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Factors Associated With Healthy Lifestyle Behaviors Among Adolescents

Article  in  Journal of Pediatric Health Care · June 2018

DOI: 10.1016/j.pedhc.2018.04.002

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Factors Associated WithHealthy Lifestyle BehaviorsAmong AdolescentsColleen M. McGovern, MPH, RN, Lisa K. Militello, PhD, MPH, RN,Kimberly J. Arcoleo, PhD, MPH, & Bernadette M. Melnyk, PhD, RN

ABSTRACTObjective: Guided by cognitive theory, this study tested anexplanatory model for adolescents’ beliefs, feelings, and healthylifestyle behaviors and sex differences in these relationships.

Methods: Structural equation modeling evaluated cross-sectional data from a healthy lifestyle program from 779adolescents 14 through 17 years old.Results: Theoretical relationships among thoughts, feelings,and behaviors were confirmed and sex differences identi-fied. Thoughts had a direct effect on feelings and an indirecteffect through feelings on healthy behaviors for both sexes.A direct effect from thoughts to behaviors existed for malesonly.Discussion: Findings provide strong support for the thinking–feeling–behaving triangle for adolescents. To promote healthylifestyle behaviors in adolescents, interventions should in-corporate cognitive behavioral skills–building activities,strengthening healthy lifestyle beliefs, and enhancingpositive health behaviors. J Pediatr Health Care. (2018) 32,473-480.

KEY WORDSAdolescent physical and mental health, healthy lifestyle be-haviors, cognitive behavior skills, path analysis

BACKGROUNDUnderstanding factors that contribute to healthy life-style behaviors in adolescents is critical to thedevelopment of interventions needed to promote posi-tive behaviors that can prevent negative physical andmental health outcomes, which may have lifelong im-plications. Cognitive theory (CT; Beck, 1979) is a modellinking a person’s thoughts to emotions and behav-iors. The basic premise of CT is that an individual’semotions and behaviors are, in large part, determinedby the way in which he or she thinks and appraisesthe world (Beck, 2011). Therefore, a person who hasnegative beliefs tends to have negative emotions andbehave in negative ways (Beck, 1979; Lewinsohn, Clarke,Hops, & Andrews, 1990; Skinner, 1960). A form of psy-chotherapy, cognitive behavior therapy (CBT) buildson CT principles. In CBT, people learn specific skillsto identify distorted thinking, modify beliefs, and changebehaviors. Negative emotions and behaviors are

Colleen McGovern, Doctoral Candidate and Graduate ResearchAssociate, College of Nursing, The Ohio State University, Colum-bus, OH.

Lisa Militello, Assistant Professor, College of Nursing, The OhioState University, Columbus, OH.

Kimberly Arcoleo, Associate Professor, Associate Dean for Re-search, Director, Center for Research Support, University ofRochester School of Nursing, Rochester, NY.

Bernadette Melnyk, Vice President for Health Promotion, Univer-sity Chief Wellness Officer; Dean and Professor, College of Nursing;and Professor of Pediatrics and Psychiatry, College of Medicine,The Ohio State University, Columbus, OH.

The original study was funded by the National Institutes ofHealth/National Institute of Nursing Research 1R01NR012171(Bernadette Melnyk, principal investigator). Manuscriptpreparation by Colleen M. McGovern was supported by a RuthL. Kirschstein National Research Service Award (T32NR014225).The content is based solely on the perspectives of the authorsand does not necessarily represent the official views of theNational Institutes of Health.

Bernadette Melnyk has a company, COPE2THRIVE, thatdisseminates the COPE program. The other authors report noconflicts of interest.

This study is registered at www.clinicaltrials.gov NCT01704768.

Some of the data in this manuscript were presented at theCouncil for the Advancement of Nursing Science conference. Noprevious manuscripts have been published with the analysesfrom this study.

Correspondence: Colleen McGovern, MPH, RN, College ofNursing, The Ohio State University, 1585 Neil Avenue,Columbus, OH 43210; e-mail: mcgovern.5@osu.edu

0891-5245/$36.00

Copyright © 2018 by the National Association of Pediatric NursePractitioners. Published by Elsevier Inc. All rights reserved.

Published online June 22, 2018.

https://doi.org/10.1016/j.pedhc.2018.04.002

Article

www.jpedhc.org September/October 2018 473

exacerbated when poor emotional regulation, problem-solving, and assertiveness skills are present.

CBT is recognized as a psychotherapy criterion stan-dard for mild to moderate anxiety or depression (U.S.Department of Health and Human Services, NationalInstitutes of Health, National Institute of Mental Health,2015). Skills from CBT (e.g., cognitive reframing, goalsetting, problem solving, behavior activation) have alsobeen successfully used in behavior change interven-tions targeting health behaviors in adolescents (Beck,2011; Hoying, Melnyk, & Arcoleo, 2016; Linardon, Wade,de la Piedad Garcia, & Brennan, 2017; Lock, 2015;Wilfley, Kolko, & Kass, 2011; Winkler, Dörsing, Rief,Shen, & Glombiewski, 2013). Le Grange, Lock, Agras,Bryson, and Jo (2015) implemented a CBT-based in-tervention for adolescents with an eating disorder thatindicated a significant longitudinal reduction in binge/purge behaviors. Winkler et al. (2013) completed a meta-analysis for Internet addiction; CBT-based interventionshad a larger effect size for a reduction in screen timeand depression compared with other treatments in adultsand adolescents.

Although there is a body of growing evidence tosupport CBT as an effective strategy to target improve-ments in mental health and healthy lifestyle behaviorsin adolescents, less is known about how the relation-ships among thoughts, feelings, and healthy lifestylebehaviors function in adolescents. Furthermore, in-herent developmental differences between adolescentmales and females may influence the effects of be-havior change interventions. For example, females havebeen recognized to be at higher risk for anxiety anddepression compared with males (Altemus, Sarvaiya,& Epperson, 2014; Avenevoli, Swendsen, He, Burstein,& Merikangas, 2015). Reviews by Haynos andO’Donohue (2012) and Kaisari, Yannakoulia, andPanagiotakos (2013) reported that compared with males,females had slightly more favorable outcomes to in-terventions to increase healthy lifestyle behaviors. Thus,a basic understanding of cognitive behavioral pro-cesses between sexes may inform how behavioralinterventions are most likely to succeed (Haynos &O’Donohue, 2012; Melnyk et al., 2013, 2015; Tate,Spruijt-Metz, Pickering, & Pentz, 2015). Scalable inter-ventions to increase healthy lifestyle behaviors shouldtarget this population to improve health outcomes duringadolescence and into adulthood.

Guided by CT (Figure 1), the objectives of these sec-ondary analyses were to test an explanatory model forthe influence of adolescents’ thoughts and feelings onhealthy lifestyle behaviors and to investigate whetherthere are sex differences in these relationships.

METHODSEthicsThe institutional review board for The Ohio State Uni-versity reviewed and approved these secondary analyses.

All participating universities and school districts ap-proved the original study.

ParticipantsBaseline measures from a longitudinal randomized con-trolled trial titled “Creating Opportunities for PersonalEmpowerment (COPE)” were used for this study (Melnyket al., 2013, 2015). Urban and suburban high schoolteens (N = 779) from 11 schools in two school dis-tricts from the Southwestern United States were included.Adolescents aged 14 through 17 years, primarily fresh-men and sophomores, were recruited and enrolled fromtheir required health education courses. Data were col-lected from January 2010 through December 2012.

Measures

Healthy lifestyle beliefs scaleHealthy lifestyle beliefs were measured using the HealthyLifestyles Beliefs scale (Melnyk, 2014; Melnyk &Moldenhauer, 2006). Previous studies show that thisscale has acceptable reliability, with Cronbach’s alphaequal to .89 (Melnyk et al., 2013). The Healthy Life-styles Beliefs scale consists of 16 items with Likert-type responses ranging from 1 (strongly disagree) to5 (strongly agree); higher scores indicate greater healthylifestyle beliefs. Examples of questions include I amsure I will do what is best to lead a healthy life, I amsure that I will do what is best to keep myself healthy,and I know what to do when things bother or upset me.

Healthy lifestyle perceived difficulty scaleThe Healthy Lifestyle Perceived Difficulty scale mea-sures perceived difficulty in engaging in healthy lifestylebehaviors. It is a 12-item measure with Likert-type re-sponses ranging from 1 (very hard to do) to 5 (veryeasy to do); higher scores reflect lower perceived dif-ficulty. Examples of items include How hard is it toexercise regularly? and How hard is it to take the timeto help plan and prepare healthy meals? Cronbach’s alphafor this measure was .88 (Braet & Van Winckel, 2000).

FIGURE 1. The cognitive behavioral therapymodel of how thoughts affect feelings andbehaviors.

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Beck youth inventoriesThe Beck Youth Inventories (BYI) for children ages7 through 18 years was used to measure adolescents’feelings. The BYI consists of five subscales: Anger,Anxiety, Depression, Self-concept (a scale to evalu-ate themselves in relation to other people they know),and Disruptive behavior. Each subscale has 20 ques-tions with Likert-type responses ranging from 0 (never)to 3 (always), and higher scores are indicative of morenegative emotions. Cronbach’s alphas for all subscaleswere greater than .89 (Melnyk et al., 2013).

Healthy lifestyle behaviors scaleThe Healthy Lifestyle Behaviors scale evaluates healthbehaviors reflective of physical activity, diet, and mentalhealth. This instrument contains 15 items with Likert-type responses ranging from 1 (strongly disagree) to5 (strongly agree), with higher scores signifying greaterengagement in healthy lifestyle behaviors. Examplesinclude I make healthy food choices, I exercise on aregular basis, I choose water as a beverage instead ofa sugared drink at least once a day, I set goals I canaccomplish, and I talk about my worries or stress everyday. Cronbach’s alpha was .85 (Melnyk et al., 2013).

Statistical AnalysisStatistical analyses were conducted using SPSS, version22.0, and Mplus 8 (Muthén & Muthén, 2017). Latent vari-ables were constructed representing thoughts, feelings,and healthy lifestyle behaviors. The latent variable forThoughts comprised the Healthy Lifestyle Perceived Dif-ficulty (reverse scored), Healthy Lifestyle Beliefs, and BYISelf-Concept (reverse scored) scales. The latent variablefor Feelings was measured by the BYI Depression, Anxiety,and Anger subscales. The Behaviors latent variable in-cluded the Healthy Lifestyle Behaviors and BYI DisruptiveBehaviors scales. The dependent variables were the latentvariables for Feelings and Behaviors. Two structural equa-tion models (SEMs) were run. First, a two-group (male,

female) SEM with maximum likelihood estimation wasspecified to test the hypothesized explanatory model fordirect and indirect effects of thoughts and feelings onhealthy lifestyle behaviors. The second model con-strained all parameters to be equal to examine whetherthe SEM models differed for males and females as evi-denced by a decrease in model fit. Statistical significancewas set at p less than .10.

RESULTSThe sample was 52% female, and the majority were ofLatino ethnicity (68%), followed by White (14%), Black(10%), Asian (4%), and Native American (4%). Most ofthe sample (76%) reported receiving public assis-tance. The mean age was 14.7 years (standard deviation= 0.73). The Table presents the descriptive statisticsfor the observed indicators of the latent variables forthoughts, feelings, and healthy lifestyle behaviors forthe whole sample and differences by sex. For the latentvariable Thoughts, adolescent males had higher re-ported beliefs in their ability to engage in healthy lifestylescompared with females. Females also scored lower thanmales on the Self-concept subscale, yet females per-ceived lower difficulty engaging in healthy behaviors.For the latent variable Feelings, proportionally femalesscored higher than males on the Depression and Angersubscales but not the Anxiety subscale. Although thedifference for healthy lifestyle behaviors between malesand females was not significant, females did have sig-nificantly higher reported disruptive behavior.

The results showed good fit of the data to the model(Comparative Fit Index = 0.98, Tucker–Lewis index =0.96, root mean square error of approximation = 0.08,standardized root mean residual = .06): thoughts andfeelings influenced behaviors, and differences in themodel were observed for males and females, as shownby a substantial decline in model fit (Comparative FitIndex = 0.77, Tucker–Lewis index = 0.67, root meansquare error of approximation = 0.22, standardized root

TABLE. Descriptive statistics for the observed indicators of the latent variables for thoughts,feelings and behaviors

Latent variable Observed variableTotal, meanscore (SD)

Males, meanscore (SD)

Females, meanscore (SD)

Meandifference p (95% CI)a

Thoughts Healthy lifestyle beliefs 63.49 (8.94) 64.41 (8.26) 62.60 (9.47) 1.81 .006 [0.52, 3.08]Healthy lifestyle perceived

difficulty28.30 (7.94) 27.13 (7.46) 29.40 (8.24) −2.27 < .0001 [−3.39, −1.15]

BYI self-conceptb −50.15 (10.22) −52.39 (9.40) −48.06 (10.51) −4.33 < .0001 [−5.75, −2.91]Feelings BYI anxiety 48.43 (9.99) 47.50 (8.78) 49.32 (10.94) −1.82 .011 [−3.23, −0.42]

BYI depression 46.55 (9.57) 45.44 (7.52) 47.60 (11.08) −2.16 .002 [−3.50, −0.83]BYI anger 45.83 (9.70) 43.96 (7.96) 47.60 (10.81) −3.64 < .0001 [−4.99, −2.29]

Behaviors Healthy lifestyle behaviors 52.01 (9.34) 53.22 (9.01) 50.89 (9.50) 2.33 .001 [1.01, 3.66]BYI disruptive behaviors 47.99 (9.76) 45.93 (8.32) 49.94 (10.59) −4.01 < .0001 [−5.35, −2.66]

Note. BYI, Beck Youth Inventories; CI, confidence interval; SD, standard deviation.ap < .05 considered statistically significant.bReverse scored.

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mean residual = .15). Figure 2 illustrates the results ofthe SEM model for males and Figure 3 illustrates theresults for females. Among males, positive thoughts wereassociated with lower levels of negative feelings (i.e.,anxiety, anger and depression; B = −0.43, p < .0001),and lower negative feelings were associated with in-creased healthy lifestyle behaviors and lower disruptivebehaviors (B = −1.04, p < .0001). Greater positivethoughts were related to higher reported healthy life-style behaviors (B = 0.39, p < .0001). There was a strongindirect effect of thinking through feeling on behav-iors (B = 0.45, p < .0001). Similar to males, for females,positive thoughts were associated with lower negativefeelings (B = −0.48, p < .0001), and lower negative feel-ings were associated with increased healthy lifestylebehaviors and lower disruptive behaviors (B = −1.55,p < .0001). However, a direct effect for thoughts onhealthy lifestyle behaviors was not observed for females.The indirect pathway from thinking through feeling onbehaviors was stronger for females (B = .75, p < .0001)than for males.

DISCUSSIONThe need to enhance healthy lifestyle behaviors in ado-lescents to prevent health behavior–related chronicconditions and long-term deleterious health out-comes have become a national imperative. Evidencereviews have indicated that self-efficacy, or the beliefthat one can affect change, and outcome expectations

can act as mediators for increasing healthy lifestyle be-haviors in children and adolescents (Cerin, Barnett, &Baranowski, 2009; Lubans, Foster, & Biddle, 2008; VanStralen et al, 2011). Findings from our study highlightthe powerful impact that cognitive beliefs toward en-gaging in healthy lifestyle behaviors, perceived difficulty,and self-concept have on healthy lifestyle behaviors(Cheie & Miu, 2016; Power, Ullrich-French, Steele,Daratha, & Bindler, 2011; Suchert, Hanewinkel, &Isensee, 2015).

Findings from thisstudy support the CBTmodel: adolescents whohave more positivethoughts about engag-ing in healthy lifestylebehaviors reported lessnegative feelings andengaged in morehealthy lifestyle behav-iors. These associationsstrongly support CT,which emphasizes theinterconnected relation-ships between thoughts,feelings, and behav-iors (Beck, 2011).Collectively, our find-ings highlight the need

FIGURE 2. Structural equation model for thinking, feeling, and behavior triangle: Males.

Findings from thisstudy support theCBT model:adolescents whohave more positivethoughts aboutengaging in healthylifestyle behaviorsreported lessnegative feelingsand engaged inmore healthylifestyle behaviors.

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for healthy lifestyle interventions to target adolescents’cognitive beliefs. Similar to CBT, targeting maladap-tive thinking with cognitive behavioral skills–buildinginterventions may influence healthy behaviors. In therandomized controlled trial from which these second-ary data analyses were conducted, adolescents whoreceived a 15-session cognitive behavioral skills–building healthy lifestyle program entitled COPE(Creating Opportunities for Personal Empowerment)Healthy Lifestyles TEEN (Thinking, Emotions, Exer-cise, and Nutrition) versus those who received anattention control program had (a) increased levels ofphysical activity, (b) lower body mass index, (c) fewerdepressive symptoms (in those who had severedepression at baseline), and (d) less alcohol use (Melnyket al., 2015). The 15-session program is composed ofseven cognitive behavioral skills–building sessions andeight sessions that focus on healthy eating and physi-cal activity. The COPE program is now recognized asan evidence-based obesity control program for ado-lescents by the National Cancer Institute’s ResearchTested Intervention Programs. The National Cancer In-stitute is dedicated to “moving science into programsfor people” and currently has a repository of over 170evidence-based intervention programs available foraccess (https://rtips.cancer.gov/rtips/index.do; NationalCancer Institute, 2016).

The results of the model test also showed sexdifferences in the thinking–feeling–behaving triangle.

Our findings suggest that for adolescent males, thereis a direct effect from thoughts to both feelings andbehaviors, but not for females. Males (in Table) hadstronger beliefs about engaging in healthy lifestyles,fewer negative feelings, and more positive behaviorscores compared with females. It is possible that fewernegative feelings allowed for a direct path from beliefsto behaviors. Conversely, for adolescent females, whohad higher reported negative feelings, our model in-dicated a direct effect from thoughts to feelings. Thesefindings further support the model, because femalesin this sample had lower reported self-concept andhealthy lifestyle beliefs (thoughts), higher depressionand anger (feelings), and higher disruptive behaviors(behaviors) compared with males. Although recent evi-dence highlights increased internalizing symptoms inadolescent females (Bor et al., 2014), we also found asignificant indirect effect from thoughts through feel-ings to behaviors for both males and females. This isan important finding. Although intervention strategiesfor adolescents should target beliefs that underminehealth, recognizing and addressing negative emotionsis vital to successful behavioral outcomes.

The interplay between physical and mental healthcan have lifelong effects. Cognitive behaviorskills such as cognitive reframing, stress management,and goal setting become critically important as inter-ventions for adolescents, particularly because thispopulation is at higher risk for skill deficits because

FIGURE 3. Structural equation model for thinking, feeling, and behavior triangle: Females.

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their executive func-tions are still develo-ping (Casey & Caudle,2013; Churchwell &Yurgelun-Todd, 2013).

Based on our results,adolescent males per-ceived a higher degreeof difficulty engaging inhealthy lifestyle behav-iors and thus may dobetter with an increasedemphasis on skills-building activities suchas goal setting, problemsolving, and overcom-ing barriers. Femaleshad lower healthylifestyle beliefs scorescompared with their male counterparts, suggesting thatan increased emphasis on intervention strategies di-rected at cognitive reframing and positive self-talk maybe necessary.

Our results highlighted the importance of mentalhealth in adolescents’ abilities to engage in healthy life-style behaviors. Anxiety disorders are the most prevalentmental health problem in adolescents, and depres-sive symptoms severe enough to impair daily functioningare reported by 36% of females and 21% of males (Perouet al., 2013). Numerous factors can contribute to highermortality related to mental health. Results from a studyby Cohen et al. (2015) indicated that perception of lackof parental support and self-criticism interacted withanxiety to predict future depressive symptoms, par-ticularly in adolescent females. U.S. guidelinesrecommend screening adolescents for depression (U.S.Preventive Services Task Force, 2016); however, ourresults suggest that scope of practice for adolescentscreening and interventions may need to be broad-ened to improve joint mental and physical healthoutcomes. Putting tools in place to more accuratelyreflect mental and physical health in adolescent popu-lations may increase the likelihood of engagement inhealth behaviors and the success of different treat-ment modalities.

Implications for PracticeFindings from this study strongly support effective andefficient resources for use in primary care. With therise in health behavior-related chronic conditions andmental health disorders in adolescents, primary carescreening for both mental and physical health prob-lems is imperative. The U.S. Preventive Services TaskForce recommends screening of all 12- to 18-year oldsfor depression (U.S. Preventive Services Task Force,2016). However, adolescents are often not screenedbecause practices do not have systems in place to deal

with teens who are depressed. To address this issue,the seven cognitive behavioral skills–building ses-sions in the COPE Healthy Lifestyles TEEN programare being used with positive outcomes in primary careand school settings to provide evidence-based cogni-tive behavioral skills to depressed and/or anxiousadolescents (Hoying et al., 2016; Melnyk et al., 2015).

In our study, almost 44% of participants reportedelevated symptoms of anxiety. The proportions of el-evated depression (31.8%), anger (16.8%), and disruptivebehaviors (21.8%) were also higher than the nationalaverages (Perou et al., 2013). These results support theneed for mental health screening, including for dis-ruptive behaviors, for adolescents, using reliable andvalid measures. Perou et al. (2013) advocate for theimplementation of standardized measures and screen-ing guidelines for clinical practice, but screening is notenough. The establishment and use of evidence-based tools and interventions to support adolescentmental health and healthy lifestyle behaviors is im-perative. Based on evidence to date, cognitive behavioralstrategies to increase the likelihood of success shouldbe at the core of interventions.

Adolescents who engage in healthy lifestyle behav-iors report a higher quality of life and fewer depressivesymptoms (Iannotti & Wang, 2013). With limited timeand resources, adolescents should be screened formental health symptoms including depression, anxiety,anger, and disruptive behaviors. Both males and femaleshave benefitted from interventions with cognitivebehaviorskills–building interventions in prior studies(Melnyk et al., 2015).Habits formed duringthe teenage years canhave lifelong implica-tions; therefore, it isvital to support thedevelopment andsustainability of healthylifestyle behaviors inthis population.

Strengths and LimitationsThe data provided further support for the impor-tance of healthy lifestyle beliefs and self-concept onhealthy lifestyle behaviors. A strength of this study wasthe inclusion of mental health, because it relates to thelarger picture of healthy lifestyle behaviors outside ofdiet and physical activity. Another strength was thatthe inclusion of both mental health and sex variablesin the analysis provides preliminary evidence for a priorilongitudinal research in the future.

This was a secondary data analysis, and thereforeonly questions related to the data captured can be an-swered. Measures relied on self-report, which carriesthe risk of response bias. Finally, the data for theseanalyses were cross-sectional; therefore, causal inferences

Althoughinterventionstrategies foradolescents shouldtarget beliefs thatundermine health,recognizing andaddressingnegative emotionsis vital tosuccessfulbehavioraloutcomes.

Habits formedduring the teenageyears can havelifelongimplications.

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cannot be made. Nonetheless, this study provides aplatform for future longitudinal research and thedevelopment and improvement of CBT interventionsneeded to guide evidence-based practice.

CONCLUSIONTo increase engagement in healthy lifestyle behaviors,our results suggest screening and targeting adoles-cents’ cognitive beliefs about engaging in healthy lifestylebehaviors. Brief, valid, and reliable measures can beimplemented in primary care and in schools to iden-tify adolescents at risk for negative mental and physicalhealth outcomes. Resources to promote healthy life-style choices in adolescent populations need to be morecomprehensive to encompass cognitive beliefs that targetphysical and mental health outcomes.

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