Eating Competence and Dietary Quality in College Students - Thesis Example

Eating competence and dietary quality in college A thesis submitted to the Graduate School of the of Cincinnati in partial fulfillment of the requirements for the degree of Master of Science in the Department of Nutritional Sciences of the College of Allied Health Sciences at the University of Cincinnati by Steven Bernard Cryder B.S. Biology Cell/Molecular, University of Cincinnati, 2009 B.S. Neuroscience Neurobiology, University of Cincinnati, 2010 Summer 2015 Committee Chair: Sarah Couch, PhD. Abstract Background: While eating should be enjoyable to all people, for many individuals, it represents trouble. Sometimes people feel guilty whenever they eat what they should otherwise not have eaten. Objective: This paper presents a study on eating competence and dietary quality among college students. Design: The study is based on the Satter Eating Competence Model also known as the ecSatter model. The study uses the model, to depict that college students among other people are encouraged to have a positive feeling regarding their eating, becoming reliable about feeding themselves, eating the food they enjoy, and eating as much food as they want by letting their body weight reflect their respective endowment as well as lifestyles. The study considers the ecSatter model very useful in enhancing eating competence among college students. To achieve this, primary data had to be obtained. The primary study includes a number of participants ranging between 50 and 85 students. Only students who took the Personal Nutritional class of winter and spring 2012 are considered for the survey. Results: From the considered literature, it is established that the dietary quality in college students is largely affected by their eating behavior. In this regard, there is a positive relationship between eating competence and dietary quality. Acknowledgements I would like to thank my mom and dad, Dick and Joy Cryder for all their guidance and endless support over the years. Thank you also to my mentor and advisor Dr. Seung-Yeon Lee for challenging me every step of the way. Without your support, this would not have been possible. Table of Contents Abstract 2 Acknowledgements 3 Table of Contents 3 LITERATURE REVIEW 5 Outline 5 Eating Competence and Usefulness of the ecSatter Model 5 Eating competence 5 Usefulness of ecSatter Model 6 Eating Behavior and Dietary Quality in College Students 8 Positive Association between Eating Competence and Health 11 Disordered Eating (Restraint Eating) and Poor Dietary Quality in College Students 12 Introduction 15 Research Question 18 Hypothesis 18 Discussion 20 Gaps in the Research 20 Work Cited 21 LITERATURE REVIEW Outline 1. Eating competence and the usefulness of ecSatter Model 2. Eating behavior and dietary quality in colleges students 3. Positive association between eating competence and dietary quality 4. Disordered eating Eating Competence and Usefulness of the ecSatter Model Eating competence For most people, eating represents trouble. People feel guilty when they eat what they should not eat and deprived when they eat what they should eat. The main worry is weight. Research has shown that when the joy of eating goes out of eating, nutrition suffers. Positive behaviors in this regard are thus associated with dietary eating concerns such as reduced calorie intake (Contento et al., 2007, p.7). In ecSatter eating competence model, people are encouraged to feel positive about their eating, to be reliable about feeding themselves, and to eat the food they enjoy. Moreover, people are advised to eat sufficiently so that they can feel contented, and to let the body weigh what it will, depending on one’s lifestyle and genetic endowment. Instead of being expected to manage to eat by rules, ecSatter advises people to base their eating on the body’s natural processes: starvation and the drive to survive, appetite and the need for enjoyment, social remuneration of sharing food, and the tendency to sustain preferred as well as balanced body weight. Interventions that focus on goal setting are therefore associated with positive impacts (Contento et al., 2007, p.7). Studies have shown that people who are competent in eating are better nourished, have better body weights and have elevated HDLs and lower triglycerides and blood stress. Surprisingly, they are also healthier psychologically and socially. People with elevated eating competence feel more effectual. They are more self-conscious, more confidence as well as more comfortable both with themselves and the community, which aid in their eating competence strategies (Contento et al., 2007, p.7). Usefulness of ecSatter Model The intention is to help the nutritionist educator in preparing educational resources and carrying out programming consistent with the ethics of the ecSatter eating Competence Model. EcSatter does not try to inspire clients and tempt them to act in a certain way. On the contrary, the model regards healthy consumption to be a shared value in the hope that the clients will feel more educated and grow with the new understanding. For instance, the urge to make people realize the importance of feeling good about food could make them end up feeling good about what they eat and thus being reliable on determing what food is most applicable to them (Ellyn Satter Institute). The model is predicted on the usefulness and effectualness psychosocial practices such as hunger and the force to stay alive; appetitive and the requirement for bio pleasure; the societal reward of allocating food; the natural tendency to maintain favorite and steady body mass. With the ability to like various foods, people can enjoy the biodiversity of food. Besides, individuals would always want to eat adequately and strive to eliminate cases of food insecurity (Ellyn Satter Institute). This would lead to enjoyment, relaxation, acceptance and comfort, which are essential parts of the ecSatter model and sustain the development of enduring eating lifestyles that are constant and satisfying. Whereas ecSatter does not tackle what and how much to eat, individuals who are ingestion competent have diets of elevated dietary quality. The diet field is in evolution from the control and regulatory-based advances of the conventional form to the ecSatter conviction based form. Control found that messages might sneak into your programming in spite of your cautious study, theoretical commitment ecSatter and genuine desire to generate trust-based resources. The sinister nature of managing messages presents a severe difficulty as this distorts and weakens the efficiency of ecSatter. The majority found that regulatory food assortment messages are so intensely fixed in their opinion that those messages appear to be the only probable way of nourishment education. In reality, when thinking in terms of the trust model, there is much to recommend in respect to assisting individuals in finding innovative and individualized answers to their food organization and child feeding disputes. EcSatter is trustworthy with respect to the approach towards, and association with, the individual. The conventional control advance is to advise individuals on what they should eat, the quantity of food, and what they have to weigh. The control approach is that people must be encouraged to do the correct thing with food choice and weight management. On the contrary, the trust model lets one tender service, attract clients to labor with, motivate them to recognize their food-linked conundrums, link with them in discovering solutions, and realize those solutions as possibilities. The trust approach is that eating healthfully and acting conscientiously with respect to body heaviness are mutual values with the client and the nutritionist, and that development is intrinsic in the ecSatter form. Clients work on their own in getting themselves along as they work together with the nutritionist in discovering their own realistic and satisfying ways of controlling, eating as well as food (Content et al., 2007). For adults, eating competence is based on the approach and behavior that guarantee getting nourished. The main concern with ecSatter is improving and dignifying the significance of eating by making it optimistic, intrinsically gratifying and joyful. This is why the model focuses on taking time to eat rather than having to eat in a rush (Ellyn Satter Institute, 2015). Eating competence is defined by ecSatter as being optimistic, flexible and comfortable. Eating is also being factual and dependable about getting sufficient, pleasant and nourishing foodstuff. EcSatter believes in the powerful and consistent tendency to eat rewarding amounts of satisfying food, and stable body mass that is in custody with the person’s genetic endowment and life. The inventory draws an inclusive description of the unified spectrum of the eating approach and actions. It is described by ecSatter that competent eaters such as those that 1) have affirmative attitudes on eating and food; 2) possess food approval skills that bear eating an ever rising variety of the accessible food; 3) have interior regulation abilities that allow instinctively consuming adequate food to provide energy and endurance and stable body heaviness; 4) and have abilities and wealth for controlling the food perspective and arranging family meals. Eating Behavior and Dietary Quality in College Students Clifford et al. (2010) established, in their research, the association between weight, attitudes, and eating competence among college students. In their research, they found out that college students, with a higher eating competence, were concerned with the quality of their diet, eating behavior, internal regulation, food preparation, food acceptance, and meal planning. A sample of 1,720 students was used in the research via an Internet survey, which was based on ecSatter inventory items. The findings obtained indicated a multiple regression in the results. The findings in this case pointed towards the fact that students concerned about their weight were more competent in eating. Schembre et al. (2009, 34) discussed the development and validation of a weight related questionnaire, which reflected to “recent advancement in the assessment and understanding of theory based eating behaviors.” The researchers followed the ecSatter inventory in the development of a new inventory which was intended to measure two constructs of dietary control (custom and compensatory moderation), vulnerability to external cues (external eating) and expressive eating. This showed that the ecSatter inventory has been a basis of all nutritional assessments. For instance, Contento et al. (2007, p.3) designed a curriculum for middle schools on science and nutrition named choice, control and change (C3), which aimed at motivating students to get involved in improving physical activities so as to gain healthier weight through an improved eating competence level. In this case, Contento et al. (2007, p.3) focused on the adoption of behaviors that enhance energy balance after dietary unhealthy behaviors such as leisure screen time and taking in foods such as sweetened drinks, fast foods, and packaged snacks (pg.3). In this case, the study suggests that the best way out is to ensure increased drinking of water, much physical activity, and eating plenty of fruits and vegetables. This curriculum involved a 24-session curriculum that helped students gain knowledge about eating competence, which definitely entails healthy eating (Contento et al., 2007, p.3). 278 middle school students in 19 science classes from 5 schools were tested in the curriculum. They were found to have improved self-efficacy and personal agency, as they became more eating competent. Competent eaters are optimistic, contented, and flexible in terms of eating. College students, who are at a high danger of having chaotic eating behaviors, frequently lack these qualities. They often express negative approaches towards food, and they echo many barriers to scheduling and preparing meals. Clifford and Keeler (2002) conducted an extensive health study that was directed to university students. In addition, it comprised interrogations on EC (ecSatter Inventory), and it also alleged obstacles to healthy eating. The drive of this study was to explore the association between apparent barriers to nutritious eating and eating competence (EC) among college students. An aggregate of 1852 respondents were classified as either to be eating competent or hardly eating competent. Independent t-test, samples and logistic regression were used to explore the relationship between EC (Eating Competence) and barriers to healthy eating. More than half (59%) of them were not eating competently. Collective barriers to nutritious eating were nonexistence of time to make healthy foods lack of finances to acquire healthy foods, stress-free access to unwholesome foods and emotions. The model was found to be statistically meaningful with a Chi-square (9, N=1735=108.64. P=0.01). Motivation to eat nutritious food (p=0.01), understanding to cook nutritious food (p=0.045), time to make healthy food (p=0.001), access to nutritious food (p=0.035), and boredom/sadness/stress (p=0.001) were all meaningfully associated to poor EC. From the results, it was established that meal organization and provision skills, as well as emotional eating uncertainties, may be vital topics to address when trying to effect students’ eating competence. Positive Association between Eating Competence and Health Eating competence contributes to improved health. With respect to this claim, eating competence requires the consideration of what is best for eating, the amount to be eaten, when to be eaten, and whether the person would love what he or she is about to eat (Ellyn Satter Institute). Such eating practices would definitely contribute to dietary eating and healthy eating. A research was conducted by Psotta et al. (2007) to determine the relationship between eating competence and biomarkers of risk for cardiovascular disease. The researchers conducted a two way clinical trial on 48 hypercholesterolemia men and women between twenty-one to seventy years of age, in an outpatient clinical research Center. From the findings, a manifold association between eating competence and CVD was identified. It was found that eating competence was directly proportional to systolic and diastolic blood pressure. Lohse et al. (2010) conducted a similar research in which they sought to establish the association between eating competence and CVD risk profiles of Spanish participants. A cross sectional survey on 638 Spanish PREDIMED participants was carried out, the use of questionnaires, to evaluate their eating behavior. In their findings, the authors, with the ecSatter inventory as a guide, identified a relationship between eating competence, and reduced weight dissatisfaction, lower BMI, and increased HDL-cholesterol. Disordered Eating (Restraint Eating) and Poor Dietary Quality in College Students Eating competence can be argued to result to distort eating. Every person has his or her own way of eating, which is governed by food security, eating competence, and dietary quality. While some people eat because they are hungry, others eat to remain healthy. The motive to eat would thus be altered by the requirements for eating competence, which fails because some people have to eat what they can afford regardless of quality or quantity. Most people do not follow the four basic requirements for eating competence. Whenever these aspects have to be applied, an individual has to adjust from the normal way of eating to the most recommended ways in order to ensure eating competence. They have to ensure that they feel good about eating, like various foods besides enjoying to learn how to enjoy new foods, eat enough, and take their time to eat. Some people do not love to eat at all and they would thus eat only because it’s the only way to stay alive although they have the resources to eat competently. Competent eating would thus result to distorted-eating since the model requires people to feel good about eating (Ellyn Satter Institute). This group of people may not have much concern on quality diet. On the other hand, other people like eating a certain type of food while competent eating would require them to try various foods. While it is required that one should eat enough, some people eat something just to stay alive (Ellyn Satter Institute, 2015). Taking time to eat is another important aspect of competent eating, which make many people have their eating habits distorted. Competent, Independent t-test, samples and logistic regression were used to explore the relationship between EC (Eating Competence, 2015) and barriers to healthy eating. More than half (59%) of the respondents were not eating competently. Collective barriers to nutritious eating were nonexistence of time to make healthy foods lack of finances to acquire healthy foods, stress-free access to unwholesome foods, and emotions. The model was found to be statistically meaningful; Chi-square (9, N=1735=108.64. P=0.01). Motivation to eat nutritious food (p=0.01), understanding to cook nutritious food (p=0.045), time to make healthy food (p=0.001), access to nutritious food (p=0.035), and boredom/sadness/stress (p=0.001) were all meaningfully associated to poor EC. From the results, meal organization and provision skills, as well as emotional eating uncertainties, may be vital topics to address when trying to effect students’ eating competence. The increase of disordered eating has persisted in relation to behaviors and attitudes expressed at an early age. Studies of youthful girls disclose that a range of emotional and physical risk factors forecast later disordered eating. They include high levels of adverse emotionality, body discontent, and early age of menarche. In addition to emotional and physical factors, it has been advocated that certain situations or cultural climates intensify the risk of eating disorders, mainly in individuals who display the aforesaid risk factors. Some investigators have recognized college as an environmental risk aspect for eating disorder. This is mainly so because prevalence degrees of eating disorders are greater in college students than in other models. Some researchers have proposed that the cultural setting of a college may be a major environmental risk influence for the start or exacerbation of disordered eating. College is diligently associated with high altitudes of stress, achievement alignment, and the role and personality deviations, factors that are relates of disordered eating. Although exact occurrence rates fluctuate, college students have remarkably high rates of body discontentment, dieting, and challenging eating. One study conveyed that nearly 80% of women diet and 50% spree eat in their first year at college. Evidence that, disordered eating may top in college was found in an earlier study conducted by Joiner et al. (1997) who contrasted eating and dieting forms among women and men when they were in college and over 10 years well ahead. Among women, bulk and body discontent were found to be considerably higher in college than once out of college (while the contrary was true for men), with the proportion of women wanting to lose weight reducing from 82% during college to 68% after college. It is proposed that the effect of social roles and peer anticipations in college have a harmful effect on the eating actions of young women, and resolved that some amount of disordered consumption may be normative in school women. According to a study conducted by Heartherton et al. (1995), it was depicted that the transition to college does not significantly change eating habits. However, it was found that women’s body’s self-sensitivities vary from high school to college. Compared to high school, other women in college characterized them as overweight and conveyed greater body dissatisfaction. Although variations in self-perceptions should be deliberated in the context of a small weight gain since high school to college, most of the respondents were not overweight, conferring to national standards. Despite substantial changes in weight, self-categorization, and body discontent, major changes in EDI Drive for Slenderness and Bulimia. Subscale notches were not found in dieting activities or eating disorder grouping. Moreover, although the facts that those participants increased in some weight after high school to college and supposed they were weightier, there was a slight drop in frequency of dieting. It is particularly notable that arrangement of eating disorder status exhibited no change from high school to college, given the important changes in self-perceptions and body discontent and that most of the women at both assessments stated that they coveted to lose weight. This study is nevertheless limited by its dependence on self-reports. Although self-report surveys are the most corporate method of investigating sensitive issues such as disordered eating behaviors, they have been assessed on several levels, including the effect of extraneous factors. In addition, while disordered eating classifications were based on principles for bulimia nervosa in the Analytic and Statistical Manual of Mental Disorders, and they have been presented to be a reliable pointer of bulimic symptomatology, they are not identified on the basis of clinical consultations. Nonetheless, consultations are not credible for assessing variation in a large unit moving after high school to college. Furthermore, the goal was to evaluate a broad range of eating forms, an objective best attained using a survey set-up. Introduction In the western culture, health-wise and professionally, food is viewed as a basis of nutrients that deliver energy, control body processes and furnish relevant compounds required for growth and care of the human body. The supposition is that people will deliberately choose foods that add to their long-term physical well being by decreasing their threat of chronic disease. There is a slight doubt that a diet well suited to human biological requirements is necessary to the existence of the species (Clifford & Keeler, 2002). EcSatter is a model developed by Ellyn Satter and is based on her clinical observations of how people do well with eating. Essentially, eating competence explains how normal people eat. It is descriptive in that sense and rigid only for that group who are not comfortable with their current eating or who are concerned about their diet and health, and seek to make a dietary transformation. Still Weight Watchers, which a lot of people hype as the finest of the diet centers because of its dependence on real, unmarked food and flexible menu options, does not help people in understanding and knowing about the inner competence on eating. This comes down to the issue of trust against control, according to the nutritionist Ellyn Satter…who takes care of “dieting casualties” in her practice. She reckons that people require learning to believe that they will get filled, even on food they think as highly desirable, and recognize that they can reliably control their own food intake, instead of depending on exterior rules to control those choices. “Weight Watchers is good at easing up food choices, teaching people how to eat carefully, and encouraging them to add to the diversity of food in their diet,” states Satter. “But it is still essentially a control stance they apply” (Satter, 2007, p.56). When people rely on exterior rule ranges, and diet cops to control their eating, their association to food remains delicate. Distorted eating would then arise when competent eat is introduced to them. The increase of disordered eating has persisted in relation to behaviors and attitudes expressed at an early age. Studies on youthful girls disclose that a range of emotional and physical risk factors forecast later disordered eating. These risk factors include high levels of adverse emotionality, body discontent, and early age of menarche. In addition to emotional and physical factors, it has been advocated that certain situations or cultural climates intensify the risk of eating disorders, mainly in individuals who display the aforesaid risk factors. Some investigators have recognized college as an environmental risk aspect for eating disorder, which is mainly given that prevalence degrees of eating disorders are greater in college students than in other models. Some researchers have proposed that the cultural setting of a college may be a major environmental risk influence for the start or exacerbation of disordered eating. There are four factors that make up eating competence. One such factor is having a good attitude towards food and eating. In this regard, eating competence involves one feeling good about food and eating as as feeling good about feeling good (Ellyn Satter Institute, 2015). It typically involves enjoying the food and not feeling guilty about the food or the enjoyment. Another factor entails trying out new things without necessarily fearing any type of food and managing to eat a decent variety. In this regard, a person likes a variety of foods and he or she enjoys learning to adoring new food (Ellyn Satter Institute, 2015). The third factor involves internally regulating how much one eats where by one should seek to understand whether he or she trusts himself or herself to eat adequately. This aspect implies eating until satisfied, both emotionally and physically (Ellyn Satter Institute, 2015). The last factor entails ensuring that food is available and that and one has regular meals. It entails giving thought to both nutrition and taste as one selects food. In her research, Satter (2007) described the efficiency of Satter eating model as a model that provided the definition for an interconnected continuum of positive eating habits and positive behavior. The model has been based on bio-psychosocial processes such as “hunger and the force to live on, craving and the need for skewed reward and the biological propensity to maintain preferred, stable body weight” (Satter, 2007, p. 64). Satter observed that competent eaters possessed positive attitude towards food. This presentation of ecSatter inventory is supported by Statts and Lohse (2009) in their research. They tested the reliability of ecSatter inventory by self-reported questionnaires distributed among 259 participants, and tested subscale coefficients for contextual skills, food acceptance, and internal regulations. The researchers obtained psychometric evidence about the steadfastness of this model. They stated that although a little revision was required in some items of the model, the model could efficiently be used to measure eating competence. This paper reviews literature that assesses the association of eating competence, and distorted eating to dietary quality. It looks at the various researches and works done in relation to the topic. Research Question The research question serves the purpose of determining type of study, what the researcher intents to study as well as the specific objectives to be addressed. In this regard, the research questions was as follows: What is the association between eating competence and dietary quality in college students? Hypothesis The research hypothesis was as follows: It is predicted that there will be a positive association between eating competence and dietary quality in college students. Methods The study is based on the Satter Eating Competence Model also known as the ecSatter model. The study uses the model, to depict that college students among other people are encouraged to have a positive feeling regarding their eating, becoming reliable about feeding themselves, eating the food they enjoy, and eating as much food as they want by letting their body weight reflect their respective endowment as well as lifestyles. The study considered the ecSatter model very useful in enhancing eating competence among college students. It utilized a predetermined criteria for the recruitment in terms of number of participants, inclusion and exclusion criteria, and vulnerability of participants, risk considerations, associated benefits, and the general recruitment activities. Considerably, the study utilized between 50 and 85 participants. Only students who were in the Personal Nutritional Class in winter and spring 2012 were included. Nevertheless, issues of vulnerable participants were considered like the case of pregnant women since they are normally required to have a prescribed diet. Generally, the survey was meant to start with personal questions such as age, gender, race, and activeness level for pregnant and international students. Other important considerations included risks and discomfort especially from participating. There was thus the need for a consent process. Regarding the consent process, the information had to be presented to the potential participants. The research team had to inform the participants about the project as well as give information about the consent form. All the participants had to be comfortable for the questions to be asked. This was only through having them agree with their participation terms and condones, which was depicted by their willingness to sign the consent forms. Discussion Gaps in the Research This study was meant to cover what previous studies have not covered or accomplished. This aspect was possible through consideration of both existing literature to establish what has or not been covered and then conducting a primary study to study what has not yet been studied. Interviews where thus important. In the abovementioned research, the interview was conducted online. The respondents in this case are likely to lie because there is no facial expression. The students may have filled the questionnaire just for fun. This could imply that some of the information would have been inaccurate (Kvale, 1996, p.67). Another shortcoming may be the fact that only a sample of students was interviewed; this may not represent the point of view of all the other students. The sample population would have been bigger to be truly representative of the sample required. Most studies conducted have covered only students generalizing on the use of the ecSatter model. Students may not represent the whole population of people. In most researches, weight is the factor that is being considered most of all as the only one causing problems for healthy eating. Work Cited Clifford, D., & Keeler, A. The relationship of perceived barriers to healthy eating and eating competence on a college campus. CA: California State University. 2002. Print. Content, I., Calabrese-Barton, A., Koch, A., Lee, H., & Sauberi, W. Enhancing personal agency and competence in eating and moving: Formative evaluation of a middle school curriculum choice and change. J Nutr Educ Behav, Vol.39 No.5, 179–86. 2007. Print. Ellyn Satter Institute. The Satter Eating Competence Model (ecSatter). 2015. Web . 20 April 2015. Heartherton, F., Nichols, P., Mahamedi, F., & Keel, P. Body weight, dieting, and eating disorder symptoms among college students, 1982 to 1992. American Journal of Psychiatry, Vol. 152, pp.1623–1629. 1995. Print. Joiner, T., Heatherton, D., Rudd, D., & Schmidt, B. Perfectionism, perceived weight status, and bulimic symptoms: Two studies testing a diathesis-stress model Journal of Abnormal Psychology, Vol. 106, No.1, 145–153. 1997. Print. Keys, A., Brozek, J., & Henschel, A., Food-insecurity contributes to obesity among Colorado children and pregnant women. Minnesota: Univ. of Minnesota Press. 1950. Print. Krall, J., & Lohse, B. Interviews with low-income Pennsylvanians verify a need to enhance eating competence. Journal of the American Dietetic Association, Vol. 109, No.3, 476–473. 2009. Print. Kvale, S. InterViews: An Introduction To Qualitative Research Interviewing. Sage Publications, 1996. Lohse, B., Psota, T., & Estruch, R. Eating competence of elderly Spanish adults is associated with a healthy diet and a favourable cardiovascular disease risk profile. J. Nutr., Vol.140, No.7, 1322–1327. 2010. Print. Polivy, J. Psychological consequences of food restriction Am Diet Assoc, Vol.96, No.6, 589– 92. 1996. Print. Posta, T., Lose, B., &West, S. Associations between eating competence and cardiovascular disease biomarkers. J Nutr. Educ. Behav., 39 (suppl), 171–178. 2007. Print. Satter, M. Eating competence: Definition and evidence for the Satter Eating Competence Model. J Nutr Educ Behav, Vol. 39 (suppl), 142–153. 2007. Print. Satter, M. Nutrition education with the Satter Eating Competence Model. J Nutr Educ Behav, 39 (suppl), 189–194. 2007. Print. Schembre, S., Greene, G., & Melanson, K. Development and validation of a weight- related eating questionnaire. Eat Behav. Vol.10, No.2, 119–24. 2009. Print. Tolliver, R., & Shupe, A. The biology of human starvation. Health watch, Vol.86, 1–7. 2012. Print. Stats K. J., and Lohse B. Interviews with low-income Pennsylvanians verify a need to enhance eating competence. J Am Diet Assoc, Vol.109, No.3, 468–73. 2009. Print. Read More