Perceived Severity of Interrelated Cardiometabolic Risk Factors among U.S. College Students

Abstract

Background:

Cardiometabolic risk factors are related to the early onset of chronic health conditions.

Purpose:

To identify factors associated with perceptions about the severity of three interrelated cardiometabolic risks (i.e., high blood pressure, obesity, and cardiovascular disease) among U.S. college students.

Methods:

Data were analyzed from 1,361 college students using an internet-delivered survey. Least squares regression models were fitted. Primary independent variables of interest were sex and cigarette smoking status.

Results:

Relative to nonsmokers, smokers perceived high blood pressure (B=−0.09, P=0.001), obesity (B=−0.12, P<0.001), and cardiovascular disease (B=−0.12, P<0.001) to be significantly less severe. Across models, females perceived all three cardiometabolic risk factors to be more severe (P<0.005). Relative to non-Hispanic whites, Hispanic and Asian/Pacific Islander students perceived all three cardiometabolic risk factors to be less severe (P<0.002). Compared to normal weight students, overweight (B=0.41, P=0.039) and obese (B=−0.72, P<0.001) students reported higher severity perceptions about obesity only.

Discussion:

There are discordances between perceived severity of interrelated cardiometabolic risks among college students by personal factors.

Translation to Health Education Practice.

Smoking prevention and cessation interventions are needed to educate college students about cardiometabolic risks associated with cigarette smoking, especially among male and minority students.

INTRODUCTION

An increased prevalence of modifiable cardiometabolic risk factors, which contribute to a large burden of morbidity and mortality, has been observed among U.S. young adults.^1,2 Recent trends indicate approximately 36% of young adults are obese,³ and about 11% of males and 7% of females have high blood pressure.⁴ Risks associated with overweight and obesity include early onset of chronic health conditions such as hypertension, coronary heart disease, type 2 diabetes, and an increased risk of early mortality before age 55.⁵ Annual medical costs attributable to these potentially preventable conditions in the U.S. are about $147 billion.⁶

Current cigarette smoking is another leading modifiable factor for accelerating cardiometabolic disease risk.⁷ About eight of every 100 young adults currently smoke cigarettes, with higher rates reported among males.⁸ An inverse relationship exists between cardiometabolic risk factors and educational level, with those with higher education (e.g., college graduates) having lower prevalence of hypertension,⁴ obesity,⁹ and cigarette smoking⁸ than those with less education. However, these relationships may be complicated by sex and race/ethnicity.^4,8,9 For example, females overall and those in the lowest education group have higher rates of obesity than males, but rates are very similar among those who attained some college or a college degree.⁹

College is a unique and transitional period where students’ health behaviors can negatively shift to increase cardiovascular disease (CVD) risk due to a change in social and environmental factors.¹⁰ Prior research indicates that students typically have poor diets,¹¹ are sedentary,¹² and that weight and adiposity increase over the college years,^13,14 which are factors that influence cardiometabolic disease. Additionally, college student graduates represent about 15% of adults who engage in current smoking.¹⁵ Thus, about eight million U.S. college graduates engage in current smoking, which tends to be lighter smoking behavior than those who did not graduate.¹⁶ Although an increasing magnitude of concomitant comorbidities are well documented among young adults, much less is known specific to college students. Modifying cardiometabolic risk factors among U.S. young adults, including obese weight status, high blood pressure, and smoking behavior, is important to prevent chronic disease development during the adult years and premature death.⁵ For example, the immediate and long-term benefits of quitting smoking have been widely documented to reduce smoking-attributable morbidity and mortality such as hypertensive disease and cardiovascular disease.⁷ Thus, it is important to identify risks (e.g., smoking behavior) and perceptions of cardiovascular disease among college students to inform intervention efforts specific to this population.

The Health Belief Model (HBM) is an individual-level theoretical framework used to assess individuals’ perceptions of susceptibility and severity of health problems, perceptions of benefits and barriers to avoid health problems, and cues to action and self-efficacy that influence decisions to act.^17,18 Specifically, HBM has six constructs: 1) perceived susceptibility, which is the belief that the individual is susceptible to a health problem such as cardiovascular disease; 2) perceived severity, which is the belief the condition has severe health consequences; 3) perceived benefits, which is belief that the individual taking action will benefit from reducing their susceptibility and severity; 4) perceived barriers, which is the belief that the consequences of inaction are outweighed by the benefits of protective behavior; 5) cues to action, which are factors that promote action among individuals (e.g., physician reminder for a preventive exam); and 6) self-efficacy, which is the individual’s confidence in his/her ability to successfully perform the action.

HBM is widely used to assess cardiovascular-promoting health behaviors among college students such as weight management¹⁹ and physical activity²⁰ because health motivation is a key focus of the framework.¹⁸ While applying all HBM constructs provides practitioners with a holistic picture, it is important to assess perceptions of severity related to well-known risk factors (e.g., smoking) that increase college students’ actual susceptibility of developing poor cardiometabolic outcomes (e.g., cardiovascular disease).

Purpose

Despite evidence of well-known contributors that increase cardiometabolic risks (e.g., being overweight and obese and smoking cigarettes), college students are at increased risk for developing poor cardiometabolic health outcomes.^5,7 However, there is a gap in the literature about how persistent cardiometabolic risk factors are associated with perceived severity of cardiometabolic risks. The purpose of this study was to identify factors associated with perceptions about the severity of three interrelated cardiometabolic risks (i.e., high blood pressure, obesity, and cardiovascular disease) among U.S. college students. We hypothesized that college students who had a body mass index [BMI] status of overweight and obese would have lower severity perceptions of high blood pressure, obesity, and cardiovascular disease. We also posited that students who currently smoked cigarettes would have lower severity perceptions across all three cardiometabolic risks.

METHODS

Participants and Procedures

Using an internet-delivered questionnaire, data were collected from undergraduate and graduate college students enrolled in two Texas universities over a two-week period. At each respective institution, participants were recruited through email-based university-regulated delivery systems and academic department administrators sent emails. The URL address for the internet-delivered questionnaire was included in the body of recruitment emails. Reminder emails were sent approximately five days after initial recruitment emails were delivered.

Participants took approximately 10 minutes to complete the 51-item questionnaire. All participation in the study was voluntary, and identifying information was not collected from participants. No incentives were provided. We obtained Institutional Review Board approval from both participating universities.

A total of 81,715 students potentially received study recruitment emails (49,129 students at the first institution and 32,586 students at the second institution). Of those, 2,054 students responded to the survey with a response rate of 2.5%.²¹ Of those who responded to the survey, 1,639 completed the instrument with a completion rate of 79.8%.

Given the purpose of this study, participants over age 30 (n=128) were initially omitted from analyses. Then, those with missing data for race/ethnicity (n=35) and BMI (n=115) were omitted from analyses. The final analytic sample was 1,361 college students.

Instrumentation and Measures

The internet-based questionnaire was developed by the research team to better understand perceptions and health indicators related to cardiovascular risk among college students. The primary health condition of interest was obstructive sleep apnea, which is largely driven by obesity, cardiometabolic risk factors, and behavior.²² The research team comprised of scholars, practitioners, and Certified Health Education Specialists in the fields of health education, public health, health services research, and dentistry. In this context, the questionnaire asked participants about their health behaviors, family health history, and severity perceptions about cardiovascular-related consequences. The intent of the survey was to assess how known cardiometabolic risk factors influence students’ perceptions of health ramifications associated with obstructive sleep apnea (e.g., snoring, daytime sleepiness, difficulty concentrating, irritability, depression, obesity, high blood pressure, cardiovascular disease). Face and content validity of the questionnaire were established by the research team and vetted with other health experts prior to being employed. The 51 questionnaire items included a combination of different question types including Likert-type scale questions and closed- and open-ended questions. Subscales were not included in the questionnaire, but items were separated by severity perceptions, personal risk, and personal behaviors. Additionally, other sections of the questionnaire asked about cardiometabolic-related diagnoses and health conditions of the participants’ biological mother, biological father, biological maternal grandparents, and biological paternal grandparents. While the questionnaire did not ask about all HBM constructs, questions were asked about perceived severity of risk factors. The questionnaire also asked about personal factors and characteristics such as height and weight to determine BMI, smoking behavior, and demographics.

Dependent Variables.

The dependent variables for this study were participants’ severity perceptions of three cardiometabolic-related conditions. Participants were asked to separately rate how severe they considered high blood pressure, obesity, and cardiovascular disease. Participants were asked, “On a scale from 1 to 10, please rate how severe you think the following health issues are…”. A response choice of one indicated “not severe at all” and 10 indicated “extremely severe.”

BMI Status.

Participants were asked to self-report their height (in feet and inches) and weight (in pounds). These values were converted to meters and kilograms, respectively, and used to calculate participants’ BMI.²³ BMI scores were then placed in the following categories: normal weight (BMI=18.5 to 24.9kg/m²), overweight (BMI=25.0 to 29.9kg/m²), and obese (BMI ≥30.0kg/m²).

Current Cigarette Smoking.

Participants were asked to report their average cigarette consumption per week. Participants were asked, “In the average week, how many days do you smoke 1 or more cigarettes?” Response choices ranged from 0 days to seven days. This variable was dichotomized to indicate whether a participant smoked ≥ 1 cigarette in an average week (no, yes).

Demographics.

Personal characteristics of the participants included age (years), sex (male, female), and race/ethnicity (non-Hispanic white, African American or black, Hispanic or Latino, or Asian or Pacific Islander).

Statistical Analyses

All analyses were performed using SPSS (version 25). Descriptive statistics were calculated for all study variables, which were initially compared by participants’ sex and current cigarette smoking status. Pearson’s chi-squared tests were used for categorical variables. Independent sample t-tests were used for continuous variables. Then, a series of three ordinal least squares (OLS) regression models were fitted to identify factors associated with perceived severity of the three cardiometabolic risk factors: high blood pressure, obesity, and cardiovascular disease.

RESULTS

Table 1 reports the sample characteristics compared by sex and cigarette smoking status. On average, participants were age 20.97 (±2.69) years. The majority of participants were female (64.2%) and non-Hispanic white (67.8%). Approximately 21% of participants were Hispanic, 22.9% were overweight, and 15.3% were obese. Almost half (47.0%) of participants reported smoking ≥ 1 cigarette in an average week. On average, participants’ severity perceptions about cardiometabolic conditions were moderately high with scores of 6.81 (±3.13) for high blood pressure, 7.24 (±3.02) for obesity, and 7.28 (±3.45) for cardiovascular disease (on a scale from 1–10).

Table 1.

Sample Characteristics by Sex and Tobacco Use Status

		Sex				Used Tobacco in Past Week
	Total (N = 1,361)	Male (n = 487)	Female (n = 874)	χ2 or t	P	No (n = 722)	Yes (n = 639)	χ2 or t	P
Age (range 18 to 30 years)	20.97 (±2.69)	21.25 (±2.78)	20.81 (±2.63)	2.84	0.005	20.93 (±2.61)	21.01 (±2.79)	−0.579	0.563
Sex				--	--			3.864	0.049
Male	35.8%	--	--			33.4%	38.5%
Female	64.2%	--	--			66.6%	61.5%
Race/Ethnicity				8.06	0.045			6.017	0.111
Non-Hispanic White	67.8%	64.7%	69.6%			68.6%	67.0%
African American	4.9%	5.7%	4.5%			4.2%	5.8%
Hispanic	20.9%	20.9%	20.8%			22.0%	19.6%
Asian / Pacific Islander	6.4%	8.6%	5.1%			5.3%	7.7%
BMI Status				31.34	<0.001			2.56	0.278
Normal Weight	60.8%	50.9%	66.4%			61.5%	60.1%
Overweight	23.9%	30.2%	20.4%			24.7%	23.0%
Obese	15.3%	18.9%	13.3%			13.9%	16.9%
Tobacco Use in Past Week				3.86	0.049			--	--
No	53.0%	49.5%	55.0%			--	--
Yes	47.0%	50.5%	45.0%			--	--
Severity Perceptions (1 to 10)
High Blood Pressure	6.81 (±3.13)	6.42 (±3.14)	7.03 (±3.11)	−3.47	0.001	7.10 (±2.93)	6.49 (±3.32)	4.69	<0.001
Obesity	7.24 (±3.02)	6.72 (±3.05)	7.52 (±2.97)	−4.69	<0.001	7.59 (±2.81)	6.84 (±3.21)	4.52	<0.001
Cardiovascular Disease	7.28 (±3.45)	6.88 (±3.58)	7.50 (±3.36)	−3.12	0.002	7.69 (±3.23)	6.81 (±3.64)	3.58	<0.001

When comparing study variables by sex, males were significantly older than females (t=2.84, P=0.005). More racial diversity was observed among males (χ²=8.06, P=0.045). A significantly larger proportion of males were overweight or obese (χ²=31.34, P<0.001) and reported current cigarette smoking (χ²=3.86, P=0.049). On average, female participants reported higher severity perceptions than males for high blood pressure (t=−3.47, P<0.001), obesity (t=−4.69, P=0.001), and cardiovascular disease (t=−3.12, P=0.002). When comparing study variables by cigarette smoking status, on average, nonsmokers reported higher severity perceptions than current smokers for high blood pressure (t=4.69, P<0.001), obesity (t=4.52, P<0.001), and cardiovascular disease (t=3.58, P<0.001).

Table 2 reports findings from the OLS regression model fitting perceptions of high blood pressure severity. On average, females (B=0.60, P=0.001) and nonsmokers (B=−0.58, P=0.001) reported higher severity perceptions about high blood pressure. On average, compared to non-Hispanic whites, Hispanic (B=−0.74, P=0.001) and Asian/Pacific Islander (B=−1.13, P=0.002) participants reported lower severity perceptions about high blood pressure.

Table 2.

Linear Regression: Perceptions of High Blood Pressure Severity

					95% C.I.
	B	S.E.	t	P	Lower	Upper
Age (from 18 to 30)	0.06	0.03	1.90	0.058	0.00	0.13
Female (vs. Male)	0.60	0.18	3.36	0.001	0.25	0.94
African American (vs. non-Hispanic White)	0.31	0.39	0.80	0.426	−0.46	1.08
Hispanic (vs. non-Hispanic White)	−0.74	0.21	−3.47	0.001	−1.15	−0.32
Asian / Pacific Islander (vs. non-Hispanic White)	−1.13	0.36	−3.14	0.002	−1.83	−0.42
Overweight (vs. Normal Weight)	0.21	0.21	1.03	0.304	−0.19	0.62
Obese (vs. Normal Weight)	0.08	0.25	0.31	0.758	−0.41	0.56
Used Tobacco in Past Week	−0.58	0.17	−3.45	0.001	−0.91	−0.25
Adjusted R Square = 0.030

Table 3 reports findings from the OLS regression model fitting perceptions of obesity severity. On average, females (B=0.83, P<0.001) and nonsmokers (B=−0.72, P<0.001) reported higher severity perceptions about obesity. On average, compared to non-Hispanic whites, Hispanic (B=−0.84, P<0.001) and Asian/Pacific Islander (B=−1.22, P<0.001) participants reported lower severity perceptions about obesity. Compared to normal weight participants, on average, overweight (B=0.41, P=0.039) and obese (B=0.94, P<0.001) participants reported higher severity perceptions about obesity.

Table 3.

Linear Regression: Perceptions of Obesity Severity

					95% C.I.
	B	S.E.	t	P	Lower	Upper
Age (from 18 to 30)	0.04	0.03	1.27	0.204	−0.02	0.10
Female (vs. Male)	0.83	0.17	4.89	<0.001	0.50	1.16
African American (vs. non-Hispanic White)	−0.16	0.37	−0.43	0.670	−0.89	0.58
Hispanic (vs. non-Hispanic White)	−0.84	0.20	−4.17	<0.001	−1.24	−0.45
Asian / Pacific Islander (vs. non-Hispanic White)	−1.22	0.34	−3.57	<0.001	−1.89	−0.55
Overweight (vs. Normal Weight)	0.41	0.20	2.07	0.039	0.02	0.79
Obese (vs. Normal Weight)	0.94	0.23	3.99	<0.001	0.48	1.40
Used Tobacco in Past Week	−0.72	0.16	−4.46	<0.001	−1.03	−0.40
Adjusted R Square = 0.055

Table 4 reports findings from the OLS regression model fitting perceptions of cardiovascular disease severity. On average, nonsmokers (B=−0.84, P<0.001) and females (B=0.54, P=0.005) reported higher severity perceptions about cardiovascular disease. On average, compared to non-Hispanic whites, Hispanic (B=−0.99, P<0.001) and Asian/Pacific Islander (B=−1.25, P=0.001) participants reported lower severity perceptions about cardiovascular disease.

Table 4.

Linear Regression: Perceptions of Cardiovascular Disease Severity

					95% C.I.
	B	S.E.	t	P	Lower	Upper
Age (from 18 to 30)	0.03	0.04	0.83	0.409	−0.04	0.10
Female (vs. Male)	0.54	0.20	2.79	0.005	0.16	0.93
African American (vs. non-Hispanic White)	−0.06	0.43	−0.13	0.894	−0.90	0.79
Hispanic (vs. non-Hispanic White)	−0.99	0.23	−4.26	<0.001	−1.45	−0.53
Asian / Pacific Islander (vs. non-Hispanic White)	−1.25	0.39	−3.19	0.001	−2.03	−0.48
Overweight (vs. Normal Weight)	0.19	0.23	0.83	0.408	−0.26	0.63
Obese (vs. Normal Weight)	−0.26	0.27	−0.95	0.342	−0.79	0.27
Used Tobacco in Past Week	−0.84	0.19	−4.53	<0.001	−1.20	−0.47
Adjusted R Square = 0.037

DISCUSSION

The present study identified factors associated with the perceived severity of high blood pressure, obesity, and cardiovascular disease among U.S. college students. Overall, students reported a moderately high severity perception across all three factors with high blood pressure receiving the lowest perceived severity score and obesity and cardiovascular disease receiving similar higher scores. The difference in perceived severity scores across the three cardiometabolic conditions studied indicates college students mostly recognize weight-related severity, but underestimate high blood pressure severity.

Our findings highlight important points about the health-risk perceptions of college students. Elevated blood pressure is one of the most frequently reported single metabolic syndrome criteria found in college students.²⁴ Evidence suggests college-aged adults with high blood pressure are at increased risk for developing cardiovascular issues, and at elevated risk for cardiovascular-related mortality and all-cause mortality years later.²⁵ Despite college students frequently engaging in behaviors that increase risk for developing high blood pressure (e.g., substance use, physical inactivity, poor diet), there might be a disconnect in knowledge and perceptions due to optimistic bias.^26,27 The college years are a critical transitional period with increased engagement in health-risk behaviors due to factors such as increased exploration and movement toward independence, freedom, and adult privileges.²⁸ These factors, coupled with peer influence and social norms that lead to underrating personal risks, make it more difficult for college students to accurately assess health risks and behaviors such as cardiovascular disease.²⁹ However, given the current landscape of health information accessibility, further studies are needed to better understand the discordance between actual risk and perceived severity.

We found disproportionately high rates (47%) of smoking at least one cigarette during an average week among our college sample, over three-fold above the national average of current smoking rates (13.7%).⁸ Male students had significantly higher rates of cigarette smoking in an average week than female students, similar to national findings.⁸ One potential reason for such high cigarette smoking rates could be that students frequently engage in a chronic, low consumption pattern termed “social smoking,” where students intermittently smoke on some days instead of every day in social situations with peers.³⁰ Prior studies indicate that half of college students who smoked cigarettes in the past 30 days did not consider themselves smokers.^31,32 Synthesized evidence from tobacco industry research reports that individuals who engage in social smoking have perceived immunity to personal smoking-related health risks but recognize these consequences for other smokers.³⁰ This is concerning since college students may not self-identify as smokers and/or be unresponsive to prevention intervention efforts created for current smokers. Additionally, prior work has found that college students who engage in experimental (i.e., less than 100 cigarettes smoked in lifetime but smoked in past 30 days) and current cigarette smoking³³ or who initiate smoking³⁴ during the college years report greater alcohol consumption than nonsmokers. Future research should measure tobacco use by product type and frequency of use, and measure alcohol and other drug use in order to assess substance use comprehensively.

Despite being at increased risk for high blood pressure and cardiovascular disease, compared to nonsmokers, students who were current smokers perceived all three cardiometabolic conditions to be less severe. While most college students who smoke may fall into the light and intermittent smoking category,³⁵ a couple of factors may be responsible for influencing risk perceptions of cardiometabolic diseases. One possible factor could be that young adult smokers may undervalue the health consequences associated with smoking compared to nonsmokers.^29,36 Young adult smokers who engage in light smoking do not connect their light or intermittent smoking with delayed onset smoking-related conditions.³⁶ For example, prior research found that compared to college student nonsmokers, smokers did not fully understand the short-term smoking risks and were half as likely to believe health risks were associated with infrequent smoking (e.g., a few days a week or on weekends only).³⁷ Prevention messages should cover the potential short-term and long-term health hazards of light smoking among college students.

The HBM construct of perceived severity was the primary focus of this study. Students who were overweight and obese had significantly higher perceived severity of obesity compared to students who were normal weight. A prior review of the literature indicates that obesity is appropriately perceived as a health risk and disease by obese patients.³⁸ However, this differed from prior HBM research that found college students with higher BMIs perceived being overweight as less severe.¹⁹ This relationship is complex, especially concerning known factors that influence BMI. For example, other research using HBM found that college students’ perceived severity of cardiovascular disease was associated with higher physical activity behavior, but no difference was found for nutrition behavior.³⁹ Other research found that college students with higher BMI were more likely to have discrepancies between their reported and actual engagement in recommended physical activity levels to reduce chronic diseases (e.g., hypertension, cholesterol, and cardiovascular disease).²⁰ Further, we did not find differences between BMI groups based on perceived severity of high blood pressure and cardiovascular disease. This finding is interesting since there is overlap in the occurrence of the three cardiometabolic risks assessed in the current study. For example, high BMI is associated with increased cardiometabolic risks including high blood pressure² and cardiovascular disease such as early atherosclerosis.^40,41 Our study, aligned with the American Heart Association’s scientific statement,⁴⁰ highlights the need for educational efforts to identify obesity-related health risks.

Prior studies have found that women have a higher severity perception for a variety health-related risk factors.^42–44 Similarly, we found that female students have a higher severity perception of high blood pressure, obesity, and cardiovascular disease compared to male students. We also found that compared to non-Hispanic white students, Hispanic and Asian/Pacific Islander students had lower severity perceptions of high blood pressure, obesity, and cardiovascular disease. Our findings are similar to previous research that found Hispanics at high risk of cardiovascular disease underestimate their risk.⁴⁵ Our findings may be attributed to several factors including: a lack of targeted health education, language barriers, and/or cultural differences among Hispanics and Asians.^45,46 Without proper interventions that address the knowledge gaps or needed resources to affect change in those at highest risk of cardiovascular disease, individuals may believe there is nothing they can do to decrease their risk for certain illnesses.⁴⁷

The current study’s results are subject to limitations. First, we relied on self-report data and did not use biometric or biochemically-validated indicators to measure BMI status and nicotine concentrations. Second, we employed a cross-sectional survey design to collect information from college students enrolled at two universities in one geographic area. Thus, temporal or causal relationships cannot be inferred and results cannot be generalized to other geographical areas. Third, the broad email-based participant recruitment effort yielded a small return, which may limit generalizability of the study sample to the student bodies of these two universities. However, when comparing the study sample and university student characteristics, age and race/ethnicity breakdowns were comparable, but our sample had a slightly higher proportion of females. Fourth, information about all tobacco products or number of quit attempts were not collected. Since the college student-aged population engages in current cigarette smoking (7.8%) and e-cigarette vaping (7.6%) at similar rates⁸ and e-cigarette use is a gateway to cigarette smoking,⁴⁸ future research should consider assessing cardiometabolic risks by tobacco product type.

TRANSLATION TO HEALTH EDUCATION PRACTICE

These study findings are highly relevant to all health educators, and particularly specialists who work in college settings. Specifically, we found there are discordances between perceived severity of interrelated cardiometabolic risks among college students by personal factors including sex, race/ethnicity, cigarette smoking, and BMI status. Low severity perceptions of high blood pressure, obesity, and cardiovascular disease were more pronounced among males, Hispanics, Asian/Pacific Islanders, and cigarette smokers. Although current cigarette smokers perceived cardiometabolic risk factors as less severe than nonsmokers, the likelihood of developing multiple cardiovascular-related comorbidities is high among smokers.

A central goal of higher education is to improve target academic outcomes including student performance, which is associated with student engagement in healthy behaviors.⁴⁹ Certified Health Education Specialists are charged with responsibilities of planning, implementing, and evaluating health education and health promotion-related efforts.⁵⁰ The present study applied the Certified Health Education Specialist responsibilities and competencies.⁵⁰ For the assessment of needs and capacity (area I), we sought to assess the needs for health education and health promotion among college students by collecting existing data about the present study’s topic through a literature review and identified a gap. For evaluation and research (area IV), we designed and conducted a survey research study to collect data to address the gap in the literature and determine the influence factors have on college students’ cardiometabolic risk perceptions. We used communications (area VI) and ethics and professionalism (area VIII) to promote our findings that contribute to the health education profession. As outlined below, these data can be used by Certified Health Education Specialists to plan (area II), implement (area III), and evaluate (area IV) future programming, as well as for advocacy (V) and leadership and management (area VII).

Concerning obesity perceptions in the present study, college students of normal weight reported lower severity perceptions than those who were overweight or obese. These results highlight the need for health educators to take strong action to address false perceptions of cardiometabolic risk factors and disease among college students in programming. Findings from this study may assist in the tailoring of such interventions to target common misconceptions and reach populations with elevated risk. Health educators could plan and implement healthy lifestyle programs that focus on making healthy choices and provide the supports and linkage to services to ensure maximum opportunity for success. Such programs could specifically focus on physical activity and nutrition, leverage existing resources, and require minimal financial investment. Healthy lifestyle programs have been shown to directly impact college students’ health in many ways (e.g., mental health promotion, weight management) and indirectly impact student retention and their academic success.⁵¹ Additionally, health educators could help to promote healthy eating behaviors and advocate for healthy options to be made available on campus.

While it is well-known that smoking cessation has a direct benefit on cardiometabolic outcomes, the amount and frequency of smoking behavior and how smokers self-identify are essential to smoking cessation efforts.⁵² Specifically, nondaily or light cigarette smokers have been identified as one of the most interested subgroups in quitting smoking,⁵³ but they tend to not view themselves as smokers.^31,32 For example, if college students only smoke when in social settings with friends once a week, they may not perceive themselves as a current smoker. However, the college student would be considered a current smoker by the most commonly used definition of smoking.⁵² Thus, health educators should offer interventions to all college students to prevent and screen for all smoking behavior. Based on our study findings, interventions are especially needed for male and minority college students. It is important to educate college students about what is considered current smoking behavior, identify those who smoke but do not consider themselves smokers, and educate them about the negative health consequences of infrequent, casual, or light current smoking behavior.

Health educators should inform college students about interrelated cardiometabolic risks associated with smoking. There are many free resources available to Certified Health Education Specialists that are specific to college campuses. For example, the American Cancer Society and Center for Tobacco Control launched the Tobacco-Free Generation Campus Initiative, which provides resources and tools for students, information to promote tobacco cessation resources on campus, and recommendations for initiating smoke-free campus policies.⁵⁴ If the college campus of interest does not have a campus smoke-free policy implemented, health educators may consider advocating for such a policy because smoke-free campuses can effectively reduce smoking among college students.⁵⁵