Thesis final manuscript 2014

i
ASSOCIATIONS WITH STRESS: A CROSS-SECTIONAL COMPARISON OF
WELLNESS IN OLDER ADULTS
By
SHELBY BENCI, B.S. (California Polytechnic State University, San Luis Obispo) 2012
CHAD EARL, B.S. (Bradley University) 2000
APRIL IRVINE, B.S. (Johnson & Wales University) 2012
JULIE LONG, B.S. (California Polytechnic State University, San Luis Obispo) 2012
NIKKI NIES, B.S. (Montclair State University) 2013
JESSICA SCHIAPPA, B.S. (Benedictine University) 2013
RESEARCH MANUSCRIPT
Submitted in partial fulfillment of the requirements for the degree of
MASTER OF SCIENCE in NUTRITION AND WELLNESS
In the College of Education and Health Service,
Benedictine University, Lisle, Illinois
Research Advisor:
Dr. Bonnie Beezhold, MHS, CHES
December 2014

ii
By
SHELBY BENCI, B.S.
CHAD EARL, B.S.
APRIL IRVINE, B.S.
JULIE LONG, B.S.
NIKKI NIES, B.S.
JESSICA SCHIAPPA, B.S.
The Research Manuscript submitted has been read and approved by the Research
Advisor. It is hereby recommended that this Research Manuscript be accepted as
fulfilling part of the Master of Science in Nutrition and Wellness graduate degree in the
College of Education and Health Services at Benedictine University, Lisle, Illinois.
________________________________ _________________________________
Signature of Bonnie Beezhold, PhD, Signature of Karen Plawecki, M.S., Ph.D.
MHS, CHES, Research Advisor Director, M.S. in Nutrition and Wellness
APPROVED FOR BINDING
_________________________________
Signature of Catherine Arnold, M.S., Ed.D.
Chairperson, Nutrition Department
APPROVED COMPLETION OF
RESEARCH REQUIREMENT
__________________________________
Signature of Alan Gorr, Ph.D., M.P.H.
Dean, College of Education and Health
Services
December 11, 2014________________ December, 2014___________________
Date of Oral Defense Intended Graduation Date (December 2014)

iv
© Copyright by
Shelby Benci, Chad Earl, April Irvine, Julie Long, Nikki Nies, Jessica Schiappa
2014: All Rights Reserved

v
TABLE OF CONTENTS
Page
LIST OF TABLES vii
ACKNOWLEDGEMENTS x
STRUCTURED RESEARCH ABSTRACT xi
CHAPTER 1: INTRODUCTION 1
Introduction 1
Study Purpose 3
Hypotheses 4
Variables to be Examined 6
CHAPTER 2: LITERATURE REVIEW 8
Dimensions of Wellness 8
Mental Wellness by Chad Earl 9
Physical Wellness by Chad Earl 9
Social Wellness by Chad Earl 10
Spiritual Wellness by Chad Earl 11
Health and Wellness of Older Adults 12
Depression by Jessica Schiappa 13
Associations of Stress and Depression by Jessica Schiappa 14
Weight by April Irvine 15
Physical Activity by April Irvine 16
Dietary Patterns in Older Adults by April Irvine 17
Health and Wellness of the Vowed Religious Community 19
Dietary Patterns in Vowed Religious Communities by Nikki Nies 19
Blood Pressure by Nikki Nies 19
Comparison of Groups by Nikki Nies 20
Mechanisms of Stress 22
Impact of Chronic Stress on Physical Wellness by Shelby Benci 24
Impact of Chronic Stress on Mental Wellness by Shelby Benci 26
Impact of Chronic Stress Eating Behaviors and Weight by Shelby Benci 28
Stress and Aging by Shelby Benci 30

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Mitigating Factors of Stress 30
Multivitamin/Mineral Supplementation by Julie Long 31
Omega 3 Fatty Acids by Julie Long 32
Fruits and Vegetables by Julie Long 34
Physical Activity by Chad Earl 35
Social Support by Chad Earl 36
Spiritual Practices by Chad Earl 37
CHAPTER 3: METHODOLOGY 39
Research Study Design 39
Research Study Recruitment 39
Data Collection Methods and Process 41
Validity and Reliability of Methods 44
Measurement Tools 48
Statistical Procedures 54
CHAPTER 4: FINDINGS 56
Stress & Health & Lifestyle Factors Hypotheses 1-4
by Shelby Benci 59
Alcohol & Health & Lifestyle Factors Hypotheses 5-8
by Jessica Schiappa 62
Sweets Intake & Health & Lifestyle Factors Hypotheses 9-13
by Julie Long 65
Physical Health Measures & Health & Lifestyle Factors Hypotheses 14-18
by Chad Earl 68
Geriatric Depression Scale & Health & Lifestyle Factors Hypotheses 19-23
by Nikki Nies 72
Amount of Sleep & Health & Lifestyle Factors Hypotheses 24-27
by April Irvine 75
CHAPTER 5: DISCUSSION 80
Overall Findings 80
Stress 80
Depression 84
Sweets Intake 85
Alcohol Intake 88
Sleep 90
Physical Health Measures 91
Strengths and Limitations 93
Conclusions 94

vii
REFERENCES 95
APPENDIX A: Cross-Sectional Wellness Study IRB Document 115
APPENDIX B: Wellness Survey 136
APPENDIX C: Recruitment Tools 143
APPENDIX D: Signed Informed Consent Form 146
APPENDIX E: Registration and Testing Procedures 147
APPENDIX F: Health Assessment Data Collection Tools 150

viii
LIST OF TABLES
Table Page
1. Demographic and Lifestyle Characteristics by Group…………………………...57
2. Health and Wellness Characteristics by Group………………………………….58
3. Comparison of Means between Living Groups………………………………….59
4. Associations between PSS and Health and Lifestyle Factors……………………61
5. PSS Multiple Linear Regression Analysis……………………………………….62
6. Comparison of Means of Weekly Alcohol Intake between Living Groups……...63
7. Comparison of Means between Binned Weekly Alcohol Intake Groups………..64
8. Associations between Alcohol Intake and Stress………………………………...65
9. Comparison of Means of Sweet Intake…………………………………………..66
10. Significant Correlations of Variables with Sweets Intake……………………….67
11. Multiple Linear Regression Analysis of Sweets Intake………………………….68
12. Comparison of Means between Groups of Heart Rate & Body Fat……………..69
13. Correlations with Physical Parameters and Perceived Stress……………………69
14. Associations with Muscle Mass………………………………………………….70
15. Body Fat and Heart Rate Associations…………………………………………..71
16. Comparison of Stress Means between Muscle Mass Groupings………………...72
17. Comparison of Means with Geriatric Depression Scale Scores…………………73
18. Significant Correlations of Variables with Geriatric Depression Scale………….73

ix
19. Multivariate Analyses of Predictors of Depression……………………………...74
20. Significant Correlations of Variables with Geriatric Depression Scale………….75
21. Comparison of Means between Genders and Hours of Sleep……………………75
22. Comparison of Means between Living Groups with Hours of Sleep……………76
23. Comparison of Means between Sleep Hour Binned Groups…………………….77
24. Significant Correlations of Variables with Sleep Hours…………………………79

x
ACKNOWLEDGEMENTS
We would like to first thank our advisor, Dr. Bonnie Beezhold, for her support
and guidance through this entire process. We would also like to thank our family and
friends for their endless love and support. We express our sincere gratitude and thanks to
one another, as none of this could have been completed without each other’s support,
effort, and time. Thank you to all who have helped us on this journey.

xi
ABSTRACT OF RESEARCH MANUSCRIPT
By
SHELBY BENCI, B.S.
CHAD EARL, B.S.
APRIL IRVINE, B.S.
JULIE LONG, B.S.
NIKKI NIES, B.S.
JESSICA SCHIAPPA, B.S.
Benedictine University, Lisle, Illinois
December 2014
Research Advisor: Bonnie Beezhold, PhD, MHS, CHES
Background: Chronic stress negatively impacts wellness and is associated with physical
and mental chronic disease. Certain lifestyle factors can mitigate stress and improve
health outcomes.
Objective: To examine the relationships of stress with physical, emotional, social,
spiritual health measures, and diet and lifestyle factors in older adults living in two
different communal environments.
Methods: Cross-sectional study of 67 participants were recruited from vowed religious
communities and an independent retirement community. Study assessments included a
survey containing demographic and lifestyle questions, brief validated questionnaires
measuring perceived stress and other wellness dimensions, a 24-hour recall questionnaire
and anthropometric measurements.

xii
Results: Of the 67 participants, 35 resided in vowed religious communities and 32
resided in an independent retirement community. A significant difference in reported
depression, as measured by the Geriatric Depression Scale-15, was found with the vowed
religious community reporting a higher mean score than the independent retirement
community (2.12 vs. 1.16, p = .020). Percent body fat (38.55 vs. 33.26, p = .025) and
heart rate (75.86 vs. 68.41, p = .029) were also significantly different by living group,
with higher values in the vowed religious community compared to the independent
retirement community. Spirituality, vitamin D intake, and daily sweets intake explained
50% of the variance in perceived stress scores in multivariate analyses.
Conclusion: Our findings suggest that older adults living in vowed religious
communities do not experience greater well-being than those living in independent
retirement community. Perceived stress in older adults may be reduced by certain
lifestyle practice.

1
CHAPTER 1
INTRODUCTION
Problem Description and Rational
Worldwide, stress is the second most common health problem that can negatively
impact an individual’s wellness 1
. Unhealthy levels of stress can negatively impact both
mental and physical health in every age group. The U.S. Census Bureau projects that by
2050, 20% of the U.S. population will be over the age of 65 2
. Increased exposure to
stressful life events and oxidative damage from chronic stress may specifically impact
older adults over younger generations 3
. Stress and negative emotions activate the
hypothalamic-pituitary-adrenal (HPA) axis to release cortisol into circulation 4
.
Prolonged activation of this axis has been associated with inflammation, physical and
mental health problems, and mortality 5
. Specifically, stress can also induce
inflammatory brain-altering processes and are now thought to exacerbate brain aging 6,7
.
Chronic exposure to acute stress and cortisol is related to DNA and RNA damage in older
adults 7
. In a recent study that compared stress levels of caregivers and non-caregiving
controls, it was shown that the cumulative effect of daily stressors promoted elevations in
blood inflammatory markers 8
.

2
Moreover, chronic stress is associated with negative physical and mental health
outcomes such as cardiovascular disease, metabolic syndrome, weight gain and late-life
depressive symptoms 2,9
. Stress can affect mental health through dysfunction of the HPA
axis and increased serum cortisol levels, which may cause depression, decreased quality
of life and negative emotions. In older adults, increased perceived stress and stressful life
events can lead to an increase in depressive symptoms 2
. Research also suggests that there
is increasing variability in self-esteem at progressively older ages, which increases stress
levels 10,11
. Age-related declines in older adults’ self-esteem could derive from a loss of
social roles, social isolation, or an increase in physical health problems 12
. In fact,
optimism has been found to buffer the association between perceived stress and elevated
levels of diurnal cortisol 13
.
Dietary factors can influence mental health. A healthy diet and physical activity
has been shown to decrease perceived stress and improve health outcomes and health-
related quality of life 14
. A recent prospective study published in the Journal of the
Academy of Nutrition and Dietetics assessed the associations between self-reported stress
and dietary intakes and dietary behaviors of adults in the United States 15
. The study
found that higher perceived stress scores were associated with higher fat intake of the
calories consumed, greater intake of high-fat snacks, and fast food 15
. This suggests that
people who perceive themselves to be more stressed are more likely to eat an unhealthy
diet, which over time can lead to health problems including excess weight gain and
obesity 15
.
Lifestyle and environmental factors can also be influential with respect to mental
health. The stress or support in one’s everyday living environment may affect perceived

3
stress or depression. A vowed religious life lived in a close community may positively
influence these factors and even provide physical health benefits. Far removed from 21st
century social and cultural norms and pace, an ascetic lifestyle is one of self-discipline,
an absence of self-indulgence and regular acts of fasting, all of which may benefit ones
mental and physical health 16,17
. For example, a prospective study in Italy that
investigated blood pressure, an indicator of stress, followed 144 nuns and 138 similar
laywomen controls for 20 years, and found that blood pressure did not increase with age
in the nuns compared to laywomen, an unexpected result only found in comparisons with
hunter-gatherer groups 18
. While monks and nuns live a structured, cohesive, minimalist
lifestyle, adults living in an independent community typically are not limited by such
constraints, which may lead to mental health differences between the two populations. In
American older adults, 80% have at least one chronic disease and 50% have two or more.
In a study of 1085 independently living adults over the age of 60, those with more
chronic disease diagnoses had an increase in depressive symptoms and a decrease in
health-related quality of life 19
.
Study Purpose
The aim of our study was to explore various dimensions of wellness: physical,
emotional, social, and spiritual, with a focus on stress, and associations with diet, lifestyle
factors, and physical health parameters in older adults. We also compared the wellness of
adults in different communal environments, by exploring these factors in both a vowed
religious community and an independent living community. Due to the older age of
adults in vowed religious environments, we limited our community group to 65 years and

4
older. Participants completed a survey with demographic questions as well as four
wellness scales; we also obtained physical measurements and took a 24-hour dietary
recall. We hypothesize that those living in vowed religious communities have less stress
and healthier dimensions of wellness than those living in an independent living
community.
Hypotheses
 Relationship between Stress and Health and Lifestyle Factors
o H10: There is no difference in stress reported by gender in older adults.
o H20: There is no difference in stress reported by the vowed religious
community and the independent retirement community in older adults.
o H30: Perceived stress is not related to health and lifestyle factors in older
adults.
o H41: Certain health and lifestyle factors contribute to or predict perceived
stress in older adults.
 Relationship between Alcohol and Health and Lifestyle Factors
o H50: There is no difference in weekly alcohol intake between genders in
older adults.
o H60: There is no difference in weekly alcohol intake between the vowed
religious community and independent retirement community in older
adults.
o H70: Perceived stress scores will not be different in levels of alcohol
intake in older adults.

5
o H80: Weekly alcohol intake is not related to stress or other lifestyle and
health factors in older adults.
 Relationship between Sweets Intake and Health and Lifestyle Factors
o H90: There is no difference in sweets intake by gender in older adults.
o H100: Sweets intake per day does not differ in the vowed religious
community compared to the independent retirement community in older
adults.
o H111: Sweets intake is related to perceived stress in older adults and other
health and lifestyle factors
o H121: Perceived stress scores are different by sweets intake level in older
adults.
 Perceived Stress and Body Composition:
o H131: Physical health parameters are associated with stress in older adults.
o H141: Muscle mass was associated with lifestyle factors in older adults.

6
H150: There are no differences in physical health parameters between
older adults in the two living environments.
o H161: Body fat and heart rate are associated with lifestyle factors in older
adults.
o H170: Perceived stress scores do not differ in older individuals with lower
and higher muscle mass.
 Relationship between Geriatric Depression Scale and Health and Lifestyle Factors
o H181: Older adults living in the vowed religious group will report less
depression than those living in the independent retirement group.
o H191: Health and lifestyle factors significantly related to depression
explain the difference in depression we observed between living groups in
older adults.
o H201: Depressive symptoms reported by participants will be associated
with health and lifestyle factors in older adults.
 Relationship between Amount of Sleep and Health and Lifestyle Factors
o H210: There is no difference in reported hours of sleep per night by gender
in older adults.
o H220: There is no difference in reported hours of sleep per night between
the vowed religious community and independent retirement community in
older adults.

7
o H230: There is no difference in health and lifestyle factors related to sleep
in three categories in older adults.
o H240: Reported sleep hours per night is not related to health and lifestyle
factors in older adults.
Variables To Be Examined:
o Demographics
o Perceived Stress
o Social Support
o Spirituality
o Depression
o Body Composition and Anthropometrics
o Blood pressure and heart rate
o Diet Composition

8
CHAPTER 2
LITERATURE REVIEW
Dimensions of Wellness
Wellness can be defined as the quantifiable daily practice, state or condition of
being in adequate physical, emotional, and mental health 20
. In 1959, wellness research
originated with the work of Dr. Halbert Dunn. He coined the term “High Level Wellness
for Man and Society”, and his research focused on the synergistic relationship and impact
of health status relating to the mind, body and spirit 21
. The research efforts and models of
practitioners since then have attempted to create, clarify and quantify variables that
impact “high level wellness” 20
. Currently, in allied healthcare there are several
classification systems used to measure wellness including the Six Dimensional Model,
the Twelve Dimensional Model of Wellness, and the Sixteen Dimensional Model of
Wellness. All the models are multidimensional in nature and attempt to quantify the
physical, mental, social, and spiritual behaviors that contribute to health 20,21
. The rest of
this section will focus on the four most common domains of wellness: mental, physical,
social, and spiritual.

9
Mental Wellness
Positive mental wellness has a positive impact on a person’s overall health.
Mental wellness or health as defined by the World Health Organization is a state of well-
being in which the individual realizes his or her own abilities, can cope with the normal
stresses of life, can work productively and fruitfully, and is able to make a contribution to
his or her community. An optimistic mental outlook has been shown to have a positive
impact on physical health measures, recovery from disease or trauma, and maintenance of
routine social engagement 22-24
. A cohort study of 41,275 men diagnosed with clinically
localized prostate cancer from 2004 to 2007 were recruited to examine the relationship
between mood disorders and treatment outcomes 25
. The study found that men with
depressive disorder overall had worse mortality than those who were not depressed 25
.
In addition, a prospective study of 46 college students looked at the impact of a
positive emotion and risk of depression following a traumatic experience, September 11,
2001 26
. The study found that students who exhibited the highest levels of optimism,
maintained a positive outlook on life, experienced frequent positive emotions and tended
to resist depressive symptoms following the events of September 11, 2001 26
. These
studies illustrate that individuals who displayed an optimistic perspective tended to better
mental wellness, than those who with a negative outlook.
Physical Wellness
People with better physical wellness including measurements such as BMI,
normal lipid and glucose levels are more likely to have a better quality of life and longer
life expectancy. The second dimension of wellness, physical wellness, is classified by

10
having healthy ranges of anthropometric values, laboratory blood parameters,
cardiovascular measures, and physical capacity scores 27
. A prospective cohort study of
1023 community-dwelling older adults tracked changes in allostatic load, which is a
measure of physiological wear and tear on the body including measurements such as
BMI, lipid panels, and blood glucose levels, over a 10-year period and compared these
factors to the sample’s mortality rate 27
. Findings revealed that higher allostatic load or
rapidly increased allostatic load scores significantly increased mortality risk in older
adults 27
.
In addition, a prospective study of 489 African American youth in the rural south
were assessed for changes in allostatic load at 11 years old and then at 19 years old 28
.
The study illustrated that those who received consistent, supportive parenting and
positive friend influence had more ideal physical health measures, greater emotional
stability, and less behavior problems in school, at home and in the community 28. These
two studies demonstrate that objective physical health change is a valid and reliable
measurement of individual global wellness. Both studies demonstrate that changes to
physical health markers correlate to physiological function that strongly contribute to
overall life span and health.
Social Wellness
The third dimension of wellness that has a large impact on one’s overall health is
social wellness. The social dimension recognizes the need for contribution and positive
interaction with one’s family, friends and community members 22,29,30
. In a cross-
sectional study of 316 Korean older adults, the effect of social support, religious

11
practices, and daily stressors on overall well-being was examined 23. The results showed
that higher perceived stress levels were associated with higher incidence of depression
and decreased life satisfaction. The individuals that received the most social support,
performed regular spiritual practices, engaged in frequent family interaction, and
participated in scheduled group leisure activities had significantly lower stress values and
higher quality of life 23
.
In another cross sectional study of 755 pregnant Chinese women in their second
trimester were recruited to examine the direct and moderating effects of social support in
mitigating perceived stress associated with depressive or anxiety symptoms 31. The
findings showed that perceived stress, anxiety, and depression were lower in individuals
who had family members that were actively engaged in their lives. The study also
showed that individuals benefit from positive environments including: occupation, home,
local community, and medical providers that were supportive and showed concern for
their needs 31. These studies demonstrate that those who have more social support and
are actively involved in community activities have better social wellness. This increase in
social wellness positively effects overall wellness.
Spiritual Wellness
The final dimension of interest is spiritual well-being; research shows that those
with increased spirituality are healthier. Spiritual wellness addresses the search for a
meaning and purpose to human existence, and includes a deep appreciation for the
expanse of life and natural forces that exist in the universe. It is important to note that the
terms spiritual and religious are not synonymous. Religiousness as defined by Merriam-

12
Webster dictionary refers to being dutiful and conscientious when performing a specific
practice. Spiritual defined by Merriam-Webster dictionary means relating to, consisting
of, or affecting the spirit and or relating to sacred matters.
A study of 502 African Americans aged 50-105 years old were surveyed to
observe the impact of church attendance and level of involvement in their congregation
on perceived stress and mental health parameters 29
. Results indicated that individuals
who were highly involved in their church community felt that they had a church family
that would help them in times of illness or tragedy, and had the ability to pray to God for
help with their personal burdens, concerns, or crises 29
. People who were spiritually
active had lowered perceived stress values when compared to those who did not engage
in similar behaviors 29
. In another study of 316 adults, 65 years old or greater living in a
retirement community examined the impact of spiritual coping practices and social
support on depression and life satisfaction. The study found individuals who exhibited
the greatest utilization of spiritual coping practices combined with social support
demonstrated the lowest depression scores and highest life satisfaction 23
. These studies
demonstrate that those who are spiritually active had overall better quality of life and
health. This shows that belief in something greater is an important aspect to living a
healthy lifestyle.
Health and Wellness of Older Americans
Mental disorders such as stress, depression, and anxiety are common in the older
American population and can have detrimental effects on a person’s livelihood. Research
shows that mental disorders, such as perceived stress, can be destructive to an

13
individual’s life. In a cross-sectional study of 689 women aged 45-60, qualitative data,
such as stressful life events, health-related quality of life, mental health, chronic disease,
and depression were collected using the Life Stressor Checklist-Revised (LSC-R), Short
Form Health-Related Quality of Life (SF-12), and the Center for Epidemiologic Studies
Depression Scale (CES-D). Researchers found was that those who reported more life
stressors also reported more chronic disease 32
. Similarly, in a population-based study of
6,207 adults measured socio-demographics, health behaviors, psychosocial measures,
cognitive function and health history. The findings of the study included that increasing
levels of stress was associated with cognitive decline in older adults aged 65 years and
older 33
. Thus these studies show that perceived stress may lead to more chronic disease
and cognitive decline in older adults.
Depression
Depression in older adults may increase inflammation and risk of chronic illness.
In an experimental study of 138 adults, depressive symptoms, anxiety, and stress were
measured using the Center for Epidemiological Studies Depressive Scale, the Beck
Anxiety Inventory, Trier Social Stress Scale and the Childhood Trauma Questionnaire.
Whole blood was also drawn and analyzed to measure interleukin-6 concentrations. The
researchers found that participants who expressed more depressive symptoms also
demonstrated more inflammation and increased inflammation increased the risk for
chronic diseases, such as cancer, heart disease, and diabetes 34
.
In a similar study, data was analyzed from the Health and Retirement Study. This 12-
year prospective study examined 3,645 individuals between the ages of 62-74 years old.

14
The study used the Center for Epidemiological Studies Depressive Scale to observe self-
reported depression, and a self-report of chronic illness. They found that in older
working adults, participants with depression at baseline had a significantly higher risk of
developing chronic diseases, specifically diabetes mellitus, heart disease and arthritis 35
.
This indicates is that depression in older adults may have negative effects on health;
specifically it may increase inflammation and risk of chronic disease.
Associations of Stress and Depression
Research shows that depression and perceived stress in older adults are associated
with one another. In a longitudinal study involving 70 elderly depressed subjects,
hippocampal volume, perceived stress levels and life stressors were evaluated using the
Montgomery-Asberg Depression Rating Scale, MRI data, and a self-report questionnaire
concerning life stress. The researchers found that among the depressed participants there
was a higher prevalence of negative life events and higher perceived stress scores 36
.
Similarly, in a cross-sectional study of 54 community-dwelling older women, memory
function, perceived stress, life events, activities, and depression were measured with a
questionnaire that the participants completed, that included the General Frequency of
Forgetting Scale, Perceived Stress Scale, Geriatric Scale of Recent Life Events, Activities
Checklist, and Geriatric Depression Scale 37
. Researchers found that perceived stress,
along with anxiety and depression was affiliated with memory complaints, as stress can
impact the brain’s memory center, the hippocampus 37
. This suggests that adverse mental
health issues in older adults, in particular stress and depression, may influence one
another and lead to further mental illness and memory problems.

15
Weight
Weight status plays an important role in overall health and wellness of older adults. In a
cross-section study published in the Journal of American Medical Association, Flegal et
al. examined the prevalence of overweight and obesity in the aging population 38
. The
researchers used Body Mass Index (BMI) to measure body fat a person carries based on
height. The results showed that the obesity prevalence in 2011-2012 overall was 35.4%
for the whole sample, 32% for men, and 38.1% for women 38
. Over one-third of the older
adult population is obese. Since obesity has been linked with increase risk of heart
disease, diabetes, and hypertension this is a very serious concern.
Similarly, in a cross-sectional analysis of US adults aged 65 years and older,
Fakhouri et al. examined the prevalence of overweight and obesity based on BMI 39
. The
researchers found that for both men and women the prevalence of obesity was higher
among those aged 65‒74 years compared with those aged 75 years and older, and over
the past 10 years the prevalence has overweight and obesity has increased in this
population 39
. Also, non-Hispanic black women were more obese than non-Hispanic
white women, and those with a college degree were less obese than those with some
college experience 39
. These findings suggest that over time there has been a increase in
prevalence of overweight/ obesity in the older adult population and that weight status
varies by ethnicity and education level. However, it appears that those who are over 75
years have a decrease in weigh, which may be due to changes in dietary intake and
physical activity as person ages.

16
Physical Activity
Physical inactivity of the American older adult may contribute to a decline in
overall well-being. The Older American Report 2012, measured older adults’ physical
activity patterns using self-reported surveys and comparing the results to the 2008 US
Physical Activity Guidelines 40
. The results showed there has been a 5% increase in the
number of individuals meeting the federal physical activity guidelines from 1998 to 2010
40
. However, even with this improvement in the number of older adults meeting physical
activity recommendations the 11% of individuals meeting US physical activity guidelines
remains substantially low. A cross-sectional study of 975 adults aged 65 years and older
published in the American Journal of Epidemiology, examined associations between
physical activity level (e.g. sedentary to vigorous activity) and well-being variables (e.g.
chronic health complications, BMI, life satisfaction, depression, and perceived stress) 41
.
Researchers found that participation in physical activity was positively associated with
physical health and well-being 41
.
In addition, greater sedentary time was negatively associated with physical health
and perceived well-being; whereas, light, moderate, and high physical activities were all
positively associated with physical health and perceived well-being 41
. Additionally, a
study by Bankoski et al. investigated the association between sedentary activity and
metabolic syndrome among 1,367 older adults, aged 60 and older 42
. Sedentary times
during waking hours were measured by an accelerometer and metabolic syndrome was
defined using the Adult Treatment Panel III criteria. Over all, the sample spent 9.5 hours
sedentary, and individuals with metabolic syndrome spent even more time sedentary than
compared with people without metabolic syndrome 42
. Independent of physical activity,

17
the amount of sedentary time was significantly related to metabolic risk 42
. Overall,
participation in physical activity was positively associated with physical health and well-
being for the older adult population, but despite this finding, the majority of older adults
spend their time sedentary and physical inactivity, which can increase the risk metabolic
syndrome and other chronic diseases.
Dietary Patterns in Older Adults
Diet plays an important role in overall health and well-being. The current trends
in health and wellness of the older adult population aged 65 years and older is
characterized by poor diet quality, as defined by not meeting United States (US) dietary
guidelines. The Older American Report 2012, a cross-sectional analysis, examined health
and wellness factors of 40 million US adults, aged 65 years and older. Diet was measured
using the Healthy Eating Index-2005, and diet quality of participants was compared to
recommendations of the 2005 Dietary Guidelines for Americans 40
. According to the
report, 79% of adults between the ages 65-74 years believed they were in good health,
but the data actually indicated that this population was not meeting US dietary guideline
recommendations through their current dietary patterns 40
. This is a concern because
older adults with overall poor quality diets have an increased risk of chronic disease
compared to those with high quality diets.
A 10 year cohort study of 2,200 participants aged 55 years and older, published in
the Journal of Academy of Nutrition and Dietetics, investigated the association between
diet quality, quality of life, and activities of daily living 43
. The researchers found that the
majority of participants had poor diet quality; however, those who had adequate nutrient

18
intake reported better quality of life 43
. In fact, participants who consumed more than 5
servings of vegetables per day, ate low-fat dairy products and whole grains, and followed
a low sodium diet had a 50% reduction of disability of activities of daily living in 5 years
43
. In addition, improved dietary intake was associated with more education, increased
duration of exercise, and lower body mass index 43
. All of these findings support the idea
that regularly eating a high quality diet improves overall health and wellness of older
adults. Additionally, a study from the Journal of Cancer, investigated health behaviors
and associations with quality of life outcomes in 753 participants aged 65-87 years old 44
.
The researchers found that individuals who participated in regular moderate-to-vigorous
exercise and consumed a plant based, low-fat diet had better quality of life health
outcomes 44
. Also, researchers found that physical inactivity may predict poor diet
quality, decreased social function, and an increase in chronic health complications 44
.
The findings from the Older Adult American report and the studies by Gopinath
et al. and Mosher et al., suggest that overall, older adults’ dietary patterns are
characterized by poor quality including consuming below the recommended 5 servings of
vegetables per day, choosing white grains instead of whole wheat grains, and eating
foods high in concentrated sweets and sodium. Furthermore, the data suggests that older
age, less education, and higher BMI were associated with increased risk of activities of
daily living disability. These results suggest that diet may be a predictor in the health and
wellness of the aging population, and diet plays an important role in the overall health
and wellness of the aging population.

19
Health and Wellness of the Vowed Religious Community
The vowed-religious community adheres to a life of self-discipline and active spiritual
practices, and there is a theory that this kind of lifestyle positively impacts the health and
wellness of this community. People in religious orders often follow a stricter diet and do
not participate in many activities that can increase daily stress 45,46
.
Dietary Patterns in Vowed Religious Communities
Monks and nuns often adhere to strict dietary practices that align with their
contemplative lifestyle, which can affect overall health. Many adopt a lacto-ovo
vegetarian diet and as a result of these dietary restrictions, some vowed religious persons
diets’ are low in B vitamins, calcium, iron, magnesium and zinc 45,46
. For example, zinc
deficiencies may be explained by high intake of phytate rich foods and decreased calcium
intake due to fasting. Monks who fast regularly have favorable nutrient and food intake
profiles. Overall, they had decreased intake of total fat, saturated fat, and trans fatty acids,
with higher intake of iron, folate, legumes, fish, seafood, and fiber in comparison to
laypersons. While fasting is an integral part of the monastic life, benefits go beyond
spiritually, including a greater nutrient composition 25,46
.
Blood Pressure
It appears that those living in religious orders have lower blood pressure, which
may be result psychosocial influences. A 32-year prospective study by Timio et al.,
looked at differences of anthropometric and blood pressure measurements, blood panels
and overall health practices of 144 white nuns and 138 healthy laypersons 18
.
Researchers found that over the 32 years laywomen’s blood pressure significantly

20
increased, whereas nuns’ blood pressure remained nearly stable 18
. Researchers noted that
other variables that often affect blood pressure including age, race, lifestyle habits, did
not vary between the two groups. Therefore, researchers speculated that psychosocial
influences including conflict, anxiety and aggression might have been the determining
factor for an increase in blood pressure in laywomen. This study suggests that women in
religious orders may have better mental health factors lead to a healthier lifestyle.
Moreover, an additional study found nuns’ cardioprotective health remains stable
compared to laywomen who have increased blood pressure with age 47,48
. The study
found that laywomen had more non-fatal cardiovascular events than nuns, 31 versus 69,
with psychological stress being the underlying cause of such events 47,48
. In these studies
it appears that psychosocial experiences of those in religious orders may be a factor in the
prevalence of lower blood pressure.
Comparison of Groups
While older adults’ daily habits are not as uniform as those living in the vowed
religious community, many older adults appear to be living a happy, healthy life. A
cross sectional study conducted by Cha et al., 2012, sought to uncover the successful
aging factors in Korean adults 49
. Using the self-liking/self-competence scale, self-
efficacy scale, interpersonal relationship scale, self-achievement instrument, and
successful aging scale, it was found the largest contributor to successful aging was self-
esteem. Additional factors included level of involvement in religious activities, which
provides a positive view on life, including group meditation, social gatherings, prayer,
and increased positive thinking. While religion cannot be held entirely responsible for

21
older adults’ mindset, it does indicate it is an activity that promotes a positive, active
lifestyle 50
.
Moreover, a study led by Schlehofer et al., 2008, aimed to gain a better
understanding of how the average older adult sees religion and spirituality and if there
was a difference in views found between the sample 50
. Participants had a hard time
providing concrete definitions of spirituality, even though they considered themselves
highly religious, and subjects saw religion as an opportunity to be part of a community,
ability to make connections with others, and to be part of a larger identity 50
. While older
adults’ perspective on religion is not as structured as those living in the vowed religious
community, those living in the independent retirement community recognize the
importance of constant spiritual practices.
It’s evident the vowed-religious community and independent retirement
community older adults have distinct qualities. The vowed-religious live a very
structured life, with activities and roles clearly defined and are given a balance of solitude
and communal scheduled time, recognizing the importance of both for overall personal
growth. Material possessions and food consumption are secondary to serving, with
obedience, fasting, and discipline being key aspects of the culture. Comparatively,
independent older adults living a modern life are characterized more by “free will”. Diets
are more liberal with age, yet the amount of physical activity is often left unadjusted with
increased food intake. Additionally, older adults’ make their own schedules, which are
dictated by personal interests, not by rank or position in the community. While the
vowed-religious live a minimalist life, independent older adults live at the other end of
the spectrum, with less structure and more flexible decisions.

22
Mechanisms of Stress
Stress is a state of altered homeostasis in response to mental or physical stressors.
Many things can cause stress in an individual’s life such as work, life events and financial
problems. Stress can cause symptoms such as depression, anxiety and sleep issues as well
as negative health outcomes such as cardiovascular disease, weight gain, and insulin
resistance 51
.
The normal stress response includes both physiological and behavior responses
that strive to restore homeostasis. Two main physiological systems are involved in the
normal stress response, the sympathetic nervous system and the hypothalamic-pituitary-
adrenal axis (HPA axis) 52
. The sympathetic nervous system is very fast acting and works
to quickly adapt to stressful situations through the release of epinephrine and
norepinephrine 52
. The HPA axis is slower acting, which allows for long-term adaption to
a stressful condition 52
. The HPA axis activates the corticotropin-releasing factor in the
hypothalamus, which then stimulates the release of adrenocorticotropin hormone from
the pituitary gland. This causes the release of glucocorticoids, stress hormones, from the
cortex of the adrenal glands. Glucocorticoids regulate the stress response through a
negative feedback loop with the hypothalamus and pituitary gland. The normal stress
response occurs in response to acute stressors. Prolonged exposure to acute stressors is
known as chronic stress. Chronic stress can alter the body’s normal stress response,
metabolism and homeostasis, and may produce psychological and physiological damage
4
. Cortisol is a main glucocorticoid that is associated with pro-inflammatory molecules
and cytokines such as interleukin-6 (IL-6) and C-reactive protein (CRP) 8
. High amounts
of daily stressors can lead to chronic low-grade elevation of those inflammatory markers

23
8
. Elevation of IL-6 and CRP is associated with increased risk of weight gain, depression,
cardiovascular disease, insulin resistance, diabetes, cancer, autoimmune disease, frailty,
and mortality 8
. A cross sectional study of 53 caregivers and 77 non-caregivers were
observed to determine if daily stressors impact circulating levels of IL-6 and CRP. The
caregivers had a greater occurrence of daily stressors as well as an increase in the
inflammatory markers IL-6 and CRP 8
. This demonstrates the inflammatory response that
is associated with chronic stress.
Cortisol levels have been found to increase rapidly after awakening. This
measure, if monitored frequently, can be used as a baseline for adrenocortical and HPA
axis activity 53
. After awakening, serum cortisol increases by 50-60% regardless of sleep
duration, quality and routines 53
. Since the cortisol awakening response is consistent, if
monitored closely, it can reveal subtle changes in cortisol levels and HPA axis activity 53
.
In a twin study of 104 pairs aged 8-64, cortisol awakening was measured with saliva
samples 0, 30, 45 and 60 minutes after awakening, and participants filled out surveys
regarding psychosocial factors such as stress, self-esteem and self-efficacy. Those with
higher perceived chronic stress had increased cortisol awakening responses, showing the
relationship between chronic stress and altered hormonal cycles 53
. A study of 22 healthy
individuals had their blood and saliva tested 0, 15, 30, 45 and 60 minutes after awakening
54
. The participants who were chronically stressed had an enhanced cortisol awakening
response and those whose chronic stress lasted for years or had reached a burn out stage,
where they were no longer able to cope with their stress, had a blunted cortisol response
and increased feedback sensitivity 54
. This demonstrates the relationship between chronic
stress and the disruption of normal hormone responses. The normal stress response in the

24
body involves multiple physiological and behavioral responses. When there is over
exposure to stress, there can be a dysfunction of the normal stress response, which can
lead to negative health outcomes.
Impact of Chronic Stress on Physical Wellness
Chronic stress has been linked to negative health outcomes such as cardiovascular
disease, metabolic syndrome and weight gain. Job stress, marital stress and financial
stress all impact these negative health outcomes. Repeated social or environmental stress
can cause a dysregulation of the normal stress response and alter the activation HPA axis
and glucocorticoids, leading to cardiovascular, immune and metabolic symptoms 2
.
Cardiovascular disease is a common negative health outcome related to chronic
stress. The mechanisms relating stress and cardiovascular disease include both behavioral
and physiological factors such as smoking, lack of exercise, insulin resistance, and
increased blood pressure 55
. The INTERHEART study, a case-control study that matched
11,119 participants with a first myocardial infarction and 13,648 healthy controls across
52 countries, measured psychosocial stress, including work, home, financial and life
stress in participants. The results of INTERHEART study demonstrated the association
between increased psychosocial stress and risk for myocardial infarction 51
. Behavioral
factors are also involved in cardiovascular risk and stress. A group of 10,308 government
employees, aged 35-55 years old, were studied to determine the risk for coronary heart
disease related to chronic work stress. Work stress was associated with lower physical
activity, poor diet, metabolic abnormalities and a higher rise of morning cortisol 56
.

25
The mechanism by which stress increases cardiovascular risk likely involves HPA
axis dysfunction and cortisol regulation 57
. In a prospective cohort study of 479 initially
healthy men and women, blood pressure and cortisol reactivity were measured at baseline
and at a three-year follow up. There was an association between hypertension and cortisol
reactivity 57
. Cortisol can directly influence the physiological systems that are
responsible for regulating blood pressure; the results of this study demonstrate that HPA
axis hyperactivity is involved in the mechanism that related stress to cardiovascular risk.
Chronic stress is related to both increased cardiovascular disease and death associated
with cardiovascular disease. A 2012 study focused on perceived stress following an acute
myocardial infarction (AMI) in hospitalized patients in the United States. Patients with
higher perceived stress following their AMI hospitalization had an increase in mortality
within two years 55
.
Cortisol is an insulin antagonist; during chronic stress there are high levels of
serum cortisol and this may alter normal insulin production and functionality in the body
58
. Metabolic syndrome is a group of risk factors related to cardiovascular disease, insulin
resistance and obesity. Chronic stress can contribute to the risk for metabolic syndrome,
through both physiological mechanisms and behavioral mechanisms associated with
stress such as poor diet and smoking. A prospective cohort study of 10,308 participants
had work stress and biological markers of metabolic syndrome measured four different
times over a course of fourteen years. Work stress increased the risk for metabolic
syndrome in a dose-response manner and those with chronic work stress had double the
chance of developing metabolic syndrome in their lifetime 58
. Additionally, in a
prospective cohort study of 120 women followed for fifteen years, psychosocial factors

26
such as perceived stress and depression were measured, as well as serum metabolic
syndrome markers. Women who had higher amounts of stress in their life had an
increased risk of developing metabolic syndrome 59
. Psychosocial factors, such as stress,
can increase risk of developing metabolic syndrome through physiological or behavioral
mechanisms.
The allostatic load model demonstrates how psychological demands such as
excess stress can negatively impact ones physiological health. An Australian cross-
sectional study looked at psychosocial factors and their affect on arthritis in women ages
51-61 years old. Those with moderate to high perceived stress had a 2.5 fold increase in
report of arthritis demonstrating that increased perceived stress can manifest through
negative physiological health outcomes 60
. Critical illness is an example of an acute
stressor and therefore often results in elevated cortisol levels and pro-inflammatory
cytokines. A case control study matched 158 patients in the intensive care unit (ICU)
with 64 controls and measured different markers of the hormonal stress response. The
ICU patients had elevated cortisol levels caused from both over production of cortisol as
well as altered cortisol clearance during the time of acute stress 61
.
Impact of Chronic Stress on Mental Wellness
The normal stress responses involving glucocorticoids and the HPA axis is also
related to mental health. Chronic stress may be related to cognitive impairment 4
.
Increased activity in the HPA axis and elevated amounts of serum cortisol is associated
with depression 62
. Cortisol is able to cross the blood brain barrier, where it can activate
receptors and alter central nervous system activity 52
. A high concentration of stress

27
hormones can also inhibit neurogenesis, the creation of new neurons, which may alter
mental health 63
. Five hundred and sixty-five participants who met the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major
depressive disorder were evaluated using surveys and blood samples. Those with
dysfunction in the HPA axis had agitation symptoms and cognitive disorders within their
major depressive disorder diagnosis 62
. In 2013, 125 adults ranging from 67-94 years old
were studied to determine an association between allostatic load, the dysfunction of the
HPA axis and glucocorticoid response due to increased environmental and social stress,
and depressive symptoms. Participants were interviewed to determine allostatic load
score and overall depression risk. Higher allostatic load scores were associated with
increased depressive symptoms 2
. These studies demonstrate the association between the
HPA axis and mental health. Dysfunction of the normal stress response and increased
exposure to acute stressors can negatively impact mental health.
Mental health may also be affected by the stress response through behavioral side effects
of stress, such as altered sleep patterns and quality of life. A cross-sectional study of 181
older adults focused on the relationship between perceived stress and mental health.
Those with higher perceived stress had reduced quality of life, increased depressive
symptoms, and increased sleep disturbances 32
. This demonstrates a different relationship
between stress and mental health.
Stress may also affect mental health through mood and emotions. Stress is often
related to negative affect and may be due to high cortisol levels through the dysfunction
of the HPA axis. A randomized controlled trial of 232 participants underwent either a
Trier Social Stress Test or a placebo stress test and had their saliva tested for cortisol

28
levels, emotional responses were rated using the Positive and Negative Affect Schedule
52
. Those who experienced the Trier Social Stress Test had higher cortisol levels and
higher negative affect than those who underwent the placebo stress test, which
demonstrated that stress can alter mood and emotions through dysfunction of the HPA
axis and hormonal mechanisms 52
. Stress can affect mental health through dysfunction of
the HPA axis and increased serum cortisol levels, which may cause depression, decreased
quality of life and negative emotions.
Impact of Stress on Eating Behaviors and Weight
Weight gain is often caused from a positive energy balance, but stress and its
effects on behavior and metabolism can contribute to obesity risk 64
. As discussed earlier,
chronic stress can be a predictor of metabolic syndrome and cardiovascular disease, both
of which are also related to obesity 64
. In a 2011 longitudinal study of 72 participants,
BMI was measured as well as social stressors, including work and social life. Social
stressors were found to be significant predictors of BMI 65
. A prospective, 19-year study
in London aimed to evaluate the relationship between chronic work stress and obesity in
over 10,000 participants aged 35-55 years old. The study revealed that chronic work
stress predicted both general and central obesity 64
. Chronic stress alters the normal stress
response, leading to altered adrenocortical activity, insulin resistance, abdominal obesity
and metabolic syndrome 64
. A 2013 study examined the relationship between stress and
physical health in older Australian adults ages 60-70 years old. The results showed that
those who reported higher life stressors had higher BMI and increased occurrence of
chronic disease 32
.

29
Chronic stress may impact obesity both directly and indirectly through behaviors
such as poor diet, alcohol consumption and low physical activity 64
. An observational
study on government in employees sought to demonstrate a relationship between work
stress and blood pressure. Results showed that increased work stress led to increased use
of coping mechanisms such as alcohol consumption, unhealthy eating patterns and
physical inactivity 66
. These coping mechanisms are associated with obesity. Stress may
change diet and exercise behaviors, which may impact and influence body weight and
weight gain during times of chronic stress 67
. In a 9-year longitudinal cohort study, 1,355
US adults were followed with psychosocial stress and BMI being measured regularly.
Results showed that psychosocial stress contributed to weight gain in those who had a
higher baseline BMI, and stress can caused some participants to eat more or less than
usual and alter eating habits 67
.
A healthy diet and physical activity have shown to decrease perceived stress and
improve health outcomes and health-related quality of life 14
. A randomized controlled
trial of overweight and obese women aimed to determine if diet and exercise could
increase psychosocial factors and health related quality of life. The women were assigned
to one of four interventions: dietary weight loss, aerobic exercise, combined diet and
exercise, or control. The combined diet and exercise group saw the largest positive
outcomes on psychosocial factors, including stress, and health related quality of life 14
.
Stress can negatively impact weight and eating behaviors through both direct and indirect
mechanisms such as alteration of the normal stress response and coping devices like junk
food and alcohol.

30
A healthy diet and exercise may improve health outcomes and lead to better quality of
life. Control of stress may improve eating habits, weight and quality of life.
Stress and Aging
The U.S. Census Bureau projects that by 2050, 20% of the U.S. population will be
over the age of 65 2
. Within this age group, increased perceived stress and stressful life
events can lead to an increase in depressive symptoms 2
. Increased exposure to stress can
accelerate the biological aging mechanisms such as inflammation and telomere length 7
.
Psychological stress is associated with increased oxidative damage, which contributes to
aging and age-related chronic diseases such as neurodegenerative, metabolic,
cardiovascular diseases and cancer 7
. The stress hormone cortisol is released after
stimulation by an acute stressor and chronic exposure to acute stress is related to DNA
and RNA damage in older adults 7
.
Mitigating Factors of Stress
While perceived stress is a mental health factor that affects many Americans,
even those in the older Adult population, there is a growing body of evidence that has
found that there are many healthy ways to mitigate the symptoms of stress 68-70
. These
stress relieving tactics range from dietary habits to physical activity to social and spiritual
support. Many researchers focus on dietary patterns and foods that are associated with
increased and decreased stress in a variety of populations. Research has found diets high
in fruits and vegetables, high in omega-3 fatty acids, using multi-vitamin supplements are
predictors for decreased stress in people.

31
Multivitamin/Mineral Supplements
Currently, there is a belief that regular multivitamin/mineral supplementation may
lower stress. Reasons for taking these supplements include improving mental function
and for improvements in stress and tiredness. Researchers have looked at one supplement
in particular, Berocca, a high dose B-complex vitamin and mineral and its effects on
mood. A double blind randomized control trial of 80 healthy men, between the ages of
18-42 years, were given either the Berocca supplement or placebo for 28 days.
Participants’ health was assessed before the 28-day intervention and after, using the
General Health Questionnaire, Hospital Anxiety and Depression Scale, and the Perceived
Stress Scale 71
. Post-hoc test revealed that the treatment group had significantly lower
perceived stress scores than the placebo group after the 28-day intervention 71
. Similarly,
a double blind, randomized, placebo controlled trial study of 215 males between the ages
30 and 55 years was given either the Berocca supplement or placebo for 33 days, and
then health and mood was assessed using varies health surveys, including the Perceived
Stress Scale 72
. Once again after the 33-day treatment period, participants in the treatment
group had significantly lower perceived stress scores 72
. Both of these studies
demonstrate that multi-vitamin/mineral supplementation in males can reduce perceived
stress of healthy individuals.
Finally, a double blind randomized trial of 173 men without a history of
aggression or impulsive behavior assessed how a multivitamin/mineral, DHA, or both
affected aggression, impulsivity, and stress. The men were divided into one of four
groups: placebo group, multivitamin/mineral group, DHA group, or
multivitamin/mineral/DHA group 73
. The researchers found that the only group that had a

32
significant decrease in stress after the intervention was the vitamin/mineral group 73
.
Once again, this reiterates that the use of a multivitamin and mineral can be helpful in
reducing stress of healthy males. Little research has looked at how a vitamin/mineral
supplement would affect females or older adults, but based on the current research, one
may hypothesize that these groups would have similar outcomes as younger, healthy
males.
Omega-3 Fatty Acids
In recent years, omega-three fatty acid supplementation and its affect on a
person’s perceived stress level has become increasingly popular area of research. The
thought behind consuming these fatty acids to reduce stress includes idea that the
polyunsaturated fatty acids act on the hypothalamic-pituitary-adrenocortical (HPA) axis,
by reducing pro-inflammatory cytokine production and stop the IL-1 signally pathway,
which in the end reduces corticotropin-releasing factor 1 (CRF) and HPA activation, and
ultimately prevents stress from rising 74
. Because there is scientific research to
demonstrate that omega-3 fatty acid supplementation may physiologically affect stress
levels, researchers have tried to demonstrate such findings in human clinical trials.
One study investigated whether omega-3 phosphatidylserine (PS)
supplementation affected the psychological and physiological measures to the acute
stressor, the Trier Social Stress Test (TSST). This was a randomized, double blind,
placebo-controlled trial, and men between the ages of 30-60 years were assigned to either
the placebo group (n =30) or the treatment group (n =30) 75. Stress was measured before
and after the 13-week supplement intervention and perceived stress was measured using

33
visual analog scales (VAS). The results showed that after 13 weeks participants with high
chronic stress who were given omega-3 phosphatidylserine supplement had significantly
lower stress scores than those who were given the placebo, but this change was not noted
in participants who were characterized as having low chronic stress levels 75
. This is an
interesting finding because it suggests that omega-3 fatty acid supplementation may only
lower a person’s perceived stress if the person has relatively high levels of chronic stress.
For people who have short episodes of chronic stress fatty acid supplementation may not
be effective in lower stress levels.
In addition as study published in 2003, assessed the effect of 7.2 gm/day of
omega-3 fatty acid supplementation on the sympathetic nervous system and stress
hormones associated with mental stress. Participants underwent mental stress tests before
beginning supplementation and 3 weeks after, and blood samples were collected to assess
stress hormones including cortisol and insulin, as well as blood pressure and heart rate 68
.
After the 3-week supplementation period blood markers of stress in participants who
underwent mental stress tests significantly decreased 68
. This shows once again that
omega-3 fatty supplementation may be beneficial in reducing mental stress, which is
important since high levels of chronic stress are associated with increased risk of many
diseases.
While these studies demonstrate that omega-3 fatty acid supplementation has
beneficial effects of perceived stress levels, there is some research that states that omega-
3 fatty acids are not beneficial for improving mood. In a randomized, double-blind,
placebo-controlled trial of 302 independent-living older adults (over 65 years) the effect
of supplementing EPA + DHA on mental wellbeing was assessed 76
. Mental well-being

34
was measured using the Center for Epidemiologic Studies Depression Scale,
Montgomery Asberg Rating Scale, Geriatric Depression Scale, and Hospital Anxiety and
Depression Scale, and participants were either given 1800 mg/d EPA + DHA, 400 mg/d
EPA + DHA, or placebo for 26 weeks. At the end of the study no differences in mental
wellness were found between the three groups, indicating that omega-3 fatty acids do not
improve older adult mental well-being 76
. Authors argue that changes in mood may not
have been seen because it is unclear what level of supplementation is needed 76
, and that
most of the surveys assessed depression, not stress, therefore for those who were not
depressed, changes in mood may not have been observed.
Fruits and Vegetables
Finally, reducing stress may be that as simple as a well-rounded, primarily plant
based diet. There is a body of evidence that shows that people who eat mostly fruits and
vegetables have lower perceived stress than those who are eating more traditional
Western diet. This diet includes greater consumption of refined grains, added sugars, and
fats and oils. A recent cross-sectional study of 3706 university students in the United
Kingdom looked at how diet affects overall mental health. Participants’ intake was
assessed with a food frequency questionnaire and mood was measured with the Perceived
Stress Scale and Beck Depression Inventory 77
. Consumption of healthy foods including
fruits and vegetables was significantly negatively associated with perceived stress and
depression. Similarly, consuming unhealthy foods like sweets, cookies, snacks, and fast
food was positively associated with perceived stress in females only 77
.

35
Similar studies have been produced in the older adult population. A cross-
sectional study of 1336 Puerto Rican older adults, 45-75 years old, looked at associations
between psychological stress and nutrition. Perceived stress was measured with a Spanish
version of the Perceived Stress Scale, and general health status and behaviors were
measured with a survey based on the NHANES III 69
. Perceived stress was negatively
associated with lower intake of protein, fruit, vegetables, fiber, and omega-3 fatty acids;
and positively associated with foods characterized by salty snacks and sweets 69
. While
these studies demonstrate the negative association between fruits and vegetables and
perceived stress, it does not indicate a casual effect between the two variables. Further
research that can show changes in perceived stress overtime in necessary for one to be
able to make the statement that diet high in fruits and vegetables can reduce stress.
Physical Activity
Research demonstrates that physical activity and formal exercise are associated
with lower perceived stress. While the terms physical activity and exercise are often used
interchangeably, they actually have different meanings. Physical activity is used to
describe low to moderate intensity aerobic chores including household, occupational or
recreational movements and physical hobbies. In comparison, exercise is a subset of
physical activity that can include aerobic movement patterns, but most appropriately used
to describe intense and deliberate physical stress including anaerobic activities. Formal
exercise is planned, structured, progressive, and performed to improve at least one aspect
of physical fitness such as: muscular strength, muscular endurance, flexibility, balance or
cardiovascular conditioning 47
.

36
In a 2013 cross sectional study of 14,804 college students, the association
between vigorous activity and perceived stress was examined to better understand the
relationship between the two 70
. Perceived stress and activity level were self-reported, and
the results indicated that individuals who performed at least twenty minutes of vigorous
exercise three days a week had lower perceived stress scores than those who had lower
frequencies of activity 70
. A similar study examined the impact of moderate physical
activity and perceived stress in a senior living population. The researchers assessed 164
individuals with who had mean age of 72 over a 4-year timeframe 78
. The results showed
that individuals who participated in moderate activities for 2-5 hours a week had lower
perceived stress scores and reduced co-morbidities when compared to those individuals
who did not 78
. These studies demonstrate that even if people are physical active only a
few hours a week, perceived stress decreases. This emphasizes the importance of
choosing an active lifestyle.
Social Support
Increased social support and community involvement are associated with better
mental health including lower perceived stress. Research shows that social engagement is
a stand-alone core behavior that can be utilized to strongly improve overall health status
64,79
. In several studies social support has demonstrated to be as significant as diet or
physical activity and can work synergistically with them to lower perceived stress and
improve physical health measures. In a 2013 cross sectional study of 14,804 college
students, researchers aimed to investigate the relationship of social activity and perceived
stress. Findings demonstrated that individuals who had five or more close friends or spent

37
two or more hours a day in some form of social communication or shared group activities
had lower perceived stress scores 70
. However, those who also exercised showed further
modulation of stress.
This study highlights that positive, consistent social support from friends and
family members are every bit as significant as diet and physical activity when improving
or sustaining health and lifespan in the long run. Individuals who want to effectively
manage chronic stress levels will need to include some degree of constructive routine
engagement with their family, friends and local community as part of a comprehensive
program 29,70,80
.
Spiritual Practices
Research shows that people who are spiritually active experience less perceived
stress than those who are not. A study of 111 undergraduate college students, between the
ages of 18 to 40 years old, looked at whether praying before a stressful situation lowered
physiological and psychological markers of stress 81
. Heart rate, blood pressure, an
Anxiety Thermometer, and the State-Trait Anxiety Inventory, Importance of Religion
scale, and Prayer Experience survey were used to measure prayer and stress scores.
Results showed that prayer lowered systolic and diastolic blood pressure values when
exposed to an acutely stressful situation, but self-talk also positively reduced levels of
stress 81
. While prayer, an aspect of spiritual practice, reduced stress, which was not the
only factor that reduced stress, in comparison no self-talk prayer did reduce stress.
Similarly, a cross-section study of 316 older adults 65 years and older living in
assisted living facilities assessed how perceived stress, spiritual coping and support,

38
active, and avoidance coping impacted depression 23
. The study found that perceived
stress and spiritual coping are significantly related to psychological well-being in older
adults including stress and depression 23
. These studies show that increased spiritual
practices positively impact a person’s stress levels. People who regularly pray, attend
church, and/or meditate may have better levels of stress and overall a healthier lifestyle.

39
CHAPTER 3
METHODOLOGY
Research Study Design
The research design was a cross-sectional study, the participants were evaluated
with a wellness survey, physical stress measures, (systolic blood pressure, diastolic blood
pressure, heart rate), anthropometric values and 24-hour dietary recall. Participants
signed consent forms that identified study parameters and personal acceptance of risk
during the data collection process.
The three requirements for participation in the study were: participants had to be
65 years of age or older. Second, individuals had to be able to engage in daily activities
without assistance and be without significant cognitive impairment. Last, the study
participant had to live in either a monastic community or in an independent living senior
community exclusively, opposed to a residential home or apartment unit.
Individuals could not participate in the study if they required assistance with
activities of daily living or had significant cognitive difficulties.
Research Study Recruitment
The total study population was collected through a convenient sample of thirty-six
individuals from four monastic communities and thirty-two individuals from an
independent retirement community.

40
Data of one participant from a monastic community had to be removed from the
sample, due to their inability to complete the survey information. The validity of our
sample was improved by having similar sex, age, ethnicity, physical health, and
socioeconomic status findings between the two communities.
The recruitment protocol began by contacting local suburban monastic and
independent living facility Directors. They were initially contacted through an
introductory standardized email, “I'm a graduate student in the Nutrition Department at
Benedictine University. My study mentor, Dr. Bonnie Beezhold, and a few other
graduate students are conducting a study to investigate diet, lifestyle, and health
measurements associated with perceived wellness….” Several days after the email was
sent out, a follow-up phone call was placed to gauge interest and further clarify
participation questions. The communities that were interested scheduled an onsite
interview with a student representative accompanied by the study mentor for a detailed
overview of the research process. The communities that decided to proceed forward with
the study were given a formal flyer advertising the study to be placed at key
thoroughfares inside their facilities. The flyer was accompanied by a sign-up form several
weeks before the data collection date. The forms and scripts are listed in Appendix C.
Study participants were asked to complete a wellness survey at station one that took
approximately 25 minutes and then move through three additional stations ranging in
time from five to twenty minutes each. Station two collected blood pressure and pulse.
Station three measured anthropometrics and station four recorded previous day’s dietary
intake.

41
Data Collection Methods
We used objective health measures that could validly assess our study sample and
were deemed reliable to measure our desired wellness dimensions of study. We started
by researching variables that could be used to quantify participants’ health and lifestyle
factors. Our efforts concluded with a set of anthropometric, physical stress measures, diet
and daily behaviors that when combined create a comprehensive summation of physical,
emotional, spiritual and mental health status. We next examined previous research studies
for tools and survey instruments that were appropriate for our study design and age
group. A complete discussion of the all the equipment used during our data collection is
listed in the measurement tools section.
Data Collection Process
The data collection process ran over a three-month period, March through May,
with data collection days occurring on several Fridays and Saturdays.
The on-site data collection followed a sequential process. The survey was
provided in a quiet area, including a consent form notifying the participants of any
potential risks during the assessment process as well as written acknowledgement of the
terms of participation. Second, blood pressure and pulse was gathered in a seated
position. The third station administered height and waist measurements, as well as the
body fat, lean muscle and weight totals. The last station, collected 24-hour dietary recall
performed in a one-on-one interview format. All data was collected on site at each
facility.

42
The study took place at five locations. The following is a listing of the
participating sites in the study with a brief description of their populations:
● St. Procopius Abbey (5601 College Rd, Lisle, IL 60532)
● Marmion Abbey (850 Butterfield Rd, Aurora, IL 60502)
● Sacred Heart Monastery (1910 Maple Ave, Lisle, IL 60532)
● School Sisters of St. Francis of Christ the King (13900 Main Street, Lemont, IL
60439)
● Monarch Landing (2255 Monarch Dr, Naperville, IL 60563)
The first three vowed religious communities listed practiced Benedictine
monasticism. Their teachings originated in medieval Italy by its principal founder St.
Benedict and can be practiced by both women and men 82
. Their lives are arranged by a
charism, or guide book that can be summarized into five large themes of the order:
Hospitality -welcoming all who enter their community, indiscriminate of their
religion or background 83
. Prayer- daily mindful focus on God individually and
collectively 83,84
. Obedience-Taking an active position of openness and availability to
God’s voice and direction in life 83,84
. Stewardship and Stability- respect for wise and
moderate use of natural resources for the good of all. Some even call Benedictines the
forerunners of the green movement and ecological consciousness. Stability refers to
remaining and working diligently in one abbey and community for one’s lifetime. Thus,
fostering the development of deep lasting relationships and concern for fellow brothers,
community organizations and members 82,84
. Love of Learning – centers around teaching
the integration of thought and action as complementary aspects of life. The actions
include preserving the intellectual and material works created from previous generations

43
and creating scholarly, artistic and scientific works which enrich and enlarge human life.
The majority of these monastic communities are in congregations for purposes of mutual
assistance and common discipline. However, Benedictine communities are diverse, with
some individuals pursuing an enclosed life with little involvement in the local church and
society. While, others insist on various degrees of involvement, ranging from
educational instruction at all levels, parochial ministry, evangelization, publication,
health care, etc. 82-84
.
School Sisters of St. Francis of Christ the King was the only Franciscan
community who participated in our study. The family of Franciscan orders was founded
in the 13th century by its principal founder St. Francis of Assisi. Franciscans take vows
of poverty, chastity and obedience and all share in the mission of living the Gospel and
serving the poor 85
. Similar to the Benedictine orders, men and women can become
followers. Some of the roles they fill in the community along with being constant
witnesses for Christ are educators, administrators, catechists in parishes, religious
teachers in parish, public schools, while simultaneously keeping a focus on promoting
and strengthening Christian values 85,86
.
In the independent living community population Monarch Landing offers a robust
independent living experience that promotes a vibrant lifestyle for active seniors. The
independent retirement community is located on a scenic campus, which is thoughtfully
constructed to be in harmony with nature. The various units are designed with welcoming
living areas, dining rooms, country kitchens, artful lighting and specialty accents
throughout its several floor plans. Residents are encouraged to make decisions about their
schedules, dining preferences, social activities, care choices, faith services, cooking,

44
fitness classes and more. Monarch Landing offers a newly constructed assisted living
memory support and soon to open rehabilitation and skilled nursing services; thus
providing complete continuing care for seniors throughout the later stages of life 87
.
The Institutional Review Board at Benedictine University approved this study.
The IRB approval level was exempt based on the anonymous survey data and low risk
nature of the physical health measures collected.
Validity and Reliability of Methods
During our study we utilized wellness surveys that are validated for older adults
in their original form and calculated outcomes based on their specific scoring instruction
88-91
. The four instruments that were used to measure the mental wellness of our
population as part of our survey were the 15-question Geriatric Depression Scale (GDS),
the Multidimensional Scale of Perceived Social Support (MSPSS), the 12-item
Spirituality Index of Well-Being and the 10-item Perceived Stress Scale (PSS). The first
instrument was the 15-question GDS, which has been used in many research studies
illustrating high validity and reliability scores (Cronbach’s alpha of 0.80) 88,92,93
. One
such study involving sixty-four outpatients aged 60 or older who met criteria for
depressive disorder comparing ICD-10 Checklist of Symptoms, Montgomery-Asberg
Depression Rating Scale (MADRS), and DSM-IV diagnostic criteria to the GDS-15
scoring values. The results were that the GDS-15 produced sensitivity and specificity
rates of 92.7% and 65.2% respectively, and positive and negative predictive values of
82.6% and 83.3% respectively 88
. These findings illustrate that the GDS -15 is a good
screening instrument for major depression as defined by both the ICD-10 and DSM-IV.
The second survey used in our assessment was the MSPSS, which is found to

45
have excellent internal consistency and test retest reliability with a Cronbach’s alpha of
0.81-0.98 in nonclinical samples and 0.92-0.94 in clinical samples 94
. The MSPSS
produced item and scale scores with adequate reproducibility; over a 2-3 month period of
time, its reliability is r=.72-.85 94
. In regards to validity, MSPSS positively correlates
with a self-concept measure and negatively with measure of depression and anxiety,
which confirms the validity of survey 95
.
The third scale added to our survey was the 12-item Spirituality Index of Well-
Being (SIWB). The SIWB is a scale that has been validated to determine subjective well-
being of an individual. Internal reliability analysis performed on the SIWB scale
indicated good reliability with a Cronbach’s alpha of .91. The 6-item subscales also
showed strong reliability values: α = .86 for self-efficacy and α =.89 for life scheme.
The last scale utilized in our survey was the 10-item PSS-10. It has been shown to
have relatively high reliability and validity within all age groups with a Cronbach’s alpha
of .82 90,96,97
. In addition to the survey data, we also collected diet information and
physical health measures. These measures have demonstrated in past research to both
independently and collectively measure risk of disease and mortality in older adults and
are also used as standards of care in the fields of traditional medicine, nutrition, public
health, exercise and complementary health. They are as follows: waist circumference,
systolic blood pressure, diastolic blood pressure, pulse, Body Mass Index, body fat and
lean mass 27,98-103
. In addition, a 24-hour dietary recall was used to collect dietary data.
The 24-hour recall approach is used in research, but has proven be reliable but invalid 104
.

46
Individuals may not report their food consumption accurately, most commonly
underreporting, due to knowledge deficits, memory lapse, demeanor of the examiner or
the environment interview situation 105
.
Threats to Internal and External Validity
Concerns with validity included wellness survey instruments, physical health variables
used to quantify wellness status and the equipment used to capture the physical health
data. To minimize these concerns, the research group members researched the literature
for the appropriate scales that were shown to be valid for the wellness parameters of
interest as well as the age group of our sample. Our team members were careful once the
scales were determined not to alter the instruments in any way and to calculate the survey
totals per the particular scale instruction. The four scales are listed as follows: Geriatric
Depression Scale (GDS), the Multidimensional Scale of Perceived Social Support
Scoring (MSPSS), the Perceived Stress Scale (PSS) and the Spirituality Index of Well-
Being (SIWB). The validity and reliability for each scale was discussed in the previous
paragraph by stating each scales average Cronbach’s value. However, several scales and
measurement techniques used in this study had individual limitations.
The PSS-10 scale is most accurate for capturing acute stress of a specific life
event or stressor that occurs within a 4-8 week period of measurement 90
. A limitation in
the SIWB in the validation of this scale is the absence of work that tests the conceptual
framework. A myriad of pathways, sequences, and relationships are suggested in the
framework, which was developed from qualitative data, but the scale lacks robust
empirical testing 89,106
.

47
The 24-hour recall is most prone to study participants “underreporting” their food
consumption 105
. To overcome these issues the interview process is conducted by trained
team members who used food models and standardized serving sizes as well as
prompting and probing of the participants to reduce incidence of misreporting or
inaccurate stating of food intake. 24-hour diet recalls are most appropriate for cross-
sectional research investigations when the study purpose requires quantitative estimates
of intake 107
.
The group also utilized physical health measures to classify wellness status. The
physical measures chosen in our study were all taken with validated equipment and by
study team members trained in its specific and proper use. To ensure consistency and
reliability each team member performed data collection at only the station they were
trained on and did not interchange between stations at any time during the data intake
process. The dietary intake was captured from the previous day by utilizing the 24-hour
dietary intake process. The 24-hour intake was taken by a member of the research team in
a one-on-one interview format utilizing standardized food models, serving size sizes cups
and questions designed to spur memory and promote accurate caloric intake reporting.
Reliability Concerns
Concerns with potential reliability existed within the data collection process.
Possible concerns were within three areas: inconsistency with the data collection
methods, inconsistency with the data processing, and pre-assessment participant factors.
To minimize reliability concerns the research group members were placed in a training
process which consisted of performing several trials on team members and being given
detailed instruction on their device or tool operation prior to the onsite collection of data.

48
The training instruction included the proper set-up, use, calibration and preparation of
that device or tool utilized to gather intake data. Team members were careful to perform
pre-checks on the equipment onsite to ensure proper working order before any data from
participants were collected. The participant factors in the study included individuals who
exercised the day of collection, ate or drank directly before the assessment, wore clothing
that was thicker or thinner than an average t-shirt, or had orthopedic injuries that could
compromise their posture and stability during measurement. To minimize these
occurrences data collection was taken in the morning at the majority of the collection
sites used in our sample. Study participants that were dressed is a way that posed a barrier
to proper assessment were asked to change or modify their clothing so that the proper
measurements could be recorded. Any individuals that had compromised posture or
balance were lightly assisted and stabilized into the best positions to gather the most
accurate data readings.
Measurement Tools
Geriatric Depression Scale (GDS-15)
A survey instrument included in our wellness survey was the 15-item Geriatric
Depression Scale (GDS-15). The 15 question Geriatric Depression Scale (GDS-15) is a
tool used to diagnose depression in the older adult population and is frequently used in
the research setting 108,109
. The survey has not only proven to successfully diagnosis
depression in the general older adult population, but also in the very old 110,111
. Our study
assesses health parameters of adults over 65 years old, therefore the GDS-15 is
appropriate for use in our research population. The questionnaire takes about 10 minutes
or less to complete. Answering ‘yes’ to the first 10 questions indicates depression; and or

49
answering ‘no’ to the remaining 5 questions also signifies depression. The answers then
that indicate depression are given a positive score of 1. The scores of all 15 questions are
added together, with a sum of 5 or greater being indicative of depression 112
.
Multidimensional Scale of Perceived Social Support Scoring (MSPSS)
A second instrument utilized in our study was the 12-question Multidimensional
Scale of Perceived Social Support Scoring (MSPSS). This tool is a subjective assessment
scale that can be used as a predictor of well-being, helps examine the influence of
stressful life events, general depression, health status and treatment effects 91
. MSPSS
measures perceived social support and adequacy of emotional support presently available
in an individual’s life. Perceived social support appears to be the most important
measurement in an individual’s perception of received support 94
. The MSPSS addresses
the availability of social support from 3 major relationships: significant others (#1, 2, 5
and 10), friends (#6, 7, 9 and 12) and family members (#3, 4, 8 and 11). Each potential
source of support is used to assess a subject’s satisfaction with support on a 7 point Likert
scale of 0 (very strongly disagree) to 7 (very strongly agree). The scoring range for the
12 questions, is between: 7 to 84; with the highest possible social support score being 84.
The categories breakdown into the following rankings: 69-84 High Acuity, 49-68
Moderate Acuity, and 12-48 Low Acuity.
Perceived Stress Scale (PSS-10)
A third tool incorporated in the survey was the 10-item Perceived Stress Scale
(PSS-10). It is a tool used to globally measure how seemingly stressful situations impact

50
a participant’s life 90
. This tool has widely been utilized by clinicians and researchers to
quantify perceived stress in a variety of populations including the older adult 7,14,78,113
.
When the PSS-10, is utilized to collect information the participants are asked how often
they feel or have felt in a specific manner over the past month; their options are: never,
almost never, sometimes, fairly often, and very often. The PSS-10 is scored by assigning
point values to how often specific feelings are experienced: never (0), almost never (1),
sometimes (2), fairly often (3), very often (4). Points are then reversed for the four
positively stated items, questions 4, 5, 7 and 8 and summed together 90
. The highest total
score possible is 24 and scores of 20 or greater indicate a period of high distress 90
.
Spirituality Index of Well-Being (SIWB)
The final tool included in the survey was the Spirituality Index of Well-Being
(SIWB). This is a subjective 12 item scale intended to determine an individual’s
perception of their spiritual quality of life 89
. The SIWB is validated and consistently
used to determine general well-being 89
. The first six items on the SIWB scale address the
concept of self-efficacy. Items seven through twelve address the concept of life scheme
106
. The SIWB employs a five point Likert scale used to determine how the participant
feels about each statement given in the SIWB scale. A “one” signifies they “strongly
agree;” two signifies they “agree;” three signifies they “neither agree nor disagree;” four
signifies they “disagree;” and five signifies the “strongly disagree.” The scale utilizes a
scoring, system that indicates higher SIWB scores translates into greater degrees of
spirituality and/or well-being 89
. To score, the mean of the items on each of the two
subscales is calculated, as well as the mean score of the combined scales. Higher scores

51
indicate increased spirituality and/or self-efficacy, with the highest total score being 60,
and the lowest total score being 0. The Highest score possible for each of the two
concepts, self-efficacy and life scheme, is 30 and the lowest score is 0 for both sections
89
.
Instrumentation and Procedures of Physical Health Measures
Physical assessments and stress measures were collected using several tools. The
first measurement collected of these parameters was blood pressure. Systolic, diastolic
and pulse were collected on the same arm three consecutive times in approximately 1
minute recurring intervals. We did not utilize the first value and formed a score by
averaging the next two blood pressure readings. The BP Tru BPM -200 automatic unit
inflates the cuff up to above the systolic pressure 35 mm hg then slowly deflates at a
constant rate until a reading can be established. The unit will automatically calculate the
systolic, diastolic, and pulse values on a screen that must be recopied to a data sheet. The
collection process was initiated with the examiner instructing the participant to sit quietly
for a few minutes prior to measurement. The examiner then asked the participant to place
their arm on the table palm up and maintain constant breathing without speaking. Then
the examiner placed the cuff around the participants arm just above the elbow and
activated the machine.
Standing Height
Height was measured using a portable stadiometer, Seca 213 portable unit. This
model can record height values ranging from 20 to 205 cm with increments as small as a
millimeter. To collect the height information, participants were asked to remove their

52
shoes, stand with their back towards the measurement post and maintain a light three
point contact position with the post (buttocks, shoulder blades, back of head). They were
instructed to look straight ahead and maintain best possible posture (chin up, head neural,
shoulders pulled back, arms relaxed with hands at the side of the thighs). The headboard
is then lowered to the top of the cranium just to the point of skull contact or significant
hair depression. Height was then recorded in centimeters and the headboard was raised
and the person was asked to step away.
Waist Circumference
Waist circumference was recorded with a pliable, but stretch resistant body tape
measure. The measurement process consisted of the examiner asking permission to locate
the umbilicus and the participant standing with feet together while maintaining optimal
posture (chin up, head neural, shoulders pulled back, arms relaxed with hands at the side
of the thighs). The participant pointed to their umbilicus and the examiner, measured
around a t-shirt, tight enough to prevent any lag in the tape. The examiner recorded the
value to the nearest 0.1 centimeter.
Weight and Body Composition
Weight and body composition were collected by employing the use of the Inbody
230 BIA Scale. This scale allows for the collection of lean body mass, fat mass, dry lean
mass, intracellular, and extracellular water, total body water, body mass index, percent
body fat, and basal metabolic rate. The Inbody can measure these aspects through the use
of eight polar tactile electrodes that sends a 50 khz electrical currents through the various
tissues of the body. That frequency is one of the highest reactance currently available on

53
the professional market for identifying various components of body composition 114
.
Research participants were asked to remove shoes, socks, electrical devices, and jewelry.
The participants were then asked to stand on the scale with bare feet and recite intake
information (height, age, sex) for the scale to tabulate findings. The scale then created a
printed profile. The examiner printed two copies one for data configuration and the other
for personal use for the client. The examiner then used hygienic wipes to clean and
sanitize the hand and feet contact points on the scale after each use.
24-Hour Diet Recall
Diet data was collected from study participants by utilizing the 24-hour diet recall
method. This method consists of listing all foods consumed by the individual during the
previous 24-hour period. The dietary interview was performed face-to-face by trained
research staff to collect general menu information and then probe for critical details. The
questions are standardized and include cooking methods, brands, time of consumption,
food types, recipes and portion sizes. Other data collected from the 24-hour recall
included length of meals and general eating framework (eat alone, eat while watching
TV, etc.). The examiners also asked study participants the time and location of meal
consumption to stimulate memory and help facilitate greater recall accuracy. The
research team members also employed the use of visual aids such as food models and
measuring cups to assist with improved intake precision and correct portion
identification. The data was reviewed again with the participant a final time before being
placed into Elizabeth Stewart Hands and Associates (ESHA) software program. The
energy, macro and micronutrient intakes were determined using a nutrient analysis
software called Food Processor, by ESHA Research, Inc. The Food Processor server

54
derives food nutrient composition from the United States Department of Agriculture’s
(USDA) national nutrient database, which is used as its primary standard reference.
ESHA Diet software
The Food Processor nutrition software has been used by dietitians, nutrition
professionals, academic institutions and other healthcare professionals for 30 years. The
data reported in the ESHA software comes from over 1800 sources, including the USDA
database, international databases, and nutrient data from food manufacturers, restaurants,
national food councils and associations.
Statistical Procedures
Our data was coded into the Statistical Package for the Social Sciences (SPSS)
numerically. SPSS by IBM is a group of an integrated products that addresses the entire
research analytical process, beginning with organizing the collected data, followed by
analysis of variables and last reporting of results. Any new variables needed based on
combined metrics or varying interpretation were created in the program and added into a
continuously evolving data set.
The following tests of statistical analysis were performed in our research study to
qualify outcomes and generate findings. A Pearson’s Correlation Coefficient was used
measure the nature of the association between two variables and the strength of their
relationship. The associations were reported if they have a p-value of less than .05.
Multiple linear regression was used to determine if a linear relationship between a
dependent variable and one or more independent variables existed, as well as the strength
of those variables to the outcome measure. Results were reported if values were

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