Impact of Type 2 Diabetes Threat Appraisal
on Physical Activity and Nutrition Behaviors
among Overweight and Obese College Students
Ann O. Amuta, PhD, MPH, CPH; Katie Crosslin, PhD, CHES; Jessica Goodman, PhD, MPH;
Adam E. Barry, PhD
Objective: We examined the impact of
threat appraisal (TA) on Type 2 diabetes
(T2D)-related protective behaviors among
high-risk college students. Methods: Us-
ing a Web-based survey, we collected data
from 319 overweight or obese undergradu-
ate students attending one of 4 Texas col-
leges/universities. Hierarchical multiple
regression analyses determined the as-
sociation between the outcome variable,
fruits and vegetables (F&V) consumption
and physical activity (PA), and TA. Re-
sults: Demographic characteristics were
entered at step 1, explaining 7% of vari-
ance in F&V consumption and 6% in PA.
T
ype 2 diabetes (T2D) is a major public health
issue, largely due to growing obesity rates,
fat distribution, and sedentary lifestyles.1
Uncontrolled blood sugar resulting from poor di-
etary choices is detrimental for the body, with
short-term complications leading to hypoglycemia,
and longstanding consequences negatively im-
pacting several organ systems. Whereas T2D his-
torically has manifested in adulthood,1,2 incidence
and prevalence rates among younger demographic
groups, such as teenagers, is rising rapidly.3 For
instance, the number of youth under 20 years of
age diagnosed with T2D in the United States (US)
is estimated to increase from 22,820 people in
2010 to 84,131 people in 2050.4 Given the growing
prevalence of T2D among younger populations, as
well as the health conditions that accompany T2D,
such as neuropathy, vascular problems, Alzheim-
Ann O. Amuta, Assistant Professor, Department of Health
Studies, Texas Womans University, Denton, TX. Katie Cross-
lin, Department of Health Studies, Texas Womans University,
Denton, TX. Jessica Goodman, James Madison University,
Department of Health Sciences, Harrisonburg, Virginia. Adam
E. Barry, Associate Professor, Department of Health & Kinesi-
ology, Texas A&M University, College Station, TX.
Correspondence Dr Amuta: aamuta@twu.edu
396
After TA was entered in block 2, the total
variance explained changed by only .008%
for F&V consumption and .009% for PA.
Conclusions: TA did not predict T2D pro-
tective behaviors and reduced variability
in the model. Being female, as well as hav-
ing a T2D family history, was significantly
associated with increased TA. Results can
inform the planning, implementing, and
evaluating of health promotion programs.
Key words: threat appraisal; type 2 dia-
betes; college students; physical activ-
ity; nutrition
Am J Health Behav. 2016;40(4):396-404
DOI: http://dx.doi.org/10.5993/AJHB.40.4.1
ers disease, and retinopathy,5 more research is
needed that examines T2D among potentially at-
risk groups, such as college students.
More than 20.2 million students attended col-
lege in the US in 2015, constituting a significant
portion of the population requiring health inter-
ventions.6,7 Approximately 22% of college students
are overweight and approximately 12% are obese.7
Furthermore, up to 24% are not involved in physi-
cal activity, 16.1% smoke, 5% drink more than 5
alcoholic drinks a day, and only about 5% eat 5
or more servings of fruits and vegetables a day.7
In addition, the college years characterize a ma-
jor shift for students because most are living away
from home for the first time and may be novices
in planning healthy/balanced meals and taking
charge of their health. All of these factors can con-
tribute to the development of T2D among college
students.8
Physical Activity in College Students
The onset of T2D can be delayed or prevented by
lifestyle changes such as increasing physical activ-
ity behavior.1 Physical activity is a critical factor in
the prevention of T2D. For example, a meta-anal-
ysis review of 10 prospective studies found that
moderate intensity exercise such as brisk walking

significantly reduced the risk of T2D.9 A cross-sec-
tional study of college students found a strong cor-
relation between aerobic exercise and reduced risk
for T2D.10 However, it is estimated that only 50% of
college students meet physical activity guidelines
of at least 150 minutes of moderate exercise per
week set forth by the government.11
Healthy Eating Behaviors in College Students
Fruits and vegetables consumption also is linked
to T2D risk/prevention. Fruits and vegetables con-
tain many beneficial nutrients and phytochemicals
that are thought to protect against the occurrence
of T2D.12,13 High intake of fruits and vegetables are
associated with a reduced incidence of T2D, partic-
ularly due to increased glucose metabolism.14 Sim-
ilarly, consumption of green leafy vegetables and
fruit was associated with a lower threat of devel-
oping T2D in the general population15 and among
overweight women.13 Despite the health benefits
resulting from adequate fruit and vegetable con-
sumption, college students typically fail to meet
recommended guidelines consuming just 4-5 serv-
ings of fruits and vegetables per week.16
Family History
T2D is a multifactorial disease involving complex
interactions among modifiable/behavioral factors
and non-modifiable risk factors (eg, obesity, eth-
nicity, sex and age).17 Non-modifiable factors, such
as genetics, are noteworthy given that parents,
children and full siblings may share up to 50% of
their genes, grandparents may share up to 25% of
genes, and maternal or paternal cousins share up
to 15% of genes.18 Thus, family history represents
an ideal indicator of risk of developing a disease
like T2D. In addition to genetics, families share be-
liefs, views, and behaviors that usually influence
the type and amount of food they eat as well as the
amount of physical activity in which they partici-
pate.19 Furthermore, family members and relatives
also share environmental factors, such as living
space and neighborhood risk/protective factors
that can also influence T2D risk.17
Theoretical Framework
The protection motivation theory (PMT) postu-
lates both fear and feelings of vulnerability about a
disease, and fosters positive health attitudes, and
ultimately, engagement in health protective behav-
iors.20,21 For example, if person believe that (1) they
are at risk or vulnerable to the onset of a disease,
(2) the consequences of the disease are impactful,
and (3) behavior change is within their skill set,
then they are more likely to engage in protective
behaviors that will slow or prevent disease onset.
Perceived severity or vulnerability to chronic dis-
eases among college students is generally low.23
Studies have found that normal weight college
students do not see T2D as a threat to their life.24
Further, students of normal weight report low risk
perceptions for developing chronic diseases and
Am J Health Behav. 2016;40(4):396-404
Amuta et al
do not attribute development of heart disease and
T2D to behavioral causes, such as unhealthy eat-
ing and sedentary behaviors.25,26 This is not sur-
prising because even with a T2D diagnosis, many
students still do not meet the recommendations
for adequate fruit, vegetable, or grain intake.27,28
Whereas there is considerable research examining
normal weight college students and the perceptions
they attach to chronic conditions, there is consid-
erably less on high-risk college students, such as
who are obese. Consequently, we examined the
perceived vulnerability component of the PMT, to
examine the threat appraisal on T2D-related pro-
tective behaviors among college students who are
clinically at a high risk for T2D (T2D family history
and overweight/obese).22 To our knowledge, no
prior studies have examined PMT among college
students who are at-risk for T2D, although stud-
ies of other adults have indicated that PMT con-
structs are predictive of physical activity behavior
in T2D.22,29 We also investigated demographic fac-
tors that are associated with T2D threat appraisal
as these demographic factors may inform more
targeted intervention programs.
Current Investigation
The purpose of this study was 2-fold. First, we
examined the demographic characteristics associ-
ated with T2D threat appraisal among overweight
and obese college students. Second, we examined
the influence of threat appraisal on college stu-
dents physical activity and fruits and vegetables
consumption behavior, above and beyond the in-
fluence of demographic characteristics, using hi-
erarchical multiple regression. We hypothesized
that despite our samples high-risk status for
T2D (overweight/obese and T2D family history),
respondents would still have low T2D threat ap-
praisal, and thus, not translate to engagement
in protective health behaviors. To the best of our
knowledge, no study has examined threat apprais-
al and T2D-related protective behaviors among col-
lege students who are at a high risk for T2D.
METHODS
Design, Sample Selection and Participants
The study design was cross-sectional. The survey
was conducted from October 2014 to January 2015.
Data were collected via a Web-based survey from
undergraduate students (18 years or older) enrolled
full time or part-time in one of 4 colleges/universi-
ties in Texas. Solicitations were sent to students
school email addresses. Prior to participation, stu-
dents were informed that the survey was voluntary
and informed consent was provided. Incentives
were provided in the form of $40 major-retailer gift
cards to participants via random drawing. A total of
7600 students were initially contacted, of whom 909
responded (12% response rate). Based on the US
Centers for Disease Control and Prevention (CDC)
recommendations, body mass index (BMI, kg/m2)
was calculated on self-reported weight and height.
DOI: http://dx.doi.org/10.5993/AJHB.40.4.1 397
Impact of Type 2 Diabetes Threat Appraisal on Physical Activity and Nutrition Behaviors...
Overweight was defined as BMI 25.0-29.9, and obe-
sity as BMI 30.0. For this present study, only par-
ticipants who were either overweight or obese were
included for analyses (N = 319).
Measures
Demographic characteristics of the participants
included age (ie, continuous variable ranging from
age 18 to 27 years), biological sex, race/ethnicity
(ie, non-Hispanic white, African American or black,
Hispanic or Hispanic/Latino), body mass index
(BMI) and T2D family history status. These vari-
ables were included because there is scientific evi-
dence that they have associations with threat ap-
praisal and T2D-related protective behaviors.30-33
Family history of T2D was assessed via the item:
Have any of your family members (mother, father,
brother, sister, grandparents on both mothers
and fathers side, aunts and uncles on both moth-
ers and fathers side and cousins on both mothers
and fathers side) ever been diagnosed with Type 2
diabetes? Possible responses were No, Yes, I severity are averaged to create a single index of
dont know, and Not applicable. Responses were
coded to create a dichotomous outcome variable
for T2D family history status, such that Yes (cod-
ed 1) indicated a positive family history and No,
I dont know, and Not applicable (coded 0) indi-
cated no family history of T2D. The questions used
to assess family history were adapted from the
questionnaire originally used by Baptiste-Roberts
et al34 to assess family history of T2D in African
Americans and was adapted to include extended
family members. Previous investigations examin-
ing family history of T2D in college students have
employed similar measures, which include extend-
ed family members.23,35
Perception of T2D risk was adopted from a prior
published study instrument.37 These items assess
risk perception via 3 questions: (1) What do you
think your chance is of developing Type 2 diabetes
in your lifetime? Possible responses ranged from
1 to 10. Students were asked to choose a number
between 0 (no chance of Type 2 diabetes) and 10
(definitely will get Type 2 diabetes); (2) What is the
chance of you getting Type 2 diabetes compared
with an average man/woman your age? Possible
responses were Much Lower (coded as 1), Slightly
Lower (coded as 2), About the Same (coded as 3),
Higher (coded as 4), and Much Higher (coded as 5);
and (3) How likely do you think it is that you will
develop Type 2 diabetes during the next 5 years?
Students were asked to choose a number between
0 (no chance of Type 2 diabetes) and 10 (definitely
will get Type 2 diabetes). These 3 items were com-
bined to create a single continuous composite
score for perceptions of T2D risk. The Cronbachs
alpha for all 3 items was good ( = 0.85).
Perceptions of T2D severity was assessed by 3
items: (1) I believe that Type 2 diabetes is severe;
(2) I believe that Type 2 diabetes is serious; and
(3) I believe that Type 2 diabetes is significant.
All 3 questions shared the same response scale:
398
Strongly Disagree (coded as 1), Disagree (coded as
2), Agree (coded as 3), and Strongly Agree (coded
as 4). All 3 items measuring perceptions of T2D se-
verity were combined to create a single continuous
composite score. The internal consistency for our
data on all 3 items was good ( = 0.78). The ques-
tions were adapted from Witte, Cameron, McKe-
on, and Berkowitz.38 Witte et al38 administered the
scale as part of a Risk Behavior Diagnosis Scale
to 179 college students regarding their attitudes
about genital warts and obtained a Cronbachs
= .90. We adapted the questionnaire by changing
genital warts to Type 2 diabetes.
Threat appraisal consists of both the perceived
severity and vulnerability towards a disease.21,23 In
view of that, we averaged both the perceived sever-
ity of T2D and perceived risk of developing T2D
to produce a single interaction score of threat ap-
praisal for each participant. We created the threat
appraisal index based on prior established litera-
ture,23,39 in which perceived risk and perceived
threat appraisal.
Physical activity (PA). Questions regarding the
duration and frequency of physical activity were
assessed via 2 items. The first item was: During
the last 7 days, on how many days did you do mod-
erate physical activities like carrying light loads,
bicycling at a regular pace, or doubles tennis? Do
not include walking. Response options included:
0 days (coded as 0); 1 day (coded as 1); 2 days (cod-
ed as 2); 3 days (coded as 3); 4 days (coded as 4); 5
days (coded as 5); 6 days (coded as 6); and 7 days
(coded as 7). The second item was: How much
time in total did you usually spend on one of those
days doing moderate physical activities? Possible
responses were open-ended and participants were
prompted to write the length of time in a box pro-
vided. All responses were in minutes. Responses
to each of these items were multiplied to create a
single, composite indicator of physical activity.36,41
For instance, if a respondent indicated they were
at least moderately active 3 days a week, and they
typically engaged in such activity for 40 minutes,
then their weekly physical activity was recorded as
120 minutes. Higher scores indicated higher levels
of physical activity each week. This question was
adapted from a vetted national survey.42
Vegetable consumption behaviors were measured
by asking participants: About how many cups of
vegetables (including 100% pure vegetable juice)
do you eat or drink each day? (1 cup of vegetables
could be equal to: 3 broccoli spears, 1 cup cooked
leafy greens, 2 cups lettuce or raw greens, 12 baby
carrots, 1 medium potato, 1 large sweet potato, 1
large ear of corn, 1 large raw tomato, 2 large celery
sticks, 1 cup of cooked beans). Possible responses
for this question were: Never (coded as 0); 1/2
cup or less (coded as 1); 1/2 cup to 1 cup (coded
as 2); 1 to 2 cups (coded as 3); 2 to 3 cups (cod-
ed as 4); 3 to 4 cups (coded as 5); and 4 or more
cups (coded as 6).
 Amuta et al

Fruit consumption behaviors were measured

by asking participants: About how many cups of Table 1
fruit (including 100% pure fruit juice) do you eat Characteristics of Overweight/Obese
or drink each day? (1 cup of fruit could be equal
College Students
to: 1 small apple, 1 large banana, 1 large orange, 8
large strawberries, 1 medium pear, 2 large plums, N = 319 Percentage
32 seedless grapes, 1 cup (8 oz.) fruit juice, cup Sex
dried fruit, 1 inch-thick wedge of watermelon).
Male 90 28.2
Possible responses for this question were: Never
(coded as 0); 1/2 cup or less (coded as 1); 1/2 Female 228 71.5
cup to 1 cup (coded as 2); 1 to 2 cups (coded as Race/Ethnicity
3); 2 to 3 cups (coded as 4); 3 to 4 cups (coded
as 5); and 4 or more cups (coded as 6). This ques- White 180 56.4
tion was adapted from a vetted national survey.42 Black/African-American 34 11.9
Fruits and vegetables (F&V) consumption. Hispanic/Latino 98 30.7
Responses to the aforementioned questions re-
garding fruits and vegetables consumption were Family History of Type 2
multiplied to create a single indicator of fruits and Diabetes
vegetables consumption. For instance, if a respon- No 136 42.3
dent indicated she or he typically ate 4 or more Yes 184 57.7
cups of vegetables each day (6 points), and con-
sumed 1-2 cups of fruit on average each day (3 Weight Status
points), then their composite fruits and vegetables Over Weight 195 61.1
consumption score would be 18 (6 x 3). Higher Obese 124 38.9
scores indicate more daily consumption of fruits
and vegetables. Cronbachs alpha was = 0.70 for Mean 20
the composite measure of fruits and vegetables SD 1
consumption. Age
Min 18
Data Analyses Max 27
Categorical and continuous variables are pre- Mean 30
sented as frequency (percentage) and mean (stan-
SD 5.4
dard deviation) respectively (Table 1). Hierarchical BMI
multiple regressions were used for all analyses. Min 25
Assumptions of normality, linearity, and multi- Max 60.8
collinearity were examined to ensure that the
results were without statistical violations; no as- Mean 80
sumptions were violated. Step 1 of the regression SD 40
model consisted of demographic characteristics Threat Appraisal
Min 6
(biological sex, T2D family History status, race
and BMI). Step 2 included threat T2D appraisal. Max 217
The rationale for the order of entry was to test how
much (if any) additional variance in T2D protective
health behaviors such as F&V consumption and Demographic Characteristics of Overweight
PA could be explained by threat appraisal above and Obese College Students Associated with
and beyond that explained by demographic char- T2D Threat Appraisal
acteristics. Separate models were conducted for There was a statistical significant relationship
F&V and PA. All analyses were conducted using between sex and T2D threat appraisal (B = 20.70,
IBM SPSS Statistics for Windows, Version 22.0 (Ar- = .236, p < .01), such that overweight or obese
monk, NY: IBM Corp). female college students had a higher T2D threat
appraisal compared to male overweight or obese
RESULTS college students. Also, participants with a fam-
Background Characteristics of Participants ily member diagnosed with T2D had higher T2D
The study sample was primarily female (71.5%; threat appraisal compared to those without T2D
N = 228). Most (56.4%) respondents were white, family history (B = 24.33, = .301, p < .01). Age
30.7% were Hispanic/Latino, and 11.9% were and race/ethnicity categories did not have any
black/African-American with an average age was statistical significant association (p > .05) with
20 years old. Most of the participants had a fam- threat appraisal for this population. The model
ily member diagnosed with T2D (57.7%; N = 184). explained approximately 54% of the variance in
Threat appraisal scores ranged from 6 to 217 threat appraisal (R = .54, R-squared = .29) (Table
(mean score = 80.59; SD = 40.91). Higher scores 2).
indicated higher threat appraisal for T2D (Table 1).

Am J Health Behav. 2016;40(4):396-404 DOI: http://dx.doi.org/10.5993/AJHB.40.4.1 399

Impact of Type 2 Diabetes Threat Appraisal on Physical Activity and Nutrition Behaviors...

Table 2
Multiple Linear Regression Analyses Showing Demographic Factors Associated
with T2D Threat Appraisal among Overweight/Obese College Students (N = 319)
Variable B SE B t p
Threat Appraisal
(Constant) -17.848 32.801 -.544 .587
Sex 20.701 4.544 .228 4.555 .000
Age -.084 1.445 -.003 -.058 .953
Hispanic/Latino 5.591 6.001 .063 .932 .352
Race Black -4.494 8.289 -.035 -.542 .588
Race White -6.991 5.976 -.085 -1.170 .243
Family History Status 24.336 4.053 .294 6.005 .000
Body Mass Index 2.451 .366 .322 6.692 .000
R 0.538
R2 0.289
F 18.040
df 7

Note.
B=unstandardized beta weight; =standardized beta weight; SE B=standard error; p < .05

Influence of Threat Appraisal on Fruit and
Vegetable Consumption Behaviors among
Overweight and Obese College Students
Demographic characteristics were entered at
step 1, explaining 6% variability in college stu-
dents F&V consumption behavior. Upon adding
T2D threat appraisal to the model (step 2), the
total variance explained changed by only .008%
(Table 3). The total variance for F&V consumption
explained by the model as a whole was approxi-
mately 7%, F (8, 307) = 2.916, p < .05. In the final
model, statistical significance was found in biologi-

Table 3
Multiple Hierarchical Linear Regression Analyses Showing the Influence of
Threat Appraisal on Fruits and Vegetables Consumption among Overweight and
Obese Adolescents (N = 319)
Variable B SE B t p
Adolescents Fruit and Vegetable Consumption
Step1: Demographic Characteristics
Sex -.629 .282 -.129 -2.229 .027
Age .016 .089 .011 .178 .859
Family History Status .208 .250 .047 .833 .406
Body Mass Index -.006 .023 -.015 -.277 .782
Hispanic/Latino -.013 .369 -.003 -.035 .972
Race White .781 .368 .177 2.122 .035
Race Black -.380 .510 -.056 -.745 .457
Step 2: Type 2 Diabetes Threat Appraisal
Threat Appraisal -.006 .003 -.112 -1.708 .089
R 0.067
2

F 2.916
df 8

400
 Amuta et al

Table 4
Multiple Hierarchical Linear Regression Analyses Showing the Influence of
Threat Appraisal on Moderate Physical Activity among Overweight and Obese
Adolescents (N = 319)
Variable B SE B t p
Adolescents Moderate Physical Activity
Step1: Demographic Characteristics
Sex -25.364 63.947 -.024 -.397 .692
Age 52.507 19.690 .159 2.667 .008
Family History Status -73.064 58.338 -.075 -1.252 .211
Body Mass Index -10.736 5.339 -.120 -2.011 .045
Hispanic/Latino 98.057 81.874 .094 1.198 .232
Race White 43.408 81.598 .045 .532 .595
Race Black 12.584 112.976 .008 .111 .911
Step 2: Type 2 Diabetes Threat Appraisal
Threat Appraisal 1.331 .774 .113 1.721 .086
R 0.054
2

F 2.205
df 8

cal sex, and being white. For biological sex, being
male increased F&V consumption by .629 cups per
day and being white increased F&V consumption
by .781 cups per day holding all other variables
constant. There was no statistically significant re-
lationship between threat appraisal and F&V con-
sumption behavior (B = -.006, = -.112, p > .05)
(Table 3).
Influence of Threat Appraisal on Physical
Activity Behaviors among Overweight and
Obese College Students
Demographic characteristics were entered at
step 1, explaining 5% of the variability in college
students PA behavior. Upon adding T2D threat
appraisal to the model (step 2), the total variance
explained changed by only .009% (Table 5). The
total variance for PA explained by the model as a
whole was approximately 5%, F(8, 309) = 2.205,
p < .05. In the final model, age was statistically
significant, such that for each year of age, physical
activity increased by 52 minutes on average per
week. Also, the lower the BMI the more the physi-
cal activity, such that with every one unit increase
in BMI, there was a 12-minute decrease in weekly
physical activity, holding all other predictor vari-
ables equal. There was no statistically significant
relationship between threat appraisal and physical
activity behavior (B = .78, = .07, p > .05) (Table 4).
DISCUSSION
We examined the demographic characteristics
associated with T2D threat appraisal among over-
weight and obese college students. Furthermore,
we examined the influence of threat appraisal on
college students physical activity and fruits and

Table 5
Model Summary (N = 319)
Model R R square R square change
Fruits &Vegetables Consumption
Model 1: Demographics .239 .057 .057
Model 2: Threat Appraisal .257 .067 .008
Moderate Physical Activity
Model 1: Demographics .212 .045 .045
Model 2: Threat Appraisal .232 .054 .009

Am J Health Behav. 2016;40(4):396-404 DOI: http://dx.doi.org/10.5993/AJHB.40.4.1 401

Impact of Type 2 Diabetes Threat Appraisal on Physical Activity and Nutrition Behaviors...
vegetables consumption behavior above and be-
yond the influence of demographic characteristics.
Overall, being female and having a family history
of T2D was significantly associated with increased
T2D threat appraisal. T2D threat appraisal, how-
ever, did not predict T2D protective behaviors and
did not account for any variability in behavior (ie,
increased physical activity and F&V consumption)
beyond demographic characteristics.
Similar to our findings, non-overweigh/obese
female college students report higher T2D threat
appraisal than male college students.36,43 It is pos-
sible our findings are due to females exhibiting in-
creased sensitivity to risk of disease and increased
levels of fear towards a disease.44 Moreover, given
that women consistently have been found to have
higher rates of perceived risk and fear, such as
risk of crime,45 it is intuitive that women in our
investigation would report greater T2D threat ap-
praisal. Women are also more likely to recognize
their weight as a health or social concern, and con-
sequently, also may experience higher threat ap-
praisal to T2D and other chronic diseases.46
The role of family history in threat appraisal and
the prevention of T2D have shown consistently
significant and positive associations.47-49 Our find-
ings were consistent with prior research docu-
menting those having a family member diagnosed
with T2D or other chronic diseases considered
themselves more likely to develop T2D.17,30,50-53 It
is possible that threat appraisal is heightened in
those with a T2D family history because the ma-
jority of people who have a family member living
with T2D may develop some significant beliefs and
knowledge about their own disease risk and may
understand the severities related to T2D.17 For ex-
ample, visiting a relative diagnosed with T2D and
learning more about risks associated with T2D de-
velopment can contribute to the formation of these
personal beliefs. The Common Sense Model of the
self-regulation of health and illness54 postulates
that beliefs about a disease (eg, T2D), are accrued
into a mental model of a persons own risk. Indi-
viduals may use these beliefs to interpret informa-
tion about T2D. For instance, when an individual
experiences a relatives battle with T2D, fondness
towards a family member with T2D and percep-
tions of resemblances between an individual and
the relative diagnosed with T2D (eg, physique) may
increase T2D threat appraisal.
Although T2D threat appraisal was not associ-
ated with T2D-related protective behaviors for this
group of high-risk college students, some studies
contradict our findings. For instance, Floyd et al23
found that threat appraisal was effective in ad-
dressing the stages of change towards achieving a
healthy sustainable lifestyle (ie, initiation, cessa-
tion, maintenance). In addition, perceptions of T2D
vulnerability and severity were associated with be-
havioral intentions and actual T2D protective be-
haviors.22,59,60 The contradictory results may be be-
cause college students do not see T2D as a threat
402
to their health, despite their high risk;38 thus, they
may continue to engage in T2D-related risky be-
haviors, making them susceptible to the develop-
ment of T2D.24 Our findings support other inves-
tigations that found students to often have exces-
sive optimism regarding the health consequences
of engaging in high risk behaviors that may affect
their health.61,62 This is cause for concern because
the participants in our study are clinically at a
high risk for developing T2D due to their weight
and T2D family history status; moreover, they also
have incorrect/reduced perceived T2D threat ap-
praisal. These results reinforce prominent findings
in fields such as health behavior and social psy-
chology pertaining to excessively optimistic biases
and perception of health risks.30,63
Limitations
It is important to see this study in context of
some limitations such as: (1) this study was cross-
sectional so it is impossible to determine causal
relationships, we are restricted to associations;
(2) the data for this study were obtained via self-
report, which is likely to have resulted in biased
estimates of actual F&V consumption and physical
activity behaviors; (3) some cases of T2D are not
yet diagnosed;1 therefore, it is possible that par-
ticipants may not have accurate information about
their T2D family history status which results in
misclassification of T2D risk. Despite these weak-
nesses, this study makes a useful contribution be-
cause it samples a young population. We are un-
aware of any other studies that specifically exam-
ined college-age students at clinically high risk for
T2D (overweight or obese and have a T2D family
history). Lastly, whereas our response rate could
be viewed as low, it is important to note the per-
centage of responders fell within other documented
levels among Web-surveys with college students.
That said, given the small number of respondents,
in relation to those invited, the representativeness
of our sample and subsequent generalizability is
limited.
Conclusion/Implications
Given the noted impact of family history on as-
sessment of disease perceived severity and vulner-
ability, we echo the CDC and contend health pro-
motion professionals promote genomics education
for the various communities they serve and also
make genomics education a component of plan-
ning health education programs.55 Health promo-
tion professionals and other medical professionals
would benefit from using this information to deter-
mine if using a family history approach to decrease
T2D risk can be effective in future prevention
strategies.53,56,57 Such strategies may include brief
genetic counseling which has been found to modi-
fy perceived control of first-degree relatives of T2D
patients58 as well as personalizing health messages
that may be more effective in motivating people to
adopt and maintain a healthy lifestyle.17 Further-

more, message-framing research emphasizes cop-
ing appraisal as a more effective means of initiating
and maintaining positive health behavors59 and fo-
cusing on the persons ability and capacity to per-
form the protective behavior.23,59,64 Research has
shown that using fear appeals in message framing
can present potent persuasive pathways for behav-
ior change; yet, scientific evidence also has shown
that fear appeals can be unsuccessful.65 It is criti-
cal that more empirical studies better understand
how these constructs are demonstrated in college
students and how they can be used to create ef-
fective college health programs. Also, it becomes
important that college students are equipped with
a clear understanding of which risk factors con-
tribute to the development of T2D. Given that col-
lege students are in a phase of professional and
personal development, the university setting pro-
vides a unique opportunity to reach many young
adults through disseminating T2D risk-reduction
information.
Human Subjects Statement
All procedures were evaluated and approved
through the Institutional Review Board affiliated
with the authors (IRB2014-0439D).
Conflict of Interest Disclosure Statement
The authors declare that they have no competing
interests.
Acknowledgements
The authors acknowledge Dr Lei Shih Chen, Dr
E. Lisako J. McKyer ,and Nimrah Riaz for assisting
with the survey instrument development. We also
acknowledge Dr Wura Jacobs for assisting with
data cleaning and preparation.
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