Dietary habits are typically developing in childhood and established by young adulthood 1. Development of healthy eating habits in young individuals could be vital for prevention of cardiovascular disease (CVD) since CVD is the leading cause of death in the United States 2. Risk factors for CVD include obesity, hypertension, hypercholesterolemia, insulin resistance, physical inactivity, and smoking 3 and recent data have shown a significant rise in the prevalence of obesity in children, adolescents and adults 4. Diets high in fat, especially saturated fat, are often linked to obesity, hypertension and hypercholesterolemia 15.

Data suggest that caloric intake is increasing among all ethnicities, age and socioeconomic groups, and diets contain more energy-dense, nutrient-poor foods 6. Evidence also suggests that consumption of foods from fast-food restaurants, which typically serve foods high in total and saturated fat, has doubled during the past 30 years 7. Consumption of unhealthy foods may be replacing that of fruits and vegetables (FV), which are known to provide essential vitamins, minerals and other nutrients 6. Even though high levels of whole grain consumption have been linked to reduced rates of CVD and colon cancer, most adults do not consume enough of these foods 8. Alcohol represents another dietary component that is associated with CVD risk factors. While moderate consumption of alcohol is protective against CVD, high levels of consumption are correlated with obesity, CVD and all-cause mortality 9. Also, evidence regarding the readiness to change dietary habits among adults also indicates that most adults are either not aware or not prepared to change their current dietary habits thus adding a layer of difficulty in trying to promote healthful eating habits 10. Given the strong link between diet and disease 11, it is important to evaluate and address dietary behaviors and readiness for change at a young age for effective prevention of CVD and related co-morbidities.

University marching band, dance team and cheer squad members perform physical activity for prolonged periods of time. It has been estimated that these athletes exercise at an intensity of 4.5–6 metabolic equivalents (METs) 12. This MET category also includes activities such as tennis, recreational swimming, golfing, bicycling and lawn mowing. Even though these band members perform intense physical activity, they represent a largely unstudied population in terms of physical characteristics, fitness levels, dietary habits, prevalence of overweight and CVD risk factors. Their dietary habits and physical fitness could be of vital importance to their well-being and performance, especially in an environment of increased heat and humidity.

The primary purpose of this study was to assess prevalence of CVD risk factors, measure dietary intake, readiness to change dietary intake and finally, examine the relationship between dietary intake and risk factors for CVD among members of an urban university marching band, dance team and cheer squad. We hypothesized that dietary factors such as low intake of grains, FV, dairy and high intake of alcohol are significantly associated with the CVD risk factors such as body mass index (BMI), waist to hip ratio (WHR), blood pressure, blood glucose and blood cholesterol.

This study examined baseline pre-season data collected in fall of 2004. This baseline analysis was part of the main study, the primary aim of which was to promote healthy eating habits and physical fitness for the prevention of obesity-related conditions and CVD among marching band, dance team and cheer squad members in an urban university (Bush et al., in preparation).

Overall a high percentage of participants reported eating fewer grains, FV and drinking fewer glasses of water than recommended. Additionally, a majority of the participants were not ready to produce a change in their eating behaviors. Our results also identified a positive association between grain consumption, alcohol intake and BMI.

Forty-five percent of the participants were overweight or obese. The high prevalence of overweight/obesity that was observed in our study concurs with other studies on college-age students which report that 20% to 40% of college students are overweight or obese 2425. The 2006 National College Health Assessment (NCHA) survey on 23,863 students reported that 31% of the U.S college students were overweight or obese based on self-reported height and weight 25. This lower prevalence of overweight in the NCHA statistics as compared to our study could be related to the ethnic distribution since 77% of the NCHA population was Caucasian as compared to 65% in our study; and Caucasians have a lower prevalence of obesity as compared to Hispanics of African Americans 26. Secondly, our study measured height and weight on all the participants. Usually in self-report, as done in NCHA, height is over-reported and weight is under-reported resulting in a lower estimate of BMI 27. The high percentage of females with a WHR ≥ 0.80 indicates an increased risk for development of atherosclerotic plaque and CVD in these participants 28. This high prevalence of overweight in these athletes, especially the females is quite concerning since it puts this population of athletes at increased risk for CVD. Also, given the rigorous training that these athletes often have to do under extreme weather conditions, it is important that they are in peak physical shape for optimal performance. These results warrant the need for design and implementation of targeted obesity-prevention programs for females in this population.

When compared to the 2000 Dietary Guidelines for Americans, our data indicate that less than 20% of participants in this urban marching band university were consuming 5 or more servings of FV per day. Similar results were observed in the 2006 NCHA survey, which reported that only 6.2% of the students were usually consuming 5 or more servings of FV a day 2930. Also, more than 70% of the participants were not consuming the recommended servings for grains. The newer 2005 Dietary Guidelines for Americans 19 recommend 2 cups (4 servings) of fruits and 2.5 cups (5 servings) of vegetables, 5.5 ounces (2 servings) for meats and, 6-ounce equivalents (6 servings) of grains (of which 3 ounces are whole grains) per day at the 2000 calorie level. When compared to these newer guidelines, majority of our study participants are not meeting the recommendations for FV and grains and, are consuming more than the recommended amount for meats. Unfortunately, the current survey did not capture the total caloric intake to determine the participants' intake of various foods relative to the total calories. Also no data was collected on whole grain intake which would have clinical implications since a diet high in low fat dairy, whole grains, and FV along with exercise is considered to be protective against several chronic diseases including obesity, CVD, and cancer 2930. The positive association between grains intake and BMI seen in our study could be suggestive of a high intake of simple carbohydrates which have been associated with overweight and obesity 31. It would be worthy for future studies to collect data on whole grain consumption and examine their relationship with CVD risk factors in this population of student athletes.

The results from the Dietary Stages of Change assessment suggest that the majority of participants are in the cognitive stages for the dietary intake of grains and FV indicating that they are not making any overt changes towards changing their eating behavior for grains and FV. These data imply that health promotion programs aimed at moving these athletes from the cognitive stages to the behavior stages by increasing knowledge and providing necessary skills to improve dietary habits are critical in this population. These data provide critical information regarding the study population's readiness to change their dietary habits which clearly indicates that, at this time, it would be counterproductive to provide action-oriented material about healthy dietary change behaviors. In fact, the focus needs to be more on raising awareness of poor dietary habits, pros of eating more whole grains, FV to move the participants towards action. It is also important to note that the Stages of Change model has potential for public health interventions as well as individual nutrition interventions by health care practitioners towards improving the dietary habits of this population. Additionally, environmental factors, such as availability of FV and whole grain foods on-campus, need to be evaluated. Psychosocial factors such as knowledge, attitudes, beliefs, self-efficacy, outcome expectations and social support influencing diet and weight status in these athletes also need to be assessed.

Greater than fifty-seven percent of the participants indicated consuming 1 or more servings of alcohol per week with more than 10% of them drinking 5 or more servings of alcohol per week. These results concur with the NCHA statistics which reported that 70% of college students used alcohol in the last 30 days 25. While moderate consumption of alcohol is protective against CVD 32, high consumption has adverse effects on health 33. Alcohol is detrimental to athletic performance since it is a diuretic, gives problems with heat regulation, causes hypoglycemia, reduces reaction-times, endurance and increases risk for injury 34. Our study also found a positive association of alcohol intake and BMI. This concurs with the literature that shows frequent consumption of alcohol is associated with weight gain given its high caloric content 35. Also, given that the average age of the study participants was 19 years; our results suggest a high prevalence of underage drinking in this population. Unfortunately, midcourse reviews of the Healthy People 2010 and Healthy Campus 2010 have shown no change nationally in alcohol use and abuse 3637. We strongly recommend using evidence-based programs that are intentionally and cautiously researched, planned, implemented and evaluated in college campuses, especially among athletes. Using health marketing, ecological/environmental, policy and social marketing approaches could potentially work to influence positive health behaviors of students. Additionally, existing alcohol and substance abuse awareness programs need to be evaluated.

Perhaps the most alarming finding of our study was the high percentage of participants with high WHR, elevated blood glucose, cholesterol and systolic and diastolic blood pressure. The major risk factors for CVD include levels of cholesterol (total cholesterol, low-density lipoprotein, and high density lipoprotein), BMI, blood pressure, cigarette smoking and diabetes 1738. Studies have shown that total cholesterol have similar predictive values as LDL for CVD secondary to the atherogenic properties of cholesterol 39. The European SCORE project advocates the use of total cholesterol in isolation 40. However, recent literature has identified TC/HDL or LDL/HDL ratios having superior predictive values with respect to CVD 38. Thus, it is a limitation of the current study that LDL, HDL values were not determined and it would be worthy for future studies to examine these measures.

These results could indicate the presence of components of metabolic syndrome among participants which is considered to be a risk factor for CVD 41. Huang et al. 41 examined the prevalence of metabolic syndrome among 163 college students. They concluded that 27% of the population was overweight and 11.7% had high blood cholesterol 41. Our study did not assess the prevalence of metabolic syndrome in this population which would have provided a greater insight into the health status and CVD risk among this population of collegiate athletes.

In sum, our results suggest a trend toward significant health risks in this elite members of a marching band unless an intervention of diet and exercise are performed. A high percentage of members of this urban marching band have a poor dietary intake and demonstrate a relatively high prevalence of overweight, hyperglycemia, hypercholesterolemia, and hypertension that increase their risk for CVD as well as other lifestyle-related illnesses. These results are especially important since these athletes participate in rigorous activities often under extreme weather conditions throughout the season and need to be in sound health for optimal performance. The unhealthy eating behaviors and a relatively high prevalence of alcohol consumption identified in the current study imply the need to evaluate existing health promotion programs aimed at improving the lifestyle of college students on campus and for evidence-based programs to be implemented. Finally, ACHA tools such as Standards of Practice for Health Promotion in Higher Education 45 and Healthy Campus 2010 37 should be used to develop, test and implement on-campus health promotion programs geared towards improving the dietary habits and reducing the prevalence of CVD risk factors in this population.

The authors declare that they have no competing interests.

SVS conceptualized the study question and design, conducted statistical analysis, interpretation of results, drafting of manuscript and reviewing of the manuscript. JAB is the Principal investigator of the study, conducted data collection, drafting and critically evaluating the manuscript. AJL did data collection, data entry, drafting of the manuscript and reviewing the manuscript. MK did data collection and critically reviewed the manuscript. DA did data collection and critically reviewed the manuscript. GB did data collection and critically reviewed the manuscript. DB participated in study design and data collection.

Informed consent was obtained from all participants prior to the study and the study protocol was approved by the University of Houston, Committee for Protection of Human Subjects.