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Lifestyle values of adolescents: results from Minnesota Heart Health Youth Program.


A great deal of attention is being paid to primary prevention of noncommunicable disease among children and adolescents. Such programs have a number of advantages over those implemented with adults. The most important may be the initiation of life-long patterns of healthful behavior.

The "Achilles heel" of programs for children and adolescents is the difficulty in creating approaches that are appealing and meaningful for them, particularly when health-enhancing behaviors may not be as highly valued as unhealthful behaviors. One of the obligatory components in the development of primary prevention programs is the search for the salient values and motivations of young people which can then be used in developing a lifestyle strategy. Since values change over the course of adolescence to adult concerns, the study of these changes may provide important clues for program structure.

Research data on attitudinal aspects of children's lifestyle are mostly confined to health-related behaviors (Story & Resnick, 1986; Perry et al., 1987; Nutbeam, 1987). In the present study, values on a broader spectrum of lifestyle patterns were assessed with the aim of identifying potential incentives for intervention. An attempt was made to answer the questions: To what extent do children and adolescents value specific health patterns as compared to other patterns, and how do these values change over time? To what degree do school-based preventive programs influence these values?


As a part of the Minnesota Heart Health Program (MHHP) (Blackburn et al., 1984), a seven-year study of sixth- through 12th-grade students was performed. The study included the five-year health-promotion program. The intervention community was made up of Fargo, North Dakota and Moorhead, Minnesota. Sioux Falls, South Dakota served as the reference community. Each community is an isolated urban center of approximately 110,000 population and is primarily white and middle class. All 6th graders (mean age 12.2 years) in both communities participated in a baseline study in 1983 (N = 2,406), and that grade cohort was followed annually through the 12th grade. Regardless of participation in earlier surveys, students were eligible to participate in the survey, forming both cohort and cross-sectional samples. Since developmental concerns are most critical to this examination, only data from the cohort sample were used.

A self-administered questionnaire assessed psychological factors and behavioral patterns. This was administered during school hours each spring, from 1983 through 1989. A section of the questionnaire concerned with various lifestyle factors and their importance to students was selected. The students were asked to respond to eight factors, on a Likert-type scale (Anastasi, 1979), to the question: "When you think about the things that really count in how you feel about yourself and life, how important to you is: (1) the number of friends students have; (2) the kind of food they eat; (3) the amount of money they can spend on themselves; (4) the amount of exercise they get; (5) the amount of TV they watch; (6) their physical appearance; (7) how well they do in school; and (8) how well they get along with their families?" The rating scale ranged from 1 (not at all important) through 5 (extremely important). These items were selected because they reflect the major arenas of adolescent life--family, school, peers, self, entertainment--and how these are valued compared with specific health-related concerns--food and exercise--that were targeted as part of the MHHP.

Intervention Program

The overall model and design of the intervention program, called the Class of 1989 Study, is described in detail elsewhere (Perry, Klepp, & Sillers, 1989; Kelder, 1991). This school-based health promotion program was conducted for five years (grades 6 through 10) from 1983 to 1987. The theoretical factors used as guidance for intervention design were based on social learning theory (Bandura, 1977) and theory developed specifically for MHHP (Perry & Murray, 1982; Perry & Jessor, 1985). These factors included changing peer group norms, providing alternative healthful role models, teaching social skills to enable the students to resist pressures to engage in health-compromising behaviors, and the generation of health-enhancing alternatives. Preventive measures within the framework of the intervention program were targeted at reducing tobacco smoking and alcohol use, increasing regular physical activity, and promoting healthful dietary habits.

Statistical Analysis

The SAS General Linear Models (SAS Institute Inc., 1989) procedure was employed to estimate changes in the parameters studied over time. Separate analyses were performed for each of the eight items for all seven years. Only those participants who were measured at baseline were eligible for any subsequent analysis. Each analysis included a term for age, gender, treatment status, treatment by gender interaction, and school identifier. Where treatment and reference differences were expected and of interest, analyses were stratified by gender and the treatment effect was tested against the school rather than individual variance as described by Murray and Hannan (1990).


Table 1 indicates the response rate for males and females in intervention and reference communities. There was a substantial decline TABULAR DATA OMITTED in participation rates by all the students by the end of the study. However, as a rule, subject attrition is inevitable in longitudinal studies, especially in this case because no attempt was made to follow up on students who moved out of the community or who had dropped out of school.

The changes in values of various lifestyle activities observed over the five-year period are presented in Figures 1 and 2. In nearly all the analyses, gender differences were revealed, and these results were analyzed for males and females separately. Some of the items were not intended to be influenced by the school preventive interventions; for example, the number of friends students have or the amount of money they can spend on themselves. On the other hand, items such as the importance of the kinds of food students eat or the amount of exercise they get were intervention targets; these results are presented separately in Table 2 by treatment and reference groups.

The three most valuable items for younger students (6th graders) were their physical appearance, academic performance in school, and relations with family members. However, over the course of the six years of follow-up, the importance of these parameters excluding appearance gradually diminished, although the three still remained the most valued at the 12th grade.

Value placed on number of friends peaked during the 8th-9th grades for both genders. This finding could be interpreted as additional evidence of the significance of peer influence at this time of life. The gradual loss of value placed on family (most likely, on parental approval) confirms the well-documented finding that the referent group changes from parents to peers as adolescents get older (Kandel & Andrews, 1987; Chassin et al., 1984). It also suggested that peer involvement may be critical during the early adolescent years.

From the figures it can be noted that most parameters tended to lose value as a function of age. Surprisingly, this finding also applied to the amount of money students (especially girls) could spend, and the amount of TV they could watch, which scored lowest among the items studied. The only characteristic which demonstrated a tendency to increase in value was physical appearance. The changes were more pronounced in boys than in girls, although in 6th through 10th grades, girls valued physical appearance more than did boys.

A significant difference between boys and girls on the importance of the kind of food they eat was observed after 7th grade through the end of the study. Although there was no significant difference between treatment and reference groups by gender, a higher value placed on food was found in the female treatment group than among female controls and all males. The primary MHHP school education program aimed at formation of healthful dietary habits was started in 10th grade, before 10th grade measurement. Therefore, the significant differences observed in the female groups treatment most likely reflected the temporary treatment effect, which gradually disappeared over the next two years. However, this might indicate the tendency for a positive influence of the MHHP program in getting the girls to be more cautious and discriminating. It also might signal females' early sensitivity to what they consume.
Table 2. Value Scores on Health-Related Lifestyle Patterns in
Treatment (T) and Reference (R) Communities

Grade 6 7 8 9 10 11 12

When you think about the things really count in how you feel
about yourself and life, how important to you is:

The kind of food you eat

Girls T 3.86 3.77 3.73 3.67 3.74 3.73 3.74
 R 3.78 3.76 3.65 3.61 3.53 3.59 3.61
 F 1.98 0.07 1.6 1.03 11.38 4.21 1.99
 p N.S. N.S. N.S. N.S. 0.02 0.09 N.S.

Boys T 3.81 3.66 3.52 3.49 3.45 3.50 3.44
 R 3.72 3.63 3.50 3.44 3.35 3.48 3.52
 F 1.7 0.27 0.16 0.14 1.87 0.15 0.54
 p N.S. N.S. N.S. N.S. N.S. N.S. N.S.

The amount of exercise you get

Girls T 3.91 3.97 4.10 4.02 4.01 3.99 3.93
 R 3.85 3.93 3.86 3.89 3.72 3.77 3.64
 F 1.31 0.45 16.83 4.76 20.56 9.02 11.64
 p N.S. N.S. 0.009 0.055 0.008 0.01 0.02

Boys T 3.86 3.95 3.90 3.97 3.94 3.97 3.90
 R 3.78 3.85 3.74 3.70 3.73 3.85 3.84
 F 0.91 1.73 4.2 12.84 6.88 2.52 0.39
 p N.S. N.S. 0.07 0.005 0.04 N.S. N.S.

The primary MHHP school education program for physical activity began in the 8th grade, before measurement. The exercise program was associated with students' values regarding physical activity as well. The amount of exercise tended to be valued more by the treatment students than by the control students, and the difference between the female groups by treatment was statistically significant in 8th through 12th grades. For males, the effect of treatment was inconsistent regarding value of physical activity (as it was regarding dietary habits).


Undoubtedly, physical appearance plays a critical role for teenagers and is valued more than any other item considered in the study. This increasing importance of physical appearance with age makes it a potentially powerful motivating factor for healthful lifestyle formation. It may be inferred from the results that addressing issues of physical appearance (rather than, for example, health-related outcomes) would be greatest interest to this age group. The question of whether as adults we want to encourage this value, is certainly open to debate. However, the "use" of personal appearance to market commercial products certainly predominates in advertising and may need to be creatively counterbalanced by health programs.

The literature indicates that at least 72% of all high school seniors watch television every day (Office of Educational Research and Improvement, 1991), and television itself might play an important role in the formation of dietary habits and physical activity patterns in children (Taras et al., 1989). Within the framework of community-based intervention programs, great attention is usually paid to mass media messages that promote both healthful lifestyles and discourage tobacco use and other health-compromising behaviors. It is unclear, however, if children value the amount of television they watch and how this value changes with age. On the basis of findings from this study, we suggest that the influence of television for contemporary adolescents may not be as significant as previously thought. A decrease in the amount of time teenagers spend watching television, along with an increase in time spent listening to the radio, was also recently reported (Radio Advertising Bureau, 1987). Although the effect of the mass media on children and adolescents needs further investigation, these findings can contribute to the planning of more effective future mass media-based primary prevention programs.

Values are major components of lifestyle patterns (Aaro et al., 1986), and their changes may reflect the efficacy of an intervention aimed at healthful lifestyle formation. The results of the study suggest that a comprehensive risk-factor intervention based on contemporary preventive approaches, can influence to a limited extent the "natural" age-related unfavorable changes in some teenagers' health-related values. This effect is seen in this study, particularly concerning the importance of the kind of food female students eat and the amount of exercise all students get. With regard to food, the nationwide teenage dietary patterns have recently been reported to be less than healthful: nearly 40% of adolescents eat fried food at least four times a week; 45% eat three or more snacks every day, over 60% of which are junk food (The National Adolescent Student Health Survey, 1989). Therefore, studies on dietary intervention and subsequent trends of healthful versus unhealthful food values among youth are important. From the question used in the present study, it cannot be concluded with confidence that the "kind of food" necessarily means there is a dilemma between healthful and unhealthful food, but even the fact that students are beginning to pay attention to this issue is promising. In addition, a recently performed analysis of actual dietary patterns in the intervention and reference communities of the Class of 1989 study showed a substantial shift toward heart-healthful diet among female students in the intervention group after the program (Kelder et al., 1993).

Lack of physical activity among adolescents remains a major public health problem. The 1990 Youth Risk Behavior Survey revealed that significantly fewer high school seniors enrolled in physical education sessions than had enrolled in previous years (Centers for Disease Control, 1990). Also, several European studies (Kardialis et al., 1990; Wold, 1989) showed that children and adolescents (mostly girls) are likely to lose interest in physical exercise over time. The same tendency was observed in the present study in the reference group. However, both boys and girls in the treatment group tended to value the amount of exercise they get more than did those in the reference group; in boys, however, the effect had worn off by the end of the study. This appears to indicate not only early health-related sensitivity in females, but the need to find specific approaches that can maintain a higher value that males give to health-related lifestyles through the high school years.

Also, our results on value of food and exercise suggest that review sessions may be helpful after two or three years of intervention to prevent the loss of interest in the value of health-related behaviors.

The low participation rate during the last two years of follow-up, especially in the reference group, is a significant limitation of the present study. Although the results obtained from those two years should be interpreted with caution, they are included here because (1) no data on changing values with increasing age in adolescents have been reported previously, so the trends found within the whole age range are unique and interesting; and (2) older adolescents represent a period during which health education measures are usually less effective, so our findings might provide some clues for developers of health education programs. Undoubtedly, the issue of how adolescent values change with age is important from the standpoint of prevention and need to be investigated on samples with larger response rates.

The present analyses also were limited by the small number of specific variables available in the questionnaire. A broader spectrum of items might be included in future studies. Nonetheless, the results of this study, we believe, contribute to our understanding of teenagers' values and priorities at different ages, and thus may help in the development of more efficacious preventive programs.


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Alexander V. Prokhorov, M.D., Ph.D., Post-Doctoral Fellow, Cancer Prevention Research Consortium, University of Rhode Island, Flagg Road, Kingston, R.I. 02881.

Steven H. Kelder, M.P.H., Predoctoral Fellow, Division of Epidemiology, School of Public Health, University of Minnesota, Suite 300, 1300 South Second Street, Minneapolis, MN 55454.

Knut-Inge Klepp, Ph.D., M.P.H., Epidemiologist, Research Center for Health Promotion, University of Bergen, Oisteinsgate 3, N-5007, Bergen, Norway.
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Author:Prokhorov, Alexander V.; Perry, Cheryl L.; Kelder, Steven H.; Klepp, Knut-Inge
Date:Sep 22, 1993
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