Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Sleep, Nutrition, Disordered Eating, Problematic Tobacco and Alcohol Use, and Exercise in College Students With and Without Diabetes

Marianne Channas Cockroft, PhD, RN; T. Robin Bartlett, PhD, RN; Debra C. Wallace, PhD, RN, FAAN

Abstract

The purpose of the current study was to examine the health behaviors of college students with diabetes and compare behaviors to college students without diabetes. This descriptive study used the American College Health Association-National College Health Assessment II and included 1,216 students between ages 18 and 24. Health behaviors related to sleep, nutrition, disordered eating, problematic tobacco and alcohol use, and exercise were examined. Students with diabetes (n = 528) reported a higher frequency of meeting exercise recommendations and less healthy behaviors related to nutrition and problematic tobacco and alcohol use. Both groups of students reported inadequate sleep. Students with diabetes reported more academic problems due to sleep difficulties, disordered eating, and problematic alcohol use. Health behaviors in both groups showed similar needs for improvement. Nurses are in a position to guide new, prospective, and continuing college students with diabetes in practicing behaviors associated with positive health outcomes. Opportunities for interventions are numerous. [Journal of Psychosocial Nursing and Mental Health Services, 57(12), 23–32.]

Abstract

The purpose of the current study was to examine the health behaviors of college students with diabetes and compare behaviors to college students without diabetes. This descriptive study used the American College Health Association-National College Health Assessment II and included 1,216 students between ages 18 and 24. Health behaviors related to sleep, nutrition, disordered eating, problematic tobacco and alcohol use, and exercise were examined. Students with diabetes (n = 528) reported a higher frequency of meeting exercise recommendations and less healthy behaviors related to nutrition and problematic tobacco and alcohol use. Both groups of students reported inadequate sleep. Students with diabetes reported more academic problems due to sleep difficulties, disordered eating, and problematic alcohol use. Health behaviors in both groups showed similar needs for improvement. Nurses are in a position to guide new, prospective, and continuing college students with diabetes in practicing behaviors associated with positive health outcomes. Opportunities for interventions are numerous. [Journal of Psychosocial Nursing and Mental Health Services, 57(12), 23–32.]

Approximately 193,000 children and adolescents in the United States younger than age 20 have type 1 or type 2 diabetes (Centers for Disease Control and Prevention [CDC], 2017a). The transition from home to college typically occurs during adolescence, a time of substantial life change; yet, how well adolescents with diabetes in the United States manage their health when they transition from home to college is not well understood (Fredette, Mawn, Hood, & Fain, 2016; Lemly, Lawlor, Scherer, Kelemen, & Weitzman, 2014). The transition from home to college often includes a change in residential, social, and learning environments. These changes along with stressors associated with academic achievement may affect daily management of diabetes. Adjusting from dependency on parents/guardians to more independent self-care management of diabetes during this transition presents challenges in metabolic control and increased risk for physical and mental health problems (Meyer, Fish, & Lou, 2017; Morrison, Dashiff, Abdullatif, & Moreland, 2012; Saylor & Calamaro, 2016).

As health practices established throughout adolescence may affect health behaviors and outcomes in adulthood, it is important to better understand the behaviors of adolescents with diabetes transitioning to college through an exploration of their self-care practices associated with nutrition, exercise, sleep, alcohol consumption, and tobacco use. The purpose of the current study was to assess the health behaviors, including those related to harm prevention, of college students with diabetes to reveal which self-care behaviors are practiced or neglected and to compare their health behaviors to college students without diabetes.

The research questions were: (1) What are the health behaviors of college students with diabetes? and (2) Are there differences in health behaviors between college students with diabetes and those without diabetes?

Method

Design and Sample

The current study is a report of the dissertation work of the first author (Cockroft, 2013). This descriptive study involved secondary analysis of data from the Spring 2009 American College Health Association-National College Health Assessment II (ACHA-NCHA II) (ACHA, 2009). The ACHA-NCHA II survey included questions related to health history, nutrition, exercise, physical health, mental health, risk behaviors (e.g., tobacco and alcohol related behaviors), and academic performance and was completed by 87,105 students at 117 schools, representing a sample of different geographic regions and campus sizes. These data are collected annually; however, public use of the data is often 3 to 4 years later than original data collection. As adolescent health behaviors from 2009 remain relevant in 2019, and for the purposes of future studies to compare changes in these behaviors over time, the findings presented here are important. (For more information on these data, access https://www.acha.org/documents/ncha/ACHA-NCHA_Reference_Group_ExecutiveSummary_Spring2009.pdf.)

For the current study, inclusion criteria were students between ages 18 and 24 who reported being diagnosed or treated for diabetes by a health care provider within the past 12 months. These criteria were met by 528 students. A comparison group was selected using a random number generator in SPSS version 21.0 from the 68,798 students who reported they were between ages 18 and 24 and had not been diagnosed or treated for diabetes. Students in the comparison group (n = 688) represent approximately 1% of students meeting the inclusion criteria, a similar proportion to that of students with diabetes. Thus, survey data of 1,216 students were examined.

Measures

Select survey questions from the ACHA-NCHA II that addressed sleep, nutrition, disordered eating, problematic tobacco and alcohol use, and exercise were used to assess self-care behaviors. Several Likert responses were converted into dichotomous variables, and other variables were combined or recoded to reflect national health guidelines on these domains of self-care.

Sleep. Sleep was measured using five items assessing adequate rest and sleep difficulties. The focus of items was consistent with the National Sleep Foundation (2015) guidelines to measure sleep. A positive response was feeling rested every day, no problems with daytime sleepiness, zero days of difficulty falling asleep, sleep difficulties not being difficult to handle, and academics not being affected by sleep difficulties.

Nutrition. Nutrition was measured using one item (e.g., daily consumption of fruits and vegetables). Healthy Campus 2020 guidelines promote consuming five or more servings of fruits and vegetables per day (ACHA, 2012). Thus, nutrition was assessed through a dichotomous variable created to reflect whether the national recommendations for consuming fruit and vegetable intake were met.

Disordered Eating. Disordered eating was measured using four items. One item was weight loss strategies. Vomiting, taking laxatives, or using diet pills were combined to form a dichotomous variable indicating unsafe weight loss strategies. Additional comparisons were conducted by looking at perceptions of being about the right weight and responding yes to questions related to eating disorder presence and outcome.

Tobacco Use. Combining the use of four tobacco products into one item was used to assess tobacco usage. For comparison analysis, a response was considered positive if the student reported never used or not within the last 30 days to each of the tobacco products.

Alcohol Use. Alcohol consumption was evaluated with seven items related to quantity of alcohol, protective drinking strategies, impact on academic performance, addiction to alcohol or other drugs, and whether students drove after drinking. Daily consumption of no more than one drink for women and no more than two drinks for men was considered moderate intake for adults, both with and without diabetes (American Diabetes Association [ADA], 2014). To determine moderate drinking patterns, a dichotomous variable representing gender guidelines for consuming one drink for women and two drinks for men considering legal age requirements was created. Protective drinking strategies (e.g., eating before or during drinking, avoiding drinking games) were measured by responses of N/A, don't drink, most of the time, or always. To determine if any protective strategies were practiced, a dichotomous variable was created. A response of no or N/A to all other alcohol questions was used for the comparison analysis.

Exercise. Participation in physical activity by type and frequency was used for exercise measurement. Exercise was assessed through a dichotomous variable to represent whether the national recommendations for exercise were met. The recommendation at the time of the study for moderate-intensity aerobic exercise for at least 30 minutes on at least 5 days weekly, or vigorous-intensity aerobic exercise for at least 20 minutes on at least 4 days weekly, or a comparable mix of moderate/vigorous aerobic activity; and muscle-strengthening exercises at least twice per week are similar to current guidelines (U.S. Department of Health and Human Services, 2018).

Data Analysis

Data were extracted from the survey for the 1,216 student records, coded, checked for accuracy and analyzed using IBM SPSS Statistics version 21.0. Descriptive statistics, including measures of central tendency, frequency, variability, and percentages, were used to describe the responses to the survey questions measuring self-care behaviors. Chi-square testing was used to compare the study groups on the selected outcomes because most were categorical.

Results

Average age of students was 20.33 (SD = 1.6 years), 37% were male, 62.7% were female, and four (0.3%) students identified as transgender. Minorities comprised 22.3% of the sample, including non-Hispanic Black, Hispanic/Latino, Asian/Pacific Islander, American Indian/Alaskan, and Native Hawaiian individuals. Full-time (95.4%) and undergraduate (90%) students comprised most of the sample. Many students lived in campus residence halls (41.6%) and more than one half were not in a relationship (53.8%). Students with and without diabetes reported similar perceived stress, place of residence, relationship status, marital status, membership in Greek social organizations, and participation in organized athletics. Statistically significant differences between groups were found in grade point average (GPA) and perceived health status. Students with diabetes reported a lower GPA and a more negatively perceived health status (Table 1).

Characteristics of Students with and Without DiabetesCharacteristics of Students with and Without Diabetes

Table 1:

Characteristics of Students with and Without Diabetes

Research Question 1 revealed important findings about the health behaviors of students with diabetes. Most students with diabetes reported they did not get enough sleep to feel rested and had problematic daytime sleepiness. Only a small portion of students met the nutrition recommendations for daily fruits and vegetables and only one quarter met the recommended physical activity levels. Furthermore, they engaged in harmful behaviors related to drinking, tobacco use, and risky driving.

The findings from research Question 2 indicated significant differences between students with diabetes and those without diabetes in sleep, nutrition, disordered eating, problematic alcohol and tobacco use, and exercise (Table 2). Fewer students with diabetes reported no extreme difficulty falling asleep, no difficulty handling sleep problems, and no academic problems resulting from sleep difficulties. A statistically significant difference was noted between groups for nutrition-related behaviors, except fruit and vegetable intake. Fewer students with diabetes (than those without diabetes) perceived that they were at their “right” weight, fewer reported no history of anorexia or bulimia, fewer reported no academic problems related to an eating disorder, and fewer reported they did not use unsafe weight loss strategies. Fewer students with diabetes consistently used at least one protective drinking strategy, reported no academic problems due to alcohol, reported no history of substance addiction, or did not drink and drive. In addition, fewer students with diabetes reported no use of tobacco products. A higher percentage of students with diabetes reported meeting exercise recommendations than students without diabetes.

Comparison of Health Behaviors of Students with and Without Diabetes (N = 1,216)

Table 2:

Comparison of Health Behaviors of Students with and Without Diabetes (N = 1,216)

Discussion

The current study revealed the need for improvement of health behaviors of college students with and without diabetes, especially related to sleep, nutrition, disordered eating, problematic tobacco and alcohol use, and exercise. There were statistically significant differences between groups in several categories, revealing students without diabetes reported better health behaviors than students with diabetes.

Of the health behaviors assessed, aspects of sleep were the most problematic for both student groups. Poor sleep is known to have detrimental effects in the general population, especially in terms of health promotion and chronic disease prevention (CDC, 2017b), and poor sleep has adverse effects on college students' academic performance and participation in risk behaviors (Gaultney, 2010; Kenney, LaBrie, Hummer, & Pham, 2012; Lund, Reider, Whiting, & Prichard, 2010; Orzech, Salafsky, & Hamilton, 2011; Phillips et al., 2017). Additional health consequences of inadequate sleep for persons with diabetes include depressed mood, reduced quality of life, decreased motivation, lower grades, and alterations in metabolic control (Barone & Menna-Barreto, 2011; Donga et al., 2010; Perez et al., 2018; Perfect et al., 2012).

The current authors' findings reveal the prevalence of sleep deficiencies among college students with diabetes. Long-term control of blood sugar may be an additional complication of inadequate sleep among college students with diabetes. Saylor, Ji, Calamaro, and Davey's (2019) study of predicted hemoglobin A1c levels related to sleep behaviors among students with type 1 diabetes living on a college campus reported hemoglobin A1c levels increased with decreased weekday sleep duration and increased napping behaviors, suggesting that sleep is a major contributor to glycemic control. These students may not be sufficiently aware of the consequences of poor sleep to their health and well-being and could benefit from further information on this topic.

The recommendations for daily intake of fruits and vegetables were met by few students in either group in the current study. These findings may reflect normative behaviors, as Santos, Hurtado-Ortiz, Amerndariz, van Twist, and Castillo (2017) found similar results among the general college population and college students at risk for diabetes. Given the importance of good nutrition to proper diabetes management, it was surprising that more students with diabetes did not incorporate healthy food choices into their regular nutritional practices.

Although most students did not report an eating disorder, approximately 12% of students with diabetes had weight-loss strategies considered to be unsafe. This finding was contradictory to a similar study of young adults with diabetes compared to a control group of college students without diabetes, where the diabetic group had significantly lower scores on the Eating Disorder Examination Questionnaire when compared to the control group (Keane et al., 2018).

Approximately 30% of students with diabetes in the current study reported using tobacco products. Although this percentage is lower than the 41.6% found in a national sample of 18 to 25 year old adults (Substance Abuse and Mental Health Services Administration, 2017), these findings are nonetheless concerning given the increased risks associated with smoking in persons with diabetes (Pan, Wang, Talaei, & Hu, 2015) and the association of smoking among all college students with high-risk alcohol use, risky driving, depression, abusive relationships, less exercise, and use of emergency and mental health services (Halperin, Smith, Heiligenstein, Brown, & Fleming, 2010).

Approximately all students used at least one protective drinking strategy, which was a positive finding. As unsafe alcohol use can be a health concern for persons with diabetes, additional encouragement to consistently use multiple protective drinking strategies should be given to these students along with information of how hyperglycemia can occur with intake of sweetened beverages and those high in carbohydrates, and alcohol-induced hypoglycemia can occur shortly after drinking and many hours after ingestion (Ansel, 2019).

Students with diabetes acknowledged more difficulty with their academics resulting from problems related to poor sleep, eating disorders, and use of alcohol, which may account for the greater percentage of students with diabetes earning poor grades. Other studies have found a negative effect on cognitive function in adolescents with diabetes related to obesity (Brady et al., 2017) and glycemic control (Abo-El-Asrar et al., 2018), which can impact academic success.

Limitations

Despite the many benefits to conducting an analysis of ACHA-NCHA II data, including a national representation of college students and large sample, there were some limitations. Specific questions about diabetes were not available, such as type of diabetes, age of onset, or state of diabetes control (e.g., hemoglobin A1c level). In addition, the survey provided self-report data at one time point and possible respondent bias. History of other acute or chronic health conditions, such as fractures or asthma, was not considered in this study; therefore, students in both groups may have had other comorbidities. Finally, generalizability is limited, as universities self-selected to participate in the survey.

Implications

The current study helps identify areas where nurses, diabetes educators, campus health personnel, counselors, and primary care providers can positively impact the health of prospective, new, and continuing college students with diabetes. Opportunities for interventions are numerous at the individual, family, and community level, prior to students entering college and after entrance. Although all students can benefit from improved health-promoting behaviors, college students with diabetes are particularly vulnerable and require differential interventions to help them maintain their health and avoid negative outcomes and mental health concerns associated with their behaviors (Clarke et al., 2018; Helgeson et al., 2018).

At the individual level, nurses in community, psychiatric and mental health, and primary care settings can assist older adolescents with diabetes as they prepare for the transition from high school to college (Ashworth, Ward, & Bingley, 2012; Helgeson et al.; 2018; Peters, Laffel, & ADA, 2011; Saylor & Calamaro, 2016). The ADA recommends that providers begin preparing patients for the transfer from pediatric to adult health care practices 1 year prior to the move (Peters et al., 2011) to ensure self-management and mental well-being (Saylor & Calamaro, 2016). Beyond providing guidance related to diabetes self-management skills that optimize metabolic control, including blood glucose monitoring, diet, and exercise, important conversations related to sleep and alcohol and tobacco use should be focused in this preparation. Attention should be given to screening adolescents for mental health problems and disordered eating and include education on risk behaviors associated with sex and substance use (Helgeson et al., 2018; Saylor & Calamaro, 2016; Simms & Monaghan, 2016). Providing a tool kit for adolescents with diabetes prior to leaving for college that includes resources for adjusting to greater independence and a new living environment, such as ADA guidelines for fruit and vegetable consumption, exercise recommendations, and safe alcohol use, could improve health behaviors. In addition, telemedicine may be useful to facilitate communication with students and provide needed support to reduce stress during the transition (Edwards, Noyes, Lowes, Haf Spencer, & Gregory, 2014; Pal et al., 2014).

At the family level, nurses and other health care providers can educate and encourage families to prepare their adolescents with diabetes for the transition to college life. Doing so may reduce maternal stress and enhance the successful transition to college for students with diabetes (Ness, Saylor, & Selekman, 2018). Parents and students should be aware of stress management strategies and mental health resources related to the new independence and academic and social pressures. Parents should be reminded of the developmental phase their child is navigating and to offer anticipatory guidance in the challenges to be faced. Moving from adolescence to adulthood includes many emotional and mental health challenges. Students should be made aware of how to identify in themselves, ways to manage stress, and avenues for assistance with mental health. College counseling and student health services may provide acute and long-term support.

Although families may have had conversations with their adolescent about the importance of nutrition and exercise in diabetes self-management, nurses can provide resources to equip parents to have discussions about the harmful effects of smoking, alcohol use, and risky driving that are unique to a person with diabetes. Nurses can empower parents to have conversations with their student about the use of a designated driver or finding other modes of transportation to avoid driving after drinking alcohol. In addition, parents, nurses, and nurse practitioners can assess and provide strategies for mental health well-being. These strategies may include seeking counseling, stress management activities, and building support systems such as recreation or study groups. Nurses can guide parents to send their student regular positive support messages and care packages containing fruits and healthy snacks and encourage them to participate in organized campus sports and other activities.

The current study also has implications at the individual and community level for college health services, as many goals of Healthy Campus 2020 apply (ACHA, 2012). In addition to encouraging students to use the college health services for their medical health care needs, campus nurses could inform students of locations of after-hours food purchases, recreational facilities, opportunities for activities such as intramural sports teams, eligibility for disability services, and resources such as smoking cessation programs to assist students in healthy nutrition, exercise, and prevention of harm. Providing this anticipatory guidance may lessen stress for incoming students and their families.

The desire for normalcy and to fit in with peers without diabetes is demonstrated in the current study. Because the perceived intrusiveness of the chronic illness upon the young adult's life may be directly and indirectly related to psychosocial outcomes, such as depressive and anxious symptoms (Bakula et al., 2019), interventions to increase awareness of chronic disease among young adults may prove beneficial. Many college students, with or without diabetes, do not see chronic disease as life-threatening and may continue to engage in behaviors that may cause harm (Amuta, Jacobs, Barry, Popoola, & Crosslin, 2016). It is important for campuses to provide an environment that promotes positive behaviors to improve health and well-being for all students, such as campus wellness centers that include facilities for physical activities and peer mentors to promote healthy behaviors. Likewise, community-level interventions designed to alter the campus drinking environment and institute smoke-free policies have been successful in decreasing alcohol-related injuries and interpersonal effects of alcohol use along with positive changes to smoking behaviors (Seo, Macy, Torabi, & Middlestadt, 2011; Wolfson et al., 2012).

College students with diabetes value connecting with peers with their same condition and such connections are shown to have positive health benefits (Fredette et al., 2016; Saylor et al., 2018). Colleges could develop more residential housing where students live in a community designed to promote overall good health (e.g., focuses on nutrition, exercise, sleep, and risk-free behaviors). This type of healthy living environment could have a positive impact on academic achievement and improve all students' self-care behaviors (Ruthig, Marrone, Hladkyj, & Robinson-Epp, 2011). Living in such a space could help students with diabetes find support for maintaining healthy behaviors through mutual interests in healthy living. Alternatively, students with diabetes could be pointed toward positive, age-appropriate online patient communities or social networks for emotional support, condition-specific information, and self-management tools to provide an additional source of community and belonging (Cantrell & Boles, 2015). Campus health services, including mental health services, can establish advocacy groups or chapters of national diabetes organizations to provide opportunities for students to connect with peer mentors and develop a network of individuals with shared health concerns and goals. Establishing connectedness to the college has been associated with educational attainment and graduation among students with childhood onset chronic illness, such as diabetes (Maslow, Haydon, McRee, & Halpern, 2012).

Conclusion

Previous studies of college students with diabetes have addressed alcohol use (Ravert, 2009) and self-management (Balfe, 2009; Ravert, Boren, & Wiebke, 2015; Wilson, 2010) and are primarily designed as qualitative studies that are limited in scope and the number of participants. The current descriptive study represented a large, diverse sample and filled a gap in the literature by examining health behaviors of college students with diabetes. Harmful behaviors related to tobacco use and driving practices have not been previously studied in this population. The health protective behaviors as well as self-care deficits and problem behaviors of students with diabetes were compared to students without diabetes. This study lays a foundation for future work that can determine trends in self-care behaviors of college students with and without diabetes.

Findings from the current study can be used by health care providers, especially nurses, to implement interventions in a variety of settings. All college students with diabetes, regardless of age of onset or type of diabetes, will benefit from additional support from families and health care providers as they move from family caregivers to independence, transfer from pediatric to adult health providers, and adjust to college life all while managing a complex chronic illness in a new academic, social, emotional, and living environment. By developing programs that address all levels of prevention for this at-risk population and empowering these individuals to leave home with more confidence to manage their health, they may achieve greater academic success in college fulfilling their goals of degree attainment, employment, and a future of good health.

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Characteristics of Students with and Without Diabetes

Characteristicn (%)
Students With Diabetes (n = 528)Students Without Diabetes (n = 688)
Gender
  Female324 (62)433 (63.2)
  Male195 (37.3)252 (36.8)
  Transgender4 (0.8)0 (0)
Race/ethnicity
  White, Non-Hispanic413 (78.2)532 (77.3)
  Black, Non-Hispanic41 (7.8)41 (6)
  Hispanic/Latino26 (4.9)53 (7.7)
  Asian/Pacific Islander49 (9.3)70 (10.2)
  American Indian/Alaskan, Native Hawaiian11 (2.1)9 (1.3)
  Biracial/multiracial22 (4.2)20 (2.9)
Year in school
  1st year undergraduate150 (28.7)188 (27.5)
  2nd year undergraduate113 (21.6)141 (20.6)
  3rd year undergraduate110 (21.1)159 (23.3)
  4th year undergraduate99 (19)122 (17.9)
  5th year undergraduate or more23 (4.4)20 (2.9)
  Graduate/professional24 (4.6)48 (7)
Age (years)
  1870 (13.3)87 (12.6)
  19120 (22.7)166 (24.1)
  20106 (20.1)137 (19.9)
  21105 (19.9)137 (19.9)
  2267 (12.7)89 (12.9)
  2335 (6.6)51 (7.4)
  2425 (4.7)22 (3.2)
Enrollment status
  Full-time498 (95.2)653 (95.6)
  Part-time19 (3.6)23 (3.4)
GPAa
  A151 (29)244 (35.7)
  B275 (52.8)330 (48.3)
  C76 (14.6)96 (14.1)
  D/F11 (2.1)2 (0.3)
Stress level
  Average or less245 (46.6)342 (50)
  More than average or tremendous281 (53.4)342 (50)
Perceived health statusb
  Excellent/very good/good416 (81.6)618 (91.5)
  Fair/poor93 (18.2)55 (8.2)
Relationship status
  Not in a relationship295 (56.3)356 (52)
  In relationship, not living together188 (35.9)276 (40.3)
  In relationship, living together41 (7.8)53 (7.7)
Marital status
  Single482 (91.8)637 (93.5)
  Married/partnered26 (5)28 (4.1)
  Separated1 (0.2)0 (0)
  Divorced1 (0.2)1 (0.1)
  Other15 (2.9)15 (2.2)
Social Greek organizations
  Not a member457 (87.5)601 (88.8)
  Member65 (12.5)76 (11.2)
Residence
  Campus residence hall206 (39.4)297 (43.4)
  Fraternity/sorority house16 (3.1)12 (1.8)
  Other campus housing32 (6.1)59 (8.6)
  Parent/guardian's home79 (15.1)75 (10.9)
  Other off-campus housing179 (34.2)224 (32.7)
  Other11 (2.1)18 (2.6)
Organized athletics
  Varsity athlete
    No460 (88.8)619 (91.4)
    Yes58 (11.2)58 (8.6)
  Club sports
    No451 (87.2)598 (89.3)
    Yes66 (12.8)72 (10.7)
  Intramural sports
    No393 (76)525 (78.1)
    Yes124 (240147 (21.9)

Comparison of Health Behaviors of Students with and Without Diabetes (N = 1,216)

Health Behaviorn (%)p Valuea
Students With Diabetes (n = 528)Students Without Diabetes (n = 688)
Sleep
  Felt rested every morning in past 7 days25 (4.8)30 (4.4)0.747
  No problem with daytime sleepiness in past 7 days49 (9.3)61 (8.9)0.791
  No extreme difficulty falling asleep in past 7 days188 (36)302 (44)0.005*
  No difficulty handling sleep problems within last 12 months338 (64.3)502 (73.3)<0.001**
  No academic problems due to sleep difficulties within last 12 months381 (73.3)542 (79.6)0.010*
Nutrition
  Met fruit and vegetable recommendations41 (7.8)36 (5.2)0.073
Disordered eating
  Perceived to be the right weight237 (44.9)389 (56.5)<0.001**
  No history of anorexia or bulimia in last 12 months488 (93.3)673 (98.5)<0.001**
  No academic problems due to eating disorder in last 12 months486 (93.5)670 (98.7)<0.001**
  Did not use unsafe weight loss strategies in last 30 days458 (87.4)642 (94.1)<0.001**
Tobacco
  No use of cigarettes or other tobacco products last 30 days365 (69.8)513 (75.6)0.026*
Alcohol
  Met age and gender criteria for legal and moderate alcohol use153 (29.8)203 (29.8)0.987
  No binge drinking in last 2 weeks304 (57.7)416 (60.6)0.299
  Consistently used at least one protective drinking strategy in last 12 months504 (95.6)673 (98.5)0.002*
  No academic problems due to alcohol within last 12 months464 (88.9)646 (94.4)<0.001**
  No diagnosis or treatment of substance use or addiction in last 12 months488 (93.5)677 (99)<0.001**
  No drinking and driving in last 30 days423 (80.4)581 (84.9)0.038*
  No driving after five or more drinks in last 30 days498 (95)662 (96.9)0.093
Exercise
  Met exercise recommendations for past 7 days143 (27.6)151 (22.2)0.034*
Authors

Dr. Cockroft is Associate Professor, University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina; Dr. Bartlett is Professor and Lifespan Researcher, University of Alabama Capstone College of Nursing, Tuscaloosa, Alabama; and Dr. Wallace is Daphine Doster Mastroianni Distinguished Professor, University of North Carolina at Greensboro School of Nursing, Greensboro, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the American College Health Association for sharing their data for this project.

Address correspondence to T. Robin Bartlett, PhD, RN, Professor and Lifespan Researcher, University of Alabama Capstone College of Nursing, Box 870358, 650 University Boulevard East, Tuscaloosa, AL 35487; e-mail: trbartlett@ua.edu.

Received: June 21, 2019
Accepted: July 22, 2019
Posted Online: September 27, 2019

10.3928/02793695-20190919-04

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