s eating
habits. I have been told that I will be asked to attend a 1-hour workshop in person at the
beginning or end of the fall soccer season. I have been told that the risk of participation is
no greater than that experienced in daily life. This study will help psychologists
understand the nutritional environment youth athletes experience and contribute to
education programs and policies to better meet their nutritional needs.

Data from this study will mostly be reported as anonymous group data, and will
confidential. However, I consent that the researcher may quote or paraphrase my
responses in scientific writing. If this occurs, I have been informed that no identifying
information will be connected with the response. Data from this study will be stored on
the password protected computer of the primary researcher. After the study, please
remember to clear your internet browser and page history to protect your confidentiality.

My participation in this study is completely voluntary and I can stop participating at any
time. By signing this form, I am giving consent to participate in this study. Deciding to
participate or not will not impact my relationship with the Soccer Club or Bowling Green
State University in any way. I will receive a $15 [Link] gift card for attending the
workshop, and another $10 if I complete the follow up survey.

If I have comments, questions, or concerns about the study, I may contact the Principal
Investigator, Jenna Marx, M.S., at (419) 327- 4306 or jmmarx@[Link]. I may also
contact the project advisor, Dr. Dara Musher-Eizenman, at (419) 372-2948 or
mushere@[Link]. Additionally, I may contact the chair of the Human Subjects Review
Board, Bowling Green State University, at (419) 372-7716 or at hsrb@[Link] with any
comments, questions, or concerns about this study.

By clicking the box below, I agree to voluntarily participate in this research study. I agree
that the purpose of the study has been explained to me, that I understand that I will be
asked a number of multiple choice and short-answer questions, and that I will answer the
questions presented truthfully and to the best of my ability.
 HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 59

☐ I agree to participate in this research study.

PLEASE KEEP THIS COPY FOR YOUR RECORDS

BGSU HSRB - APPROVED FOR USE

IRBNet ID # _702203
EFFECTIVE __09/10/2015
EXPIRES __01/19/2016

206 Psychology Building 419-372-2301 [Link]/departments/psych

Bowling Green, Ohio 43403-0232 fax 419-372-6013
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 60

APPENDIX E: STUDY II RECRUITMENT LETTER, BASKETBALL

Department of Psychology

Dear Basketball Team Parent:

As a graduate student in the Psychology Department at Bowling Green State University, I

am conducting a study on the eating habits of youth athletes ages 8-14. All parents of
basketball players ages 8-14 are eligible to participate. Therefore, I am recruiting
parents of children participating on basketball teams to participate. Each parent may
respond for only one child; multiple parents in the household may participate if more than
one child is engaged with the basketball team. The basketball team board has approved
this research, however, your participation is completely voluntary and your decision to
participate or not will in no way affect your status with the team.

If you agree to participate, I ask that you follow the link below to sign the attached
consent form to indicate your consent to participate and provide general demographic
data. You will then attend a one 1-hour workshop, where you will be asked to respond to
several surveys prior to and following a 30-minute interactive educational session. You
will also be asked to provide your email and cellular phone number, with which the
researchers will contact you twelve times during the upcoming basketball season with a
series of short questions you can answer directly by clicking the link provided. It is
estimated that each response will take less than three minutes. At the end of the season,
you will be contacted via email and asked to complete a final survey.

All responses to these surveys are anonymous, and will be kept secure on a password-
protected computer. Individual responses will not be shared with the basketball team;
however, a summary of the results will be presented to the board. Responses to open-
ended questions may be quoted or paraphrased in scientific writing, and will be reported
anonymously. Risk of participation is no greater than that experienced in daily life.

To thank you for your participation, you will receive a $15 [Link] gift card for
attending the 1-hour workshop, and another $10 if you complete the follow up survey.
You may also provide your email address to receive a summary of the results of the
study.

Please visit the following website if you are interested in participating:

[Link]

If you have questions about this study, please contact the project advisor, Dr. Dara
Musher-Eizenman, at (419) 372-2948 or mushere@[Link]. Additionally, you may
 HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 61

contact the Chair of the Human Subjects Review Board, at (419) 372-7716 or
hsrb@[Link], with questions about participant rights.

Thank you very much,

Jenna M. Marx, M.S.
Bowling Green State University

PLEASE KEEP THIS PAGE FOR YOUR RECORDS

BGSU HSRB –APPROVED FOR USE

IRBNet ID # 702203
EFFECTIVE __10/27/2015
EXPIRES __01/19/2016
206 Psychology Building 419-372-2301 [Link]/departments/psych
Bowling Green, Ohio 43403-0232 fax 419-372-6013
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 62

APPENDIX F: STUDY II CONSENT FORM, BASKETBALL

Department of Psychology

When you visit the online survey, this page will appear before you begin. If you
agree to participate, you will be asked to click a checkbox indicating consent.

I have been asked to participate in this research study on the eating habits of youth
athletes. I have been told what will occur during this study, including that I will be
contacted multiple times via text message and/or email and asked about my child’s eating
habits. I have been told that I will be asked to attend a 1-hour workshop in person at the
beginning of the basketball season. I have been told that the risk of participation is no
greater than that experienced in daily life. This study will help psychologists understand
the nutritional environment youth athletes experience and contribute to education
programs and policies to better meet their nutritional needs.

Data from this study will mostly be reported as anonymous group data, and will
confidential. However, I consent that the researcher may quote or paraphrase my
responses in scientific writing. If this occurs, I have been informed that no identifying
information will be connected with the response. Data from this study will be stored on
the password protected computer of the primary researcher. After the study, I have been
told to clear my internet browser and page history to protect my confidentiality.

My participation in this study is completely voluntary and I can stop participating at any
time. By signing this form, I am giving consent to participate in this study. Deciding to
participate or not will not impact my relationship with the basketball team or Bowling
Green State University in any way. I will receive a $15 [Link] gift card for
attending the 1-hour workshop, and another $10 if I respond to the text messages and
complete the follow up survey.

If I have comments, questions, or concerns about the study, I may contact the Principal
Investigator, Jenna Marx, M.S., at (419) 327- 4306 or jmmarx@[Link]. I may also
contact the project advisor, Dr. Dara Musher-Eizenman, at (419) 372-2948 or
mushere@[Link]. Additionally, I may contact the chair of the Human Subjects Review
Board, Bowling Green State University, at (419) 372-7716 or at hsrb@[Link] with any
comments, questions, or concerns about this study.

By clicking the box below, I agree to voluntarily participate in this research study. I agree
that the purpose of the study has been explained to me, that I have been informed that I
will be asked a number of multiple choice and short-answer questions, and that I will
answer the questions presented truthfully and to the best of my ability.

☐ I agree to participate in this research study.

 HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 63

PLEASE KEEP THIS COPY FOR YOUR RECORDS

BGSU HSRB –APPROVED FOR USE

IRBNet ID # 702203
EFFECTIVE __10/27/2015
EXPIRES __01/19/2016

206 Psychology Building 419-372-2301 [Link]/departments/psych

Bowling Green, Ohio 43403-0232 fax 419-372-6013
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 64

APPENDIX G: DEMOGRAPHIC VARIABLES ASSESSED

1. Please select your age.

2. Please select your child’s age.
3. Please select your child’s birthdate.
4. Please select your gender.
5. Please select your child’s gender.
6. Please select your marital status.
7. Please select your employment status.
8. Please select your annual household income.
9. Please select the number of children living in your home.
10. Please select your height.
11. Please select your weight.
12. Please select your child’s height.
13. Please select your child’s weight.
14. Please select your child’s height/weight percentile.
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 65

APPENDIX H: EMA MEASURES

1. Did your child drink a sports drink, energy drink, or soda/pop today?
a. Yes
i. If Yes, please specify:
b. No
2. Did your child eat fast food today?
a. Yes
i. If Yes, please specify:
b. No
3. Did your child eat candy, baked goods, or other sweets today?
a. Yes
i. If Yes, please specify:
b. No
4. Did your child eat a granola, sport, or protein bar today?
a. Yes
i. If Yes, please specify:
b. No
5. Did your child eat fruit today?
a. Yes
i. If Yes, please specify:
b. No
6. Did your child eat vegetables today?
a. Yes
i. If Yes, please specify:
b. No
7. Did your child eat a snack or drink a caloric-drink between meals?
a. Yes
i. If Yes, please specify:
b. No
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 66

APPENDIX I: FOOD FREQUENCY QUESTIONNAIRE

Please circle the answer choice that best fits your response:

1. Over the past seven days, how often did your child drink sports drinks, energy
drinks, or soda/pop?

Never Once 2-3 times 4-5 times Daily More than once daily

2. Over the past seven days, how often did your child eat fast food?

Never Once 2-3 times 4-5 times Daily More than once daily

3. Over the past seven days, how often did your child eat candy, baked goods, or
sweets?

Never Once 2-3 times 4-5 times Daily More than once daily

4. Over the past seven days, how often did your child eat granola, protein, or sport
bars?

Never Once 2-3 times 4-5 times Daily More than once daily

5. Over the past seven days, how often did your child eat fruit?

Never Once 2-3 times 4-5 times Daily More than once daily

6. Over the past seven days, how often did your child eat vegetables?

Never Once 2-3 times 4-5 times Daily More than once daily
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 67

APPENDIX J: PRE- AND POST- WORKSHOP, AND FOLLOW-UP MEASURES

FOR STUDY II

Please circle the answer choice that best fits your response:

1. I intend to provide homemade meals and snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

2. I plan to provide homemade meals and snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

3. I am determined to provide homemade meals and snacks for my child on game

days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

4. I can provide homemade meals and snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

5. I will try to provide homemade meals and snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

6. I expect to provide homemade meals and snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 68

Please circle the answer choice that best fits your response:

1. Others who are important to me pressure me to provide homemade meals and

snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

2. Other people whose opinion I value would approve of my providing homemade

meals and snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

3. Others I care about would want me to provide homemade meals and snacks for
my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

4. Other people who I admire would notice if I provide homemade meals and
snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

5. Others who I respect would judge me if I did not provide homemade meals and
snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

6. Others who are significant in my life would care if I provided homemade meals
and snacks for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 69

Please circle the number choice that best fits your response:

1. Providing homemade meals and snacks for my child on game days is:

BAD GOOD

1 2 3 4 5 6 7

2. Providing homemade meals and snacks for my child on game days is:

UNHEALTHY HEALTHY

1 2 3 4 5 6 7

3. Providing homemade meals and snacks for my child on game days is:

DIFFICULT EASY

1 2 3 4 5 6 7

4. Providing homemade meals and snacks for my child on game days is:

IMPRACTICAL PRACTICAL

1 2 3 4 5 6 7

5. Providing homemade meals and snacks for my child on game days is:

EXPENSIVE AFFORDABLE

1 2 3 4 5 6 7

6. Providing homemade meals and snacks for my child on game days is:

UNIMPORTANT IMPORTANT

1 2 3 4 5 6 7
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 70

Please circle the answer choice that best fits your response:

1. I feel in complete control over providing homemade meals and snacks for my
child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

2. It is mostly up to me whether or not I will provide homemade meals and snacks

for my child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

3. I have the power to provide homemade meals and snacks for my child on game
days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

4. I have the ability to provide homemade meals and snacks for my child on game
days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

5. I am completely in charge of providing homemade meals and snacks for my

child on game days.

Strongly Mostly Somewhat Neutral Somewhat Mostly Strongly

Disagree Disagree Disagree Agree Agree Agree

6. How much control do you believe you have over providing homemade meals and
snacks for your child on game days?

NO CONTROL COMPLETE
AT ALL CONTROL

1 2 3 4 5 6 7
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 71

APPENDIX K: FIDELITY QUESTIONS

Please circle Yes or No to answer the following questions. During the workshop, were
the following topics covered?

1. Your rights as a participant in a research study (i.e. informed consent,

confidentiality, right to withdraw).
2. The purpose of the study explained (i.e. to teach skills to parents to encourage
children's healthy eating).
3. The brain's job to keep you alive and think of possible outcomes (e.g. a lion in the
bushes).
4. How social norms influence behavior (i.e. by limiting your behavior choices).
5. Examining your thoughts as sounds (e.g. the milk exercise).
6. Examining your thoughts as helpful/unhelpful, rather than true/false (e.g. to stay
alive or win a game show).
7. Clarification of your values (e.g. Narrow down from a long list to 4-6).
8. Using your values as a compass to evaluate your thoughts and behaviors.
9. Creating implementation intentions (i.e. behavioral rules in IF-THEN format).
10. Evaluating the usefulness of implementation intentions (i.e. rating your
confidence on a scale of 0-100).

Please circle Yes or No to answer the following questions. During the workshop…
1. Did you have the chance to ask questions?
2. Did you have the chance to participate?
3. Was the information clearly presented?
4. Was the information presented tailored to your needs?
5. Did you learn skills you find useful now or could see as being useful in the
future?
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 72

APPENDIX L: WORKSHOP PROTOCOL

MATERIALS:
- Registration packets
- Pre-Workshop measures
- Post-Workshop measures
- Index cards
- Values card sort
- Pens
- Clipboards
- Chairs

OUTLINE
1. Arrival/Set-up/Pre-Workshop Measures
2. Welcome/Introductions
3. Informed Consent/Confidentiality
4. Purpose of the Workshop
5. Social Norms
6. Combating Social Norms
7. Defusion
8. Values
9. Implementation Intention/Committed Action
10. Thank You/Post-Workshop Measures/Next Steps

1. ARRIVAL/SET-UP/PRE-WORKSHOP MEASURES (5 MINUTES)

Arrive 15 minutes early for set-up. Greet participants as they arrive, and make sure they
have filled out the online registration information. If not, provide them with that question
packet. Then, ask them to fill out the pre-workshop measures. Let them know that they
should stop when they get to the stop sign in the packet, and complete the rest of the
packet at the end of the workshop. Allow enough time for participants to complete the
packet, then begin the workshop.

2. WELCOME/INTRODUCTIONS (2 MINUTES)
Facilitators should introduce him/herself. State name, year in program, and general area
of study. Also, briefly state past athletic history.

3. INFORMED CONSENT/CONFIDENTIALITY (2 MINUTES)

Before we get started, I would like to take a moment to talk about informed consent and
confidentiality. By registering for this workshop, you have given consent to participate in
this research project. Your participation is voluntary, and very much appreciated, so
thank you! I hope that we can both get a lot out of this project, so I hope you will stay
with it until the end of the season, but it is your right as a participant to withdraw at any
time.

Next, I would like to speak about confidentiality. Anything that you say during today’s
workshop is confidential, meaning it will stay in this room. Your responses to the
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 73

questions you just filled out, fill out at the end of the workshop today, and anything you
report across the season will be used in analysis, but the data will be anonymous and
linked only to your participant ID, which is your mobile phone number. My research
assistant inputs all the data, so I will not be able to identify your responses, even though
we met in person. Do you have any questions before we start? Okay, great. Now, let’s
get started!

4. PURPOSE OF THE WORKSHOP (3 MINUTES)

The purpose of today’s workshop is to teach you some skills that will help you to feed
your child a more healthy diet. While participating in sports is great for kids for a
number of reasons, research has shown that kids who participate in sports also eat more
junk food, fast food, and sweets, and drink more sugary drinks, particularly sports drinks,
than other kids. Does that resonate with your experience?

This workshop is the second part of a two part study. In the first study, parents and
coaches agreed that youth athletes drink too many sports drinks, and eat too much junk
food, fast food, and sweets. Parents reported feeding their children fast food on 70% of
game days, and based on their reports, the vast majority of this was not healthy. So there
is behavioral evidence from published research, from what the kids actually ate in the
first part of this study, and from what coaches and parents report.

So why is this a problem? Research also tells us that, unless a child is competing at an
elite level, sports drinks, extra snacks, and carbo-loading are not necessary. In fact, these
things can impair performance on the field and in school. Further, they can teach kids
unhealthy eating habits that they will carry with them later in life. Parents and coaches
both think that kids eat and drink too much junk, specifically in relation to playing a
sport. The vast majority of parents and coaches report wanting to provide healthy options
for their child or the team. Is that true for you?

5. SOCIAL NORMS (3 MINUTES)

While parents and coaches want to feed the athletes healthier, they also report several
barriers to doing so, leading parents to feed their kids less healthy than they really want.
What are a few examples of things that get in the way of your good intentions?

Your experience is similar to what prior research shows, and what other parents who
have done this workshop have reported to me. Things like time, convenience, and cost are
major factors that I’ve head and read about again and again. Later on, we are going to
talk about how to address some of these barriers, but I’d like to start with discussing one
that often goes unnoticed, which is called a social norm. Are you familiar with the
concept of social norms?

Just to make sure we are on the same page, let me explain what a social norm is. A social
norm is the usually acceptable behavior that you learn from watching what other people
do and their reactions to your own behavior. For example, bringing a post-game snack is
a social norm. Another way to think of this is a behavior that “most people” seem to do,
and might be odd not to do. Different teams and organizations have their own social
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norms. So if the norm is for the “snack mom” or “snack dad” to bring post-game
brownies, and you brought orange slices, you would be acting against the social norm.
Does that make sense?

6. COMBATING SOCIAL NORMS (2 MINUTES)

So, if it’s hard to even recognize social norms, you can imagine how difficult it would be
to work against them.. So that’s going to be Step 1 for us today- recognizing the social
norms that might lead you to act in one way, when you really want to act another way.
What social norms can you think of that exist for your child’s team? Can you think of
a way they have impacted your own behavior? (If needed, share the example of going
out for ice cream after a win, or attending a pasta dinner before a big game.)

7. DEFUSION (18 MINUTES)

Now that we have some ideas about what the social norms are, let’s talk a little more
about them. So you learn a social norm from seeing what other people do, and watching
their reactions to your own behavior. For example, you wouldn’t bring the oranges to the
game because of the reactions of the kids, other parents, and maybe even the coach.
Those things are happening in real time, you can see those reactions. But what about
when you’re at home before the game, thinking about what to bring? What prevents
you from preparing the oranges then, when nobody is around?

Interestingly, it’s still the social norm. Because even though you are not there at the
game getting feedback on your behavior, your mind can think about that situation and
come up with the consequences of your action. Even if it hasn't ever happened, your mind
can imagine the consequences. That’s an amazing thing about our human brains- they
have evolved over time to be really good at thinking about all the terrible things that
might happen in the future. This is what has kept us alive! Let me give you an example.
Imagine for a second that you’re a cave person. You’re out hunting for food. And you see
a group of trees off in the horizon, so you start walking towards it, hoping for something
to bring back and feed your family. As you get closer, you see what looks like a part of
the tree move. It’s too far away to tell what it is- so your brain leaps into action, and tells
you, “Run! It’s a lion! You’re going to die!” and so you run away. We don’t know what it
actually was that you saw- it could have been an antelope, or a gentle breeze moving the
leaves, or maybe even a trick of the sunlight. But your mind isn’t thinking about those
possibilities. It’s trying to keep you alive, so it is programmed to have you believe that all
of your thoughts are literally true. “There is literally a lion, run!” is going to have a
different outcome than, “Hmm, I wonder which of these possibilities made that
movement.” Our brains are still working this way today- which is sometimes helpful, and
sometimes not. Does that make sense so far?

So let’s come back to social norms. Your thought about the consequences, real or
imagined, of behaving contrary to the social norm, is actually the thing that’s changing
your behavior. Your mind might be thinking “Everyone is expecting me to bring
brownies. If I don’t, and bring oranges instead, my kids will be mad at me, other parents
will be mad at me, and it must be because I’m a terrible parent and my kids don’t love
me.” That’s not a pleasant thought, and brings up some unpleasant emotions with it,
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 75

right? That thought is the equivalent to “Run! It’s a lion! You are going to die!” because
your mind is treating it as literally true. Because we all want to avoid unpleasant
experiences, you listen to this thought, and because of it modify your behavior, even if
that is not what you really wanted to do. In this way, your thought becomes a behavioral
rule that you must follow. Still with me?

So, a social norm is a thought that our brain tells us is literally true. It’s scary, you
should avoid it. And because it is literally true, you don’t really have a choice in your
behavior, do you? You have to run away from the lion, you have to bring the brownies.
Your mind has complete control over your behavior!

In order to get back this control and choice, let’s take a closer look at thoughts. What is a
thought? A thought is just a string of words. And words are just strings of sounds. The
only reason they have any meaning is because we believe they do- because that is what
our minds tell us. Would you be willing to try a quick example?

Close your eyes, and think about milk. Bring an image to mind, if you can. Think to
yourself, all the different qualities that are associated with milk. Color. Texture. Flavor.
Temperature. Any emotions that might come to mind. People you associate with milk.
Time of day. What kind of container it comes in. What kind of glass is it in. What it looks
like when mixed in your coffee. What animal it came from. Where you found it at the
store. Where it lives in your refrigerator. Do you have a pretty good picture?

Okay, open your eyes. Now, we are going to do this next part together. Some people find
it a little silly, but I ask that you stick with it. Let’s say the word milk aloud. Say it again.
Say it super slow. Say it super fast. Now say it in a silly voice. Say it in a scary voice. Say
it as fast as you can for 30 seconds- go! Did you notice anything different after that
exercise?

What sometimes happens is that, when you first think of milk with your eyes closed, it’s
pretty easy to think of all the qualities of milk. But by repeating the word word over and
over in a bunch of ways and styles, eventually it loses its meaning, because you have
created space between the word and the meaning. This works with any word or image, so
I encourage you to try it at home with a thought you find gets stuck. Can you think of
how this relates to social norms? What do you think about using this method to help
feed your child healthier?

7. VALUES (15 MINUTES)

We agreed earlier that social norms are just thoughts, and that our mind automatically
assumes that every thought is literally true. But we know that not all thoughts are true,
right? Let’s try another example. If I asked you to think, “I can’t stand up,” you could
still stand up, right? So the thought is not literally true. But when we think about
thoughts, while we might want to evaluate not whether they are true or not true, it is
more important to evaluate whether they are helpful. Imagine you are on a game show,
and you would win a million dollars if you stay seated in your chair for a certain amount
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 76

of time. If I prompt you to think, “I can’t stand up” now, it’s still not true, right? You
could stand up if you wanted. But would it be helpful, and get you that million dollars?

So some thoughts keep us from doing what we think is right, like bringing the healthy
food to the game, and those are not helpful. Other thoughts can help us achieve our
goals, like winning the money in the game show, so those are helpful. And it doesn’t
matter, in both cases, whether or not the thought is literally true, it just matters if it is
helpful. So how can we tell if our thoughts are helpful or unhelpful?

This is where our values come in. Values are statements about what we want to be doing
with our life, about what we want to stand for, and how we want to behave. They are
what give our life meaning and purpose. And when we think about our values, we can use
them as a compass to help us evaluate our thoughts and choose our behaviors. Most
people have a vague sense of what their values are, so what we are going to do now is an
exercise to help you to clarify your values so you know how to tell if your thoughts are
helpful or unhelpful in guiding your behaviors towards living consistently with your
values.

Take a minute now, before looking at this paper, to think about some things that you
value. (Hand out values list.) Now, take a look at the common values listed here. Just
read through them all, and I’ll tell you what to do step by step as we go. Now, we are
going to try to narrow them down. I won’t be collecting this- it’s just for you to know
what your values are. There are no right and wrong answers. So now, go through and
cross off any that are definitely not important, or that you know are not most important.
Sometimes people feel bad crossing things off this list, but I encourage you to go along
with the process, and remember it doesn’t necessarily mean that you don't value that
thing, just that it’s not most important. Now, go through and circle any that are clearly
very important to you. Now, of those that you circled, cross off half that are less
important than the others. (Continue until 10-15 values are left.) Now, star about 5 of
those that are most important. It’s okay if you have four or six, but aim for that range.
(Hand out index cards.) On one side of the index card, please write your 5 core values.

9. IMPLEMENTATION INTENTION/ COMMITTED ACTION (5 MINUTES)

Take a look at your index card. Can you think of anything you would do differently this
week if you were to live more consistently with your values?

Now think about how you feed your child. How much does it align with your values?
How much is it driven by something other than your values- like convenience, or cost,
or social norms? Would you feed your child any differently?

What we are going to do now is to come up with something called an implementation

intention. An implementation intention is basically a behavioral rule that you make for
yourself to help you live more closely aligned with your values. These have been used and
widely supported by research in both increasing desired behaviors (e.g. exercise) and
decreasing undesired behaviors (e.g. smoking).
HEALTH KICK: HEALTHY EATING IN YOUTH SPORT 77

What it is is a simple sentence with a very specific structure. IF X event happens, THEN I
will perform Y behavior. For example, IF my child has a game, THEN I will be sure to
prepare a healthy snack the night before. Does that make sense?

Now let’s try to brainstorm how this might help you to feed you child more healthfully,
specifically on game days. What would help you accomplish that goal?

Now that we have identified behaviors that would help, please write up to three on the
reverse of your index card. The index cards are yours to keep. Research suggests that the
implementation intentions are most effective if you put it somewhere where you will see
them every day. On the one side of the index card, you have the behaviors you identified
in the implementation intentions, and the other, your values to remind you why you made
these rules in the first place.

The last step in creating a good implementation intention is to rate your confidence that
you could actually do those behaviors. If it’s too easy, we’ll think of a more challenging
change so we can actually have an impact, and if it’s too difficult, we want to either
change the intention or come up with an additional to supplement it and make it more
likely to happen so that you don’t get discouraged. How confident are you, on a scale
from 0 to 100, where 0 is not at all, and 100 is completely confident, that you could do
these behaviors next week? What about the next month?

10. THANK YOU, POST-WORKSHOP MEASURES, AND NEXT STEPS (5 MINUTES)

Today we talked about taking back control of your behavior by creating space from your
thoughts, evaluating them based on whether they were helpful or unhelpful, and
connecting with your values to make decisions. Then we created some simple rules to
help you achieve your goals. Do you have any questions about anything we talked about
today?

That’s all the information I have for you. Before you go, I ask that you please complete
the rest of the questions in your packet, and return the packet to me.

Remember, you will be receiving text messages throughout the season asking you to
respond to a series of short questions, so please do your best to complete as many as
possible. Even if you think you are not doing what you said you would do today, your
continued participation is very important to the study. I really want your honest answers!

You will also receive an email at the end of the season with a follow up survey. Thank
you again for your time and participation, I hope you learned something today that you
will use in the years to come!