Nursinghttp://nsq.sagepub.

com/
Science Quarterly
Toward a MiddleRange Theory of Weight Management
Stephanie Pickett, Rosalind M. Peters and Patricia A. Jarosz
Nurs Sci Q 2014 27: 242
DOI: 10.1177/0894318414534486
The online version of this article can be found at:
http://nsq.sagepub.com/content/27/3/242

Published by:
http://www.sagepublications.com

Additional services and information for Nursing Science Quarterly can be found at:
Email Alerts: http://nsq.sagepub.com/cgi/alerts
Subscriptions: http://nsq.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
Citations: http://nsq.sagepub.com/content/27/3/242.refs.html

>> Version of Record - Jun 19, 2014

What is This?

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on November 18, 2014

534486

research-article2014

NSQXXX10.1177/0894318414534486Nursing Science QuarterlyPickett et al.

Article

Toward a MiddleRange Theory of

Weight Management

Nursing Science Quarterly

2014, Vol. 27(3) 242247
The Author(s) 2014
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0894318414534486
nsq.sagepub.com

Stephanie Pickett, RN; PhD,1 Rosalind M. Peters, RN; PhD;

FAAN,2 and Patricia A. Jarosz, RN; PhD2

Abstract
The authors of this paper present the middle-range theory of weight management that focuses on cultural, environmental, and
psychosocial factors that influence behaviors needed for weight control. The theory of weight management was developed
deductively from Orems theory of self-care, a constituent theory within the broader self-care deficit nursing theory and from
research literature. Linkages between the conceptual and middle-range theory concepts are illustrated using a substruction
model. The development of the theory of weight management serves to build nursing science by integrating extant nursing
theory and empirical knowledge. This theory may help predict weight management in populations at risk for obesity-related
disorders.
Keywords
Orem, self-care deficit nursing theory, weight management, weight management agency
Obesity (body mass index > 30) is a major public health
problem affecting over 78 million adults in the United States
(US) (Ogden, Carroll, Kit, & Flegal, 2012). Despite the
widespread nature of the problem, significant racial disparities exist. Non-Hispanic blacks have the highest prevalence
of obesity at 47.8%, which is 11% higher than Hispanics at
42.5% and 32% higher than non-Hispanic whites at 32.6%
(Ogden, Carroll, Kit, & Flegal, 2013 ). While the markedly
high prevalence of obesity poses a significant health threat
for all Americans, African American women are at especially
high-risk as 58.6% of African American women are obese;
one of the highest rates of any group in the US (Flegal,
Carroll, Kit, & Ogden, 2012). The health consequences of
obesity include increased rates of cardiovascular disorders
(coronary heart disease, hypertension, stroke), cancer (endometrial, breast), respiratory disorders (sleep apnea), osteoarthritis, and type 2 diabetes (US Health and Human Services
[USHHS], 2010). The high prevalence of overweight and
obesity noted in Americans has been attributed in part to limited engagement in the behaviors that are necessary to manage weight such as balancing caloric intake with physical
activity (Schiller, Lucas, Ward, & Peregoy, 2012). While the
balance between calories consumed and expended will determine body weight, a great number of cultural, environmental, and psychosocial factors influence eating patterns and
exercise behaviors.
Understanding a persons health behaviors in order to prevent the onset of obesity-related disorders is consistent with
the health promotion focus of the discipline of nursing
(Fawcett, 2005). The aim of this paper, therefore, is to

describe the development of the theory of weight management that focuses on factors influencing behaviors necessary
for weight control. This middle-range theory which was
derived from the theory of self-care (Orem, 2001), can serve
as a guiding framework to explore the influence of cultural,
environmental, and psychosocial factors on weight management behaviors in populations at high-risk for obesityrelated disorders.

Middle-Range Theory Development

Theories may be differentiated by their level of abstraction
with middle-range theories being intermediate between
broad, highly abstract, unified general theories and working
hypotheses that describe specific particulars that cannot be
generalized. Middle-range theories have a narrow scope, a
limited number of concepts that while abstract, are close
enough to observed data to be incorporated into propositions
and hypotheses that can be examined empirically (Merton,
1968). The principle purpose of middle-range theories is to
guide empirical inquiry. As such, middle range theories may
assist in interpreting behaviors, situations, and events that
can be tested using research methodologies (Fawcett, 2005).
An initial step in developing a middle-range theory is to
analyze and synthesize theoretical and empirical knowledge

Ruth L. Kirschstein NRSA Postdoctoral Fellow, University of

Pennsylvania
2
Associate Professor, Wayne State University

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on November 18, 2014

243

Pickett et al.
about the phenomenon of interest (weight management).
Thus, key concepts investigated to develop the theory of
weight management focused on the cultural, environmental,
and psychological factors that influence weight control
behaviors. Of particular interest was the influence of beliefs
about personal weight and their effect on motivation to control weight. A recent systematic review of the theoretical literature revealed that within a 20-year span from 1990-2010,
the conceptual models most commonly used to examine
weight control behaviors/obesity prevention have come from
disciplines other than nursing (Fitzgibbon, et al., 2011).
Within the discipline of nursing the health promotion model
(Pender, Murdaugh, & Parsons, 2005) and the self-care deficit theory of nursing (Orem, 2001) are two models used to
examine factors influencing health behaviors. Reviews of the
two models reveal that the models have been used extensively in health promotion (Biggs, 2008; Srof & VelsorFriedrich, 2006; Taylor, Geden, Isaramalai, & Wongvatunyu,
2000). Analysis of the two models reveals congruence
between Penders conceptualization of health promotion
behavior and Orems conceptualization of self-care (Hartweg,
1990). Further review of the philosophical assumptions
(Banfield, 2011; Denyes, Orem, & Sozwiss, 2001) and model
concepts resulted in the decision to use the self-care deficit
theory of nursing (SCDNT) (Orem, 2001) as the conceptual
model from which to derive the middle-range theory of
weight management. The SCDNT was chosen because the
conceptual model includes all of the metaparadigm concepts,
and its focus on self-care is consistent with the phenomenon
of interest, which is weight management.

Analysis of the Theory of Self-care

The SCDNT consist of three constituent theories. The theory
of self-care is considered to be foundational to the theory of
self-care deficit and the theory of nursing systems. Each of
these three constituent theories is considered a grand theory
given their level of abstraction (Fawcett, 2005). It is the theory of self-care that provided the direction for developing the
middle-range theory of weight management. There are five
key concepts within the theory of self-care that were used in
developing the theory of weight management. These include:
self-care, self-care requisites, self-care agency, basic conditioning factors, and health.
Within the theory of self-care humans are viewed as holistic beings, in constant interaction with their environment.
Humans are also seen as capable of deliberate action to attain
goals, and adults are seen as having the rights and responsibilities to provide care for self. Self-care is a human regulatory function that is learned, voluntary behavior done by
mature and maturing adults in order to meet self-care requisites necessary for individuals to maintain life, health, and
well-being (Orem, 2001; Orem & Taylor, 2011). Self-care
requisites represent actions needed to bring about the internal and external conditions that maintain human structure

and functioning (Orem, 2001, p. 225). Universal requisites

address needs that are common to all human beings (air,
food, water), while health deviation requisites address prevention and control actions needed when there are deviations
from proper functioning, and developmental requisites are
concerned with promoting human development and overcoming life situations that adversely affect that development
(Denyes, et al., 2001; Orem, 2001). Together these three
types of requisites form the therapeutic self-care demand, or
the totality of actions needed for healthy human functioning.
Health, which reflects integrity of human structure and functioning, is seen as the outcome of self-care behaviors.
The ability to engage in self-care is termed self-care
agency. Self-care agency is a multidimensional concept that
includes human basic capabilities, foundational dispositions,
power components, and self-care operations (Denyes, et al.,
2001; Orem, 2001). Human basic capabilities are those that
affect knowing, reasoning, and making right judgments
(Orem, 2001, p. 261). Foundational dispositions determine
concern for health, affects goals sought, expresses conditions
that affect willingness to accept self as a self-care agent,
determines lasting habits, and provides motivation to engage
in self-care behavior (Anderson & Olnhausen, 1999; Orem,
2001). Power components are the second element of selfcare agency and refer to the human abilities that enable the
performance of self-care operations. The third element of
self-care agency is the self-care operations. These include
estimative operations that refer to a person having the knowledge of self, as well as knowledge about the course of action
needed. Transitional operations are those involving judging
and deciding to engage in needed self-care behaviors, and
productive operations are those required to actually produce
the needed self-care behaviors. Overall, self-care agency is
the comprehensive ability to take the actions needed to maintain a state of wholeness and integrity (Denyes, et al., 2001;
Orem, 2001).
A persons self-care agency is influenced by internal and
external factors known as basic conditioning factors (BCFs).
The BCFs include factors descriptive of patients (age, gender, health state), factors that relate individuals to their families and support networks (family systems, sociocultural
orientation), and factors that relate persons to their conditions and circumstances of living (resource availability)
(Banfield, 2011; Orem, 2001). In addition to influencing
self-care agency, BCFs also condition the persons therapeutic self-care demand.

Middle-Range Theory of Weight

Management
The middle-range theory of weight management was
deduced from the assumptions and concepts of the theory of
self-care and research literature regarding weight management. Key concepts within the theory of weight management
are: weight management behaviors, weight management

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on November 18, 2014

244

Nursing Science Quarterly 27(3)

Basic Conditioning
Factors

Self-Care
Agency

Weight Contextual
Factors

Weight
Management
Agency

Age
Gender
Ethnicity
Comorbidity
SES
Sociocultural
Environmental
Factors

Knowledge of weight
management
Motivation for weight
management

Self-Care

Weight
Management
Behaviors

Health

Weight Control

Physical Activity

Weight

Eating Behaviors

BMI
Central
Adiposity

Beliefs about personal

weight

Figure 1. Substruction model of the theory of weight management.

agency, weight contextual factors and weight control. The

linkages of these concepts to the theory of self-care are
shown in the substruction model depicting the vertical and
horizontal relationships of the conceptual model and the
middle-range theory (Figure 1).

Weight Management Behaviors

Weight management behavior is the concept derived from
the concept of self-care. Weight management behaviors refer
to those behaviors necessary for caloric balance including
regular physical activity (work, sports, leisure time), and eating behavior patterns. These behaviors are usually performed
to maintain health and well-being through meeting known
universal requisites in order to achieve and maintain a
healthy weight. These behaviors are deliberate and performed continuously over time in the process of daily living
(Orem, 2001). Physical activity requisites for adults include
doing at least 150 minutes a week of moderate-intensity
physical activity, or 75 minutes a week of vigorous-intensity
aerobic physical activity or an equivalent combination
(Office of Disease Prevention & Health Promotion Services
[ODHPS], 2008). Moderate intensity aerobic activity is
briskly walking fast enough to accelerate the heart rate and
vigorous intensity activity is jogging, which causes a substantial increase in heart rate (ODHPS, 2008). Forty-four
percent of Americans, 18-44 years old, report meeting these
guidelines (Schiller, et al., 2012). Thirty-three percent of
Americans report physical inactivity, getting no leisure time

physical activity (Schiller, et al., 2012). Reasons for this disparity between physical activity recommendations and practice among Americans are thought to be influenced by
sociocultural, environmental, and social support factors.
Healthy eating behavior patterns include consumption of
a diet rich in fruits and vegetables, whole grains, high-fiber,
and fish. Fat intake should be limited by choosing lean meats,
meat substitutes, skim or low-fat dairy products, and limiting
intake of foods with partially hydrogenated fats, added
sodium and sugars ([USHHS], 2010). Dietary patterns of
many Americans reveal limited consumption of fruits and
vegetables. More than 70% of Americans do not consume
five or more servings of fruits and vegetables per day. Also,
the average American consumes about 3,400 mg of sodium
each day, more than double the ideal recommended level of
1,500mg/day. In addition, most Americans consume sugar
well beyond the recommended level (USHHS, 2010). There
are many factors that influence the practice of physical activity and healthy eating needed for weight management.

Weight Management Agency

The ability to engage in weight management behaviors is
conceptualized as weight management agency, which is
deduced from the concept of self-care agency. The substantive structure of weight management agency includes beliefs
about personal weight (foundational disposition), motivation
to manage weight (power component), and knowledge of
weight management (estimative self-care operation). The

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on November 18, 2014

245

Pickett et al.
transitional and productive self-care operations can be
inferred from the behaviors actually performed. Beliefs
about personal weight may influence weight management
behaviors. Beliefs are conceptualized as the underlying cognitive component of attitudes and are considered to be a predisposition to action (Fishbein, 1963). These beliefs may be
based on knowledge about self, and may be acquired through
culture and inferred from speech or actions (Fishbein, 1963).
Beliefs about personal weight are consistent with self-awareness that determines a persons concern over their weight
related to health. These beliefs influence a persons goals
concerning their weight and their willingness to accept
responsibility for weight management behaviors.
Another element of weight management agency is motivation for weight management that can vary greatly based on
sociocultural orientation. For example, attitudes toward a
heavier body size and a tendency to underestimate their body
weight may decrease African American womens motivation
toward engaging in behaviors necessary for weight control.
Conversely, those who perceive themselves to be overweight
are more likely to make weight loss attempts (Befort,
Thomas, Daley, Rhode, & Ahluwalia, 2008).
The third element of weight management agency refers to
the operations needed to produce weight management behaviors. These operations include knowledge of the course of
action for weight control then deciding whether to engage in
these behaviors followed by taking the steps needed to produce the behaviors needed (purchasing low-fat, low-sodium
foods, joining a gym).
The estimative self-care operation is of particular importance as weight management has been associated with
knowledge of nutrition, physical activity, and obesity health
risks. Reading food labels to learn about food content before
purchase is associated with healthful eating self-efficacy and
trying to lose weight (Klohe-Lehman, et al., 2006).
Nutritional knowledge as a component of weight management agency is associated with weight management behaviors. Nutritional knowledge has been associated with greater
weight loss among overweight caregivers, while those with
limited nutritional knowledge are less likely to know that
diet may be associated with disease, read food labels, or consume a healthy diet (Klohe-Lehman, et al., 2006). Knowledge
of physical activity requirements has also been found to be
associated with increased participation in this weight management strategy (Moore, Fulton, Kruger, & McDivitt,
2010). However, knowledge alone is not sufficient, as individuals still need to make a decision to eat healthy and exercise more, and then have the resources to produce the desired
behaviors.
Overall, weight management agency is the comprehensive ability to take action in order to control weight. It is
understood that a persons weight management agency is
indirectly known by the behaviors practiced or not practiced.
However, weight management agency is influenced by internal and external factors that describe the individual and

influence weight management requirements. These factors

are known as weight contextual factors.

Weight Contextual Factors

The middle-range concept of weight contextual factors is
derived from the theory of self-cares concept of basic conditioning factors. Weight contextual factors are defined as factors that influence the capability for weight management as
well as influence the individuals requisites related to weight
(intake of food, balance between activity and rest). Weight
contextual factors include age, gender, comorbidities, sociocultural orientation, and socioeconomic and environmental
resource factors that provide some indication of neighborhood resources for physical activity and access to healthy
foods. Weight contextual factors influence or condition a
persons weight management agency. There are gender and
age differences associated with weight. National data from
2011-2012 indicate that the overall prevalence of obesity
among men and women was similar at 34.9%; however, 56.6
% of African American women were obese compared with
37.1% of African American men. Among men and women,
the prevalence of obesity tended to increase during middle
age and was sustained after middle age in women (Ogden, et
al., 2013). These data suggest that gender and age are important contextual factors to be considered for weight
management.
Comorbidities are both a consequence and a cause of
weight management behaviors. As indicated earlier, obesity
is related to a number of significant health problems.
Problems such as osteoarthritis and heart disease may limit
an individuals level of physical activity. At the same time,
health issues are reasons some women have given for engaging in weight management; (Befort, et al., 2008; Capers,
Baughman, & Logue, 2011). Thus, presence of comorbidities may have a significant influence on weight management
behaviors.
Sociocultural factors may influence weight management.
Cultural norms may impact ones weight as some cultures
do not stigmatize obesity or encourage weight loss. For
example, African American women may have a more tolerant attitude toward a larger body, which may decrease the
desire to practice behaviors leading to weight reduction for
aesthetic reasons (Befort, et al., 2008; Hendley, et al., 2011).
Also, disapproval and lack of support from family and
friends when spending time being physically active and
cooking healthier foods may affect an individuals weight
management behaviors (Aroian, Peters, Rudner, & Wasser,
2012). Environmental factors may influence the ability for
weight management. When the environment is disadvantaged, lacking resources to support physical activity and
healthy diets, weight management may be affected. Many
inner-city neighborhoods are considered disadvantaged. As
a result, many inner-city residents may be at risk for being
overweight and obese.

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on November 18, 2014

246

Nursing Science Quarterly 27(3)

Weight control
Weight control is conceptualized as health. Within the theory
of self-care, health is defined as a state of structural or functional wholeness or integrity (Orem, 2001, p.182). The outcome of weight management behaviors is considered to be
weight control as evidenced by actual body weight, body
mass index, and central adiposity being within normal
limits.

Assumptions of the Theory of Weight

Management
The theory of weight management was created based on
assumptions derived from the theory of self-care (Orem,
2001), and a synthesis of the empirical literature. Assumptions
are principles that are accepted as true without proof
(Fawcett, 2005). The assumptions of the theory of weight
management include the following:
1. Human beings are unitary beings who function as
whole persons.
2. Human beings personal view about their weight is
central to weight management.
3. Human beings require continuous input to self to
maintain their weight.
4. Weight management agency (ability to engage in
weight management behavior) is exercised through
care of self by identifying the need and being motivated to maintain a healthy weight.
5. Weight management agency (ability to engage in
weight management behavior) is exercised through
care of self by having the knowledge and resources,
judging and deciding and the ability to take action to
practice weight management behaviors.
6. Weight management behaviors (physical activity,
eating behaviors) are deliberate voluntary behaviors
that are learned within their family and broader
sociocultural system
7. Maturing human beings are viewed as being responsible for caring for self and maintaining their own
weight.
8. Weight control is a state of health

3. Components of weight management agency (weight

beliefs, motivation to engage in weight management
behaviors and knowledge of weight management
behaviors) influence weight management behavior.
4. Weight management behaviors have the potential to
positively influence health.

Conclusion and Implications

The discipline of nursing is advanced through middle-range
theory development derived from extant grand theories. The
aim of this paper was to present the middle range theory of
weight management. This middle range theory describes significant factors that may predict weight management in populations at risk for obesity-related disorders. The theory of
weight management examines the factors known to influence weight management behaviors. It purports that weight
contextual factors (demographic, sociocultural, socioeconomic factors, resources, and health states) influence weight
management agency (beliefs about personal weight, motivation to engage in weight management behaviors and knowledge of weight management), which influences the actual
practice of weight management behaviors leading to weight
control or health.
The theory of weight management was developed deductively from the theory of self-care from within the self-care
deficit nursing conceptual model and research literature.
Linkages between the conceptual model and the middlerange theory concepts were illustrated using a substruction
model. The development of the theory of weight management using a nursing conceptual model serves to build nursing science and provides propositional statements for
empirical testing to confirm the theory.
The middle-range theory of weight management may be
useful to researchers and clinicians. Researchers may test the
middle-range theory by developing hypotheses to empirically examine the theory concepts and conceptual relationships. After empirical testing, clinicians may use the theory
to assess their patients capability to be successful at engaging in behaviors needed for weight control.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the authorship and/or publication of this article.

Propositions
Propositions are statements that describe the relationship
between the concepts within a theory, as such they allow for
a broad range of hypotheses to be empirically tested.
Propositions for the theory of weight management include:
1. Weight contextual factors influence weight control
agency.
2. Influence of weight contextual factors on weight
management behaviors are mediated by weight management agency.

Funding
Manuscript preparation was supported in part by the National
Research Service Award Postdoctoral Fellowship [T32NR007100],
University of Pennsylvania, School of Nursing Philadelphia,
Pennsylvania.

References
Anderson, J. A., & Olnhausen, K.,S. (1999). Adolescent selfesteem: A foundational disposition. Nursing Science Quarterly,
12(1), 62-67.

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on November 18, 2014

247

Pickett et al.
Aroian, K., Peters, R.M., Rudner, N., & Wasser, L. (2012).
Hypertension prevention beliefs of Hispanics. Journal of
Transcultural Nursing, 23(2), 134-142.
Banfield, B. E. (2011). Environment: A perspective of the self-care
deficit nursing theory. Nursing Science Quarterly, 24(2), 96100.
Befort, C. A., Thomas, J. L., Daley, C.M., Rhode, P. C., &
Ahluwalia, J. S. (2008). Perceptions and beliefs about body
size, weight and weight loss among obese African American
women: A qualitative inquiry. Health Education and Behavior,
35(3), 410-426.
Biggs, A. (2008). Orems self-care deficit nursing theory: Update
on the state of the art and science. Nursing Science Quarterly,
21(3), 200-206.
Capers, C.F., Baughman, K., & Logue, E. (2011). Behaviors and
characteristics of African American and European American
females that impact weight management. Journal of Nursing
Scholarship, 43 (2), 133-144.
Denyes, M. J., Orem, D. E., & SozWiss, G. B. (2001). Self-care: A
foundational science. Nursing Science Quarterly, 14(1), 48-54.
Fawcett, J. (2005). Contemporary nursing knowledge analysis and evaluation of nursing models and theories (2nd ed.).
Philadelphia, PA: Davis Company.
Fishbein, M. (1963). An investigation of the relationships between
beliefs and an object and the attitude toward that object. Human
Relations, 16, 233 -239.
Fitzgibbon, M. L., Tussing-Humphreys, L. M., Porter, J. S., Martin,
I. K., Odoms-Young, A., & Sharp, L. K. (2011). Weight loss
and African American women: A systematic review of the
behavioral weight loss intervention literature. Obesity Reviews,
13, 193-213.
Flegal, K. M., Carroll, M. D., Kit, B. K., & Ogden, C.L. (2012).
Prevalence of obesity and trends in the distribution of body
mass index among US adults, 1999-2010. JAMA, 307(5),
E1-E7.
Hartweg, D.L. (1990). Health promotion self-care within Orems
general theory of nursing. Journal of Advanced Nursing, 15,
35-41.
Hendley, Y., Zhao, L., Coverson, D.L., Din-Dzietham, R., Morris,
A., Quyyumi, A.A., & Vaccarino, V., (2011). Differences
in weight perception among Blacks and Whites. Journal of
Womens Health, 20, 1808-1811.

Klohe-Lehman, D. M., Freeland-Graves, J., Anderson, E. R.,

McDowell, T., Clarke, K.K., Hanss-Nuss, H., & Milani, T.J.
(2006). Nutrition knowledge is associated with greater weight
loss in obese and overweight low-income mothers. Journal of
American Dietetic Association, 106, 65-75.
Merton, R. K. (1968). On sociological theories of the midde range.
In Social theory and social structure. New York: Free Press.
Moore, L.V., Fulton, J., Kruger, J., & McDivitt, J. (2010).
Knowledge of physical activity guidelines among adults in the
United States, healthy styles 2003-2005. Journal of Physical
Activity & Health, 7(2), 141-149.
Office of Disease Prevention & Health Promotion Services, (2008).
Physical Activity Guidelines for Americans. Retrieved from
http://www.health.gov/paguidelines/guidelines/summary.aspx
Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K.M. (2012).
Prevalence of obesity in the United States, 2009-2010 (NCHS
Data Brief No. 82D).
Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K.M. (2013).
Prevalence of obesity in the United States, 2011-2012 (NCHS
Data Brief No. 131).
Orem, D. E. (2001). Nursing: Concepts of practice ( 6th ed.).St.
Louis, MO: Mosby, Inc.
Orem, D. E., & Taylor, S. G. (2011). Reflections on nursing practice science: The nature, the structure, and the foundation of
nursing sciences. Nursing Science Quarterly, 24, 35-41.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2005). Health
promotion in nursing practice (5th ed.). Upper Saddle River,
NJ: Prentice Hall.
Schiller, J. S., Lucas, J.W., Ward, B.W., & Peregoy, J.A. (2012).
Summary health statistics for U.S. adults: National Health
Interview Survey, 2010. Vital Health Statistics, 1(252), 1-207.
Srof, B. J., & Velsor-Freidrich, B. (2006). Health promotion in
adolescents: A review of Penders health promotion model.
Nursing Science Quarterly, 19, 366-373.
Taylor, S. G., Geden, E., Isaramalai, S., & Wongvatunyu, S. (2000).
Orem self-care deficit nursing theory: Its philosophic foundation and the state of the science. Nursing Science Quarterly,
13(2), 105-110.
U. S. Department of Health and Human Services (2010). Dietary
Guidelines for Americans (7th ed.) Washington, DC: U.S.
Government Printing Office. Retrieved from http://www.health.
gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on November 18, 2014