CHAPTER ONE

1 INTRODUCTION

1.1 Background of the Study

Nutrition and lifestyles play key roles in the health status of a given population at any

point in time (Amin et al., 2008). While good feeding habits have direct positive effects on the

health of the students, the availability of food also becomes important. In a study conducted in

one of the private universities located in southwestern Nigeria, 85.6% of students sampled

reported that the choice of food they ate was influenced by its availability with no recourse to the

nutritional value. It was noted that 49.5% of the students reported a lack of brain retention which

was due to the effect of poor feeding habits among other health challenges such as stomach pain,

stooling, ulcers and food poisoning as shown in the study (Asaleye et al., 20190.

Studies have shown that adolescents leaving their parents and living away from home to

attend universities experience numerous health related behavioural changes, which include the

adoption of unhealthy dietary habits and lifestyles (Alexandrov et al., 2018; Kanarek and

Swinney 1990). These adopted habits by students are mostly attributed to drastic changes in their

environment, available resources, and frequent exposure to unhealthy foods and habits

(Raymond and Morrow, 2020).

Most undergraduate students are adolescents exposed to numerous risky behaviours that

can affect their quality of life and life expectancy as they migrate to adulthood. Studies have

shown that youths are particularly vulnerable to poor eating habits and are said to be in the habit

of eating “junk”. These poor eating habits sometimes reflect their poor knowledge of the

negative effects associated with such feeding lifestyles. In Nigeria, where there is an increase in

fast food centres in its urban cities, it becomes a major concern as most students patronize such
centres to purchase unwholesome food. Most undergraduates are likely to be responsible for the

preparation of their diets for the first time they are away from home, therefore they need

guidance on how to make informed dietary choices. Other studies have linked the lifestyle of

students, especially breakfast consumption, to their mental abilities which is reflected in their

academic performance (Kanarek and Swinney, 1990; Okeke et al., 2020 Zava and Zava, 2011).

The universities years are filled with many significant changes for students. One of the

most prominent changes that universities students face is making one’s own food choices

(Freedman, 2010). Students living both on and off campus are faced with deciding their own

eating patterns and habits. This sometimes results in poor quality diets that lack essential

nutrients and/or unwanted weight gain (Grace, 1997). Poor dietary habits practiced by

universities students may carry long term health consequences, such as increased risk for the

development of cardiovascular disease, diabetes, hypertension, and/or obesity (Engeland et al.,

2004). A universities student’s diet is typically lacking in fruits, vegetables, and dairy products,

and high in fat, sodium and sugar (Anding et al., 2001; Brunt and Rhee, 2008). Many universities

students consume a diet that is limited in variety, which increases the likelihood of not meeting

dietary recommendations and may play a role in weight gain resulting in obesity (Brunt and

Rhee, 2008).

Universities students weight gain is likely during the transition into university life, which

is a critical period when young adults’ behaviours including dietary habits are conducive to

change as they gain independence in making food choices (Silliman et al., 2004; Deshpande et

al., 2009). These groups of individuals are at higher risk of developing unhealthy eating

behaviours with inadequate nutrient intake, as shown by Gan et al. (2011). Some of these

behaviours include irregular meals, not eating breakfast, reduced fruit and vegetable intake and
increased consumption of fried food (Ganasegeran et al., 2012). Apart from the change in dietary

habits, poor exercising habits, bad time management and the increasing amount of stress from

school work also contribute to weight gain (Ozberak, 2010). Moreover, the opening of numerous

fast food stores, cafés and restaurants provide university students more opportunities to dine

outside instead of consuming self-prepared meals (Yahia et al., 2008).

1.2 Statement of Problem

Many studies conducted among universites students have concluded that this population

does not meet the recommendations set by the Dietary Guidelines (Anding, et al., 2001; Brunt

and Rhee, 2008; Davy, Benes, and Driskell, 2006; Hendricks, Herbold and Fung, 2004; Huang,

Harris, Lee, Nazit, Born, and Kaur, 2003; Silliman, Rodas-Fortier, and Neyman, 2004). This

increases universites students’ risk of becoming obese, and developing obesity related diseases

such as hypertension, cardiovascular disease, and diabetes later in life.

Also, Young adults in universities are mostly at risk of developing nutritional-related

diseases due to changes in lifestyle as they become responsible for their daily eating habits

(Amin et al., 2008; Asaleye et al., 2019; Tok et al., 2018). Most students in universities from

developing countries adopt different feeding habits and lifestyles that could affect their health.

The majority ate regular daily meals, but more than half skipped breakfast. Frequent snacking,

fried food consumption at least three times per week and low intake of daily fruits and vegetables

were commonly reported among the students. The frequency of visits to fast food restaurants was

significantly higher among the overweight/obese. Only 25.4% of the students exercised at least

three times per week. Almost all students were aware of balanced nutrition and the food

pyramid, but the knowledge was not transformed to practice (Tok et al., 2018). Apart from poor

feeding habits, unhealthy social lifestyles, such as lack of exercise and substance abuse can
negatively impact the health of students at school. Most students adopt lifestyle changes when on

campus due to peer pressure and other factors.

1.3 Research Questions

i. What are the socio-economic characteristics of the student in the study area?

ii. What are the daily food consumption survey, eating habits and food frequency of the

respondents in the study area

iii. What are the lifestyle practices of university students in the study area?

iv. What are examine the knowledge and views on dieting, balanced nutrition and self-body

image in the study area?

1.4 Aim and Objective of the Study

The aim of the study the nutrition and lifestyle practices of university students in

The specific Objectives are to:

i. examine the socio-economic characteristics of the student in the study area.

ii. examine the daily food consumption survey, eating habits and food frequency of the

respondents in the study area

iii. examine the lifestyle practices of university students in the study area

iv. examine the knowledge and views on dieting, balanced nutrition and self-body image in

the study area

1.5 Significance of the Study

Studying the change in nutritional and lifestyle practices among university students

would help educate them on the importance of preventing early development of obesity by

adopting healthy lifestyles. It is hoped that this study can increase the awareness of healthy

lifestyle and eating among young adults, thereby reducing the risks of developing chronic
diseases. Findings of this study would add to the body of knowledge on malnutrition amongst

adolescents and can also help the policymakers in formulating policies on nutrition amongst this

group ofstudents. It will also provide nutrition education program and helps to improve health

outcomes and foster healthy eating. Since the dietary pattern of adolescents encounters dramatic

changes, recognizing them and bringing a change in their food consumption pattern is essential

in improving the health status of future adults.

 CHAPTER TWO

2 LITERATURE REVIEW

2.1 Dietary Intake

Dietary intake is defined as the number of different foods or food groups that are

consumed over a given reference period (WHO, 2016). It reflects household access to a wide

variety of foods, and is used as a proxy of the nutrient adequacy for individuals (Swindale and

Bilinsky, 2016; Mirmiran, 2014). Dietary intake has long been recognized as a key element of

high quality diets because all people need a variety of foods to meet requirements for essential

nutrients (Hoddinot and Yohannes 2012). Lack of dietary intake is a particularly severe problem

in developing countries where diets are predominantly based on starchy staples and little or no

animal products (Ruel, 2013). These plant-based diets tend to be low in a number of

micronutrients including zinc, and those micronutrients often exist in the forms with low

bioavailability (Ruel, 2013).

The most commonly used method to measure dietary intake is to sum the number of

individual foods or food groups, known as dietary intake score (DDS) (Swindale and Bilinsky,

2016), consumed over a reference period, usually ranging from 1 to 3 days, sometimes 7 days. In

developing countries, this is the most popular measurement of dietary intake (Ruel MT, 2013),

due to its simplicity. The calculation of score is different if used at household or individual level.

The household dietary intake score (HDDS) reflects the economic ability of a household to

consume a variety of foods, whereas individual dietary intake score (IDDS) aims to capture

nutrient adequacy. IDDS has been positively correlated with increased mean micronutrient

density adequacy of complementary foods (FANTA, 2016) and micronutrient adequacy of the

diet in non breastfed children (Kennedy, 2017) and in adolescents (Mirmiran, 2014).
 Individual dietary intake is a useful indicator of food security (Hoddinott, 2012; Ruel,

2013), and may also play a key role in the nutritional status of different populations. For

example, a strong association between dietary intake and height for age was observed among

non-breastfed children in Kenya and Peru (Marquis, 2017). Studies conducted separately in

China, Mali, and Haiti found positive associations between dietary intake and nutritional status

in young children (Ruel, 2014). In a West African study, the rate of underweight was found to be

much higher among women with low dietary score compared to women with higher dietary

scores (Savy, 2015).

2.2 Dietary Assessment

Since the 2010s, diet has been increasingly recognised as a major determinant of health

and disease. Surveys of food are indirect indicators of nutritional status, and they should be

supplemented by surveys on behaviours such as physical activity and presence of acute or

chronic diseases (Sigulem et al., 2010). Evaluation of dietary , eating behaviours and other

behaviours is essential in all nutritional assessments, and data obtained from both quantitative

and qualitative methods are useful in this type of evaluation (Growth 2013).

2.2.1 Food

Analysis of the nutrient content of food as part of an assessment of nutritional status can

provide information that is suggestive of adequacy, or indicative of specific dietary deficiencies

(Guthrie 2016). Evaluations of nutrient s are carried out in a number of ways and there is no

single dietary method suitable for all consumption surveys. Differences exist according to the

purpose of the study, precision needed, particular population, period of interest (if it is past or

current) and available resources. Dietary methods are often classified according to "group" or
"individual" methods. Group data are based either on national food availability statistics or on

household

data while the individual dietary methods are considered as direct methods for dietary

assessment. Generally, these methods include food frequency questionnaires (FFQ), 24-hour

recall or occasionally recent recalls of three to seven days, food records or diaries, and diet

histories.

2.2.2 Eating behaviours

The studies of eating patterns are important in redefining nutritional education of

adolescents (Sigulem et al., 2010). From dietary histories, the importance of various foods or

food groups in the diet can be determined. Eating patterns and nutritional behaviours vary

frequently in adolescents, and they are influenced by many factors. These factors affect the

dietary s of adolescents, which become less constant when they make their transition to

adulthood. This in turn places them in the higher-risk category for many diseases irrespective of

the area (Story et al., 2012). Changes in eating patterns during adolescence are influenced by

cognitive, physical, social, and lifestyle factors. For example, studies of adolescent diet have

shown that food consumed at home is related to socio-economic variables, while the food

consumed outside home is independent of family background or social class groups but more a

result of peer pressure (European Food Information Council 2015). For example, the diets of

British schoolchildren showed no regional variation in consumption of unhealthy foods such as

crisps and fizzy drinks (Sheffield 2012). Some of the dietary patterns such as snacking, meal

skipping, wide use of fast food, low consumption of fruits and vegetables, and of dairy products

in some instances and faulty dieting practices in girls are quite common among adolescents in

industrialised countries, and in a few developing countries, particularly in cities (Cavadini et al.,
2019). Resmussen and colleagues, in their review of the literature for potential determinants for

fruit and vegetable in American children and adolescents (98 papers) found that the

determinants were as follows: age, gender, socioeconomic position, preferences, parental

experience, and the most vital home availability/accessibility (Rasmussen et al., 2016).

Children tended to have a higher or more frequent of fruits and vegetables than boys and

older children. Socio-economic position, preferences, parental experience, and home

availability/accessibility are all consistently positively associated with the of fruits and

vegetables. Adolescents from Western countries demonstrated knowledge of healthy food. The

barriers to knowledge were identified as time limits, availability of healthy food in school, and

lack of concern with healthy food consumption, convenience of fewer healthy alternative, taste

preference for less healthy food and lack of parental/school support (Neumark-Sztainer et al.,

2013); (O’ Dea, 2013).

2.2.3 Physical activity and lifestyle

Recent studies and reviews have summarized the benefits of regular physical activity on

several health and behavioural outcomes of adolescents and its potential for reducing the

incidence of chronic diseases that are manifested in adulthood. The level of physical activity in

adolescents is a predictor of subsequent adiposity and decreases in physical activity over the

teenage years are associated with increases in a body mass index (Kurz and Johnson-Welch

2014). Risk factors associated with cardiovascular disease in adolescence that includes

overweight status, hypertension, increased blood lipids, and cholesterol are linked to physical

inactivity (Bonnie and Spear 2012). A consensus panel from various countries developed

guidelines for physical activity for adolescents that might maintain and/or enhance health. The

guidelines state that all adolescents should be physically active daily or nearly every day as part
of play, games, sports, work, transportation, recreation, physical education, or planned exercises

in the context of family, school, and community activities. The guidelines also state that

adolescents should engage in 3 or more sessions per week of activities that last 20 minutes or

more at a time and that require moderate to vigorous levels of exertion (Sallis and Patrick 2014).

2.3 Nutrition Knowledge in Universities Students

2.3.1 Nutrition Knowledge and Dietary Behaviour

Knowledge can positively impact eating behaviour. In particular, the systematic review

by Spronk et al. (2014) investigated the relationship between nutrition knowledge and dietary

intake in mixed adult populations (community and athletic). The review identified 29 studies and

demonstrated a positive, although weak, association between increased knowledge and improved

dietary intake. It should be noted that a high heterogeneity was found in studies regarding the

assessment methods of knowledge and dietary intake which reduces the validity of inferences.

With respect to university populations, Kolodinsky et al. (2007) assessed the relationship

between knowledge and adherence to the dietary guidelines in students in the US. The study

found that for specific food groups (fruit, dairy, protein and wholegrains) an increased

knowledge was related with better food choices. A similar cross-sectional study among 1,005

students in Croatia reported that participants with higher adherence to dietary guidelines

demonstrated significantly higher levels of nutrition knowledge. Also, knowledge was positively

correlated with the intakes of fruits, vegetables, grains, dairies and meat (correlation coefficients

ranged from 0.19 to 0.21 (Kresić et al., 2009).

Nutrition knowledge seems also to indirectly impact eating habits (Wardle et al., 2000).

The study by Cooke and Papadaki (2014) among 500 university students across 37 UK

Universities found that nutrition knowledge was significantly correlated (correlation coefficient
0.20, p=0.01) and was a predictor of food labelling use. The same study also found that nutrition

knowledge was positively associated with diet quality, with or without considering use of food

labels. Similar results were found in Misra (2007) (US), which reported that nutrition knowledge,

when accompanied by positive attitudes towards usefulness, accuracy and truthfulness of food

labels, was a strong predictor of food label use in students. These findings indicate the

importance of incorporating nutrition knowledge as an outcome in health promoting strategies

and implement interventions to increase the level of knowledge in students. The following

paragraphs aim to illustrate data from existing cross-sectional studies across the world which

assessed the knowledge of various nutritional aspects among university students.

2.3.2 Nutrition Knowledge in University Students

Nutrition knowledge by university students have been investigated worldwide with eight

studies conducted in the United States, five in Canada, Asia and Africa (each), three in Europe

and only one in England (Table 2.3). The number of participants in the studies ranged from 129

(Bottcher et al., 2017) to 6,638 (Matthews et al., 2016). Some studies included students across

different academic disciplines (Boland et al., 2015) while others focused on students from a

specific field of study such as pharmacy and dietetics (Morawska et al., 2016).

According to a review undertaken by Barbosa et al. (2016), most studies aiming to assess

nutrition knowledge developed their own questionnaires and estimated the level of knowledge by

calculating the number of correct answers. A valid tool frequently used is the General Nutrition

Knowledge Questionnaire (GNKQ), developed by Parmenter and Wardle (1999) for the UK

adult population (Barbosa et al., 2016). This questionnaire assesses four aspects of knowledge,

including dietary recommendations, nutrient sources of foods, healthy food choices and diet-
disease relationships. The majority of studies (Table 2.3) found that students had a moderate

level of knowledge in most domains by correctly answering about 45%-65% of the questions.

2.3.3 Knowledge of Dietary Recommendations

With respect to studies investigating the knowledge of country-specific dietary

recommendations, the mean scores of correct answers of students were 51% in South Africa

(Peltzer, 2002), 60% in the US (Kolodinsky et al., 2007), 66% in Lebanon (Nabhani-Zeidan et

al., 2011) and 73% in the UK (Cooke and Papadaki, 2014) (Table 2.3). Regarding the

recommended intakes of specific foods, students answered correctly less than 40% of the

questions about FV (Matthews et al., 2016), less than 23% of the questions about milk and their

alternatives (Matthews et al., 2016) and 18% of the questions about fermented dairy products

(Mazier and Mcleod, 2007). Furthermore, students responded correctly about half of the

questions regarding wholegrains (score 54%) (Williams and Mazier, 2013) and healthful food

choices (score 47%) (Peltzer, 2002). These findings might indicate that a higher number of

interventions for students have been focused on increasing intakes of FV and wholegrain and less

on the intake of dairy products.

2.3.4 Knowledge of Nutrients in Foods

With regards to studies investigating the knowledge of macronutrients, students seem to

have a moderate knowledge of carbohydrates (score 61%), fibre (score 50%), protein (score

ranges 48%-72%) (El-Sabban and Badr, 2011; Al-Isa and Alfaddagh, 2014) and the different

types of fats and lipids in the diet (score ranges 50%-69%) (Mazier and Mcleod, 2007; Jasti and

Kovacs, 2010; El-Sabban and Badr, 2011; Al-Isa and Alfaddagh, 2014). These findings are

consistent with the dietary behaviour, where students reported consuming high amounts of

protein-based animal foods (meat) and exceeding the recommended fat intake.
 Regarding knowledge of micronutrients, students answered correctly about 50% to 70%

of the questions, demonstrating a moderate level of knowledge of the sources and functions of

vitamins and minerals (Table 2.3). Two studies focused on vitamin D and students’ scores were

low, ranging from 29% (Boland et al., 2015) to 43% (Zhou et al., 2016). The second study was

undertaken with medical students which might explain the higher knowledge score (Zhou et al.,

2016). For many years, vitamin D was not emphasised in the diet, as it is mainly provided via

skin exposure to sunlight. However, the last decade, research and interest in vitamin D regarding

dietary sources and human requirements has been increased, due to the high number of children

and adults identified with low serum levels (Scientific Advisory Committee on Nutrition, 2016)

2.3.5 Knowledge of Diet-Disease Relationships

When students were asked about their knowledge of the impact of diet on chronic

diseases including obesity, type 2 diabetes, bowel and cardiovascular diseases, the mean score of

correct answers was 45% in the UK (Cooke and Papadaki, 2014) and 43% in South Africa

(Peltzer, 2002). The lowest score (13%) was found in a sub-sample (low socioeconomic status)

of students from Lebanon (Nabhani-Zeidan et al., 2011). One study inquired about the dietary

practices to prevent cancer and students addressed correctly 65% of the questions (Folasire et al.,

2016) while another inquired about weight loss practices and students addressed correctly about

half of the questions (55%) (Al-Isa and Alfaddagh, 2014). The lack of substantial knowledge

regarding the implications of diet on health could exacerbate the current eating habits or

motivation of young people to adopt healthier eating habits.

2.3.6 Knowledge of Food Labels, Organic, Cultural and Functional Foods

With regards to other aspects of nutrition, a study in the US found that students

demonstrated good knowledge when asked about the Mediterranean Diet (score 73%) (Bottcher
et al., 2017), indicating that the MD is well-promoted in the country. Another study in the US

explored knowledge on food labels and found that students failed to answer 58% of questions

about claims on food labels (Misra, 2007). These findings could be explained by the existence of

multiple food labelling systems in the country (single traffic light, multiple traffic light, facts up

front, NuVal and the latest 3-star rating system), which might be difficult for people to habituate

(Gorski Findling et al., 2018). A qualitative study in Sweden conducted focus groups to explore

the interpretation of symbols and claims on food labels by students (Neuman et al., 2014). The

study concluded that students tended to consider a food item as ‘healthy’ based on its

manufacturing methods and additives rather than on its effect on physical health and body

requirements. Another study in the US explored the knowledge and consumption of organic

foods by students (Dahm et al., 2009). This study reported that 51% of students did not provide a

proper definition and 68% did not recognise the seal of organic foods. Organic food is usually

more expensive and absent from university menus which might explain the low awareness and

consumption found in the study (Dahm et al., 2009).

Another study asked Polish pharmacy students about the definition, form and function of

functional foods and students replied correctly less than 60% of the questions, demonstrating a

moderate-to-low knowledge about this food category (Morawska et al., 2016). Finally, a study in

the US among dietetic students found an inadequate knowledge when asked about foods and

dietary habits of different ethnic groups (score 63%) (Mcarthur et al., 2011). Such lack of

knowledge is important for dietitians’ competence in practice, as it is crucial to address and

incorporate individuals’ cultural and racial/ethnic characteristics when designing dietary regimes

or giving dietary advice.

2.3.7 Overall Nutrition Knowledge

 Some researchers calculated the mean score of all correct answers from different

nutritional domains to get an estimate of overall nutrition knowledge. As shown in Table 2.3,

four studies used the same tool or an adapted version (GNKQ) to assess overall knowledge

(Peltzer, 2002; Kresić et al., 2009; Barzegari et al., 2011; Cooke and Papadaki 2014). The mean

scores of correct answers in these studies ranged from 51% to 67%, suggesting a moderate level

of overall knowledge. The remaining studies found similar trends, with the lowest mean score

(43.9%) reported in Sajwani et al. (2009) and the highest score (79.7%) in Bernardes Spexoto et

al. (2015). It is worth mentioning that the first study included only non-medical students while

the second included only pharmacology and biochemistry students.

2.3.8 Factors Affecting Nutrition Knowledge

Field of study seems to be a factor associated with nutrition knowledge although

contradictive data exists. Students from health-related sciences such as Medicine or those having

prior nutrition education found to have significantly greater levels of knowledge when compared

with students from theoretical sciences such as Political, Art and Social Sciences (Bernardes

Spexoto et al., 2015; Boland et al., 2015; Bottcher et al., 2017). However, similar studies found

that prior nutrition education or studying a health-related course did not significantly impact

knowledge (Buxton and Davies, 2013; Matthews et al., 2016). Year of study might also affect

the level of knowledge as in many studies, older students had greater knowledge compared to

first year or junior students (Mazier and Mcleod, 2007; Kresić et al., 2009; Al-Isa and

Alfaddagh, 2014; Bernardes Spexoto et al., 2015).

Gender is also a predictor, as a high number of studies reported that females had

significantly higher levels of knowledge compared to their male counterparts (Peltzer, 2002;

Misra, 2007; Kresić et al., 2009; Jasti and Kovacs 2010; Bottcher et al., 2017), although there is
a limited number of studies contradicting these findings (Folasire et al., 2016) or where no

association between knowledge and gender was found (Barzegari et al., 2011; Buxton and

Davies, 2013). This variation might be explained by the fact that some health-related courses

(e.g., Nursing, Midwifery) which usually include some nutrition exposure, are female-

dominating while Political, Maths, Engineering and Business courses are male-dominating. It

could also be explained by the fact that women are more motivated to look for health-related

information compared to men (Ek, 2015). Other studies found that high socioeconomic status

(Nabhani-Zeidan et al., 2011), healthy BMI (Sajwani et al., 2009), ethnicity (non- Hispanic

white) (Jasti and Kovacs, 2010), living alone, preparing own food (Kresić et al., 2009), being a

grocery shopper (Jasti and Kovacs, 2010) as well as having good dental hygiene and high

academic achievement (Al-Isa and Alfaddagh, 2014) were positively associated with greater

nutrition knowledge in university students. However, none of these studies were undertaken in

Europe, therefore, more UK-based studies are needed to explore the association of academic and

socio-demographic characteristics and nutrition knowledge of students.

2.4 Dietary Behaviour in University Students

2.4.1 Energy, Macronutrient and Micronutrient Intakes

Total energy intake is the amount of energy (kcal) consumed by individuals daily

(Scientific Advisory Committee on Nutrition, 2011). Macronutrients include carbohydrates,

protein and fat, while micronutrients include vitamins and minerals (Department of Health,

1991). Only macronutrients and alcohol provide energy in the body while micronutrients are

caloric-free (Department of Health, 1991). To maintain optimal health and reduce disease risk,

various organisations and countries have established daily recommended intakes (Dietary

Reference Intakes, Guideline Daily Amount, etc.) to meet the nutrient requirements of
individuals (Department of Health, 1991). Findings from cross-sectional studies in Europe

(Greece, Spain) (Chourdakis et al., 2011; García-Meseguer et al., 2014) and the US (Burke et al.,

2009) reported that male students consumed on average more calories than female students while

both genders consumed higher amounts of fats than recommended. An excess intake of fat,

particularly saturated fat, can raise LDL-cholesterol which is a risk factor for cardiovascular

diseases (CVD) (Sacks et al., 2017). Intakes of saturated fat exceeded the recommended levels in

a study undertaken by Chourdakis et al. (2011), ranging from 10% to 15% of total energy intake

while the recommended limit is less than 10%.

Chourdakis et al. (2011) also found low intakes of folate in students. Decreased plasma

folate, followed by low homocysteine concentrations, is a biomarker of chronic diseases such as

CVD and cancer, while in women, adequate folate levels are crucial during reproductive and

early pregnancy periods to prevent neural tube defects of the fetus (Bailey et al., 2015). Excess

intakes of sodium (salt) were found among US students (Burke et al., 2009). A low sodium

intake has been associated with optimal blood pressure both in adults and children (Aburto et al.,

2013). Other studies among university students have also shown inadequate intakes of vitamin D

and vitamin E (Correa-Rodríguez et al., 2018). The above intakes were assessed using self-

reported 3- day food records in the studies undertaken by Burke et al. (2009) and Chourdakis et

al. (2011) and two non-consecutive 24-hour recalls interviewed by researchers in the study by

García-Meseguer et al. (2014).

2.4.2 Dietary and Drinking Habits

Nutrient intakes reflect the dietary habits of students. A cross-sectional study among

2,812 Canadian students found that only 10% of participants reached the targeted daily intake of
five or more portions of fruit and vegetables (FV), where FV intake was assessed by asking

students to record their usual intake (portions per day) (Scarapicchia et al., 2015).

Another study across seven universities in the UK assessed FV intake as well as intake of

sweets and confectionary by using a self-reported questionnaire, where students reported the

frequency of their usual consumption (El Ansari et al., 2011). This study found that only 15% of

participants consumed at least five portions of FV per day and only 32% consumed sweets less

than once per week. A similar study conducted at Michigan University (US) assessed food

frequency consumption of students by using a questionnaire to inquire, among others, about the

intake of FV, sweets, processed meat (e.g. salami, sausages), fast-food and pizza (Yahia et al.,

2016). The study reported that only 8% of males and 9% of females were eating more than two

portions of FV per day while 26% of males and 6% of females were eating processed meat twice

daily. Regarding energy-dense foods, the study reported 38% of males and 30% of females

eating sweets and cakes once to two times per week, 35% of males and 28% of females eating

fast-food once to two times per week while 35% of males and 41% of females eating at a

pizzeria every day (Yahia et al., 2016). These studies provide an estimate of students’ habitual

dietary habits, however, potential recall bias should be considered when students record their

intakes (Shim and Kim, 2014).

Drinking behaviour, and in particular the consumption of sugary drinks, are an important

part of diet as they contribute towards individuals’ total sugar and energy intake (Martinez et al.,

2016). The study by Deliens et al. (2015) among Belgian students found that mean consumption

of soft drinks was 424 ± 445 (ml/day) of which 52% derived from sugar-sweetened carbonated

beverages, 26% from fruit juices, 18% from diet soft drinks and 9% from energy and sports

drinks. Another study in a southwest university in the US found that 17.5% of students had
consumed energy drinks in the past week while energy drink consumption was positively

associated with the intake of sodas and frozen meals (Poulos and Pasch, 2015). A study among

Caribbean students showed that 74% of the participants were drinking up to five energy drinks

per month with males being higher consumers than females (Reid et al., 2015). On average, a

sugary drink contains 7-10 teaspoons of sugar. Energy drinks also contain caffeine (83- 215 mg

per can), which in high amounts, can cause elevated heart rate, headaches, increased urination

and insomnia (Reid et al., 2015).

As individuals tend to consume a cluster of foods and drinks (providing sometimes the

same nutrients) and, considering the synergistic effect of foods on health, researchers developed

dietary patterns based on the intake of food combinations (Tucker, 2010). The dietary patterns

followed by students and their implications on students’ health are described in the following

paragraphs.

2.4.3 Dietary Patterns

Indexes or scores, such as the Healthy Eating Index (HEI) (Kennedy et al., 1995) and the

Mediterranean Diet (MD) Score (Trichopoulou et al., 2003), have been used to assess a cluster of

dietary habits in order to provide an estimate of overall diet quality in various populations.

García-Meseguer et al. (2014) assessed the diet quality of 284 Spanish students by using the HEI

and the MD tools. Based on the HEI tool, only 3.9% of participants reached a greater than 80

overall score, which indicated a good diet quality, while based on the MD tool, 5.3% of students

reached a score greater than 6, indicating high adherence to the MD pattern. The same study also

reported that lunch was the largest meal of students by providing 36% of their daily energy

intake, followed by dinner (27%), snacking (21%) and breakfast (16%), implying that students
tend to consume small breakfast meals or skip breakfast altogether (García-Meseguer et al.,

2014).

This is also evident in the systematic review by Pendergast et al. (2016), which found

that breakfast was the most missed meal, skipped by 14% to 89% of the participants. A recent

published large cross-sectional study by Sprake et al. (2018) investigated the dietary habits using

a self-reported food frequency questionnaire (FFQ) in university students from five UK

universities across England. The following four main dietary patterns were identified, based on

1,448 student responses: ‘vegetarian’, ‘snacking’, ‘health-conscious’ and ‘convenience, red meat

and alcohol’. The ‘vegetarian’ and ‘health-conscious’ were nutrient-dense patterns characterised

by high intakes of pulses, fruits, vegetables and oily fish in contrary to the other two poor-

nutrient patterns, which were characterised by energy-dense snacks (e.g. biscuits, pastries,

sweets) and high intakes of fast-food and processed meat. The ‘convenience, red meat and

alcohol’ pattern was identified most consistently across universities and it was associated with

other unhealthy lifestyle habits such as eating take-away meals, smoking and physical inactivity

(Sprake et al., 2018). Adherence to healthy or unhealthy dietary patterns can significantly impact

students’ health as described in the following paragraphs.

2.4.4 Dietary behaviour (habits, patterns) and implications on health

Similar to physical activity behaviour, the longitudinal CARDIA study explored the

relationship between dietary habits of young adults and health risk in later adulthood (Duffey et

al., 2012). The researchers investigated following a ‘prudent’ dietary pattern (characterised by

high intakes of fruit, whole grains, milk, nuts, seeds) or a ‘western’ dietary pattern (characterised

by high intakes of fast-food, meat, pizza, snacks) and the incidence of cardiometabolic risk over

a 20-year period (Duffey et al., 2012).

 Those following a ‘prudent’ diet compared to a ‘western’ diet had significantly lower

levels of LDL-cholesterol (Hazard Ratio=0.87, 95% CI: 0.75-0.99), triglycerides (Hazard

Ratio=0.78, 95% CI: 0.67-0.92), hypertension (Hazard Ratio=0.84, 95% CI: 0.73-0.98) and

metabolic syndrome (Hazard Ratio=0.77, 95% CI: 0.66-0.91). Another cohort study among

19,138 Spanish university students (the SUN cohort), calculated a healthy eating score (0-10

points) at baseline, characterised by high intakes of fruit, vegetables, fish, f ibre and low intakes

of meat, sweets, and pastries, in order to investigate the incidence of cardiovascular disease at

follow-up (approximately 9 years later) (Santiago et al., 2016). The study found that a higher

healthy eating score was associated with significantly lower risk of developing CVD [for a score

of 9-10 points, Hazard Ratio= 0.31, 95% CI: 0.15-0.67)] compared to the lowest score (0-2

points).

Regarding breakfast consumption, the CARDIA study suggests that eating breakfast daily

versus occasionally protects against the development of abdominal adiposity (Hazard

Ratio=0.78, 95% CI: 0.66-0.91), obesity (Hazard Ratio: 0.80, 95% CI: 0.67-0.96), hypertension

(Hazard Ratio=0.84, 95% CI: 0.72-0.99) and metabolic syndrome (Hazard Ratio= 0.82, 95% CI:

0.69-0.98) over an 18-year period (Odegaard et al., 2013). This might be explained by the fact

that the time and content of breakfast meals seem to positively affect blood glucose, insulin and

lipid metabolism profiles (Leroith, 2012).

With regards to beverage intake, the SUN cohort study among 8,157 Spanish graduates,

found that frequent consumers (highest versus lowest quartiles) of sugar-sweetened beverages

had twice the likelihood of developing metabolic syndrome (Odd Ratio=2.2, 95% CI: 1.4-3.5)

and central obesity (Odds Ratio=2.3, 95% CI: 1.9-2.7) and were 60-70% more likely to develop

high blood pressure (Odds Ratio=1.6, 95% CI: 1.3- 2.1), triglyceride levels (Odds Ratio=1.7,
95% CI: 1.1-2.6) and impaired fasting glucose (Odds Ratio=1.6, 95% CI: 1.1, 2.2) over a 6-year

follow-up period (Barrio-Lopez et al., 2013). Similar results were found in a meta-analysis,

where high consumption of sugary drinks was positively associated with an increased risk of

obesity, metabolic syndrome, type 2 diabetes and cardiometabolic disorders (Malik et al., 2010).

2.4.5 Determinants of dietary behaviour

Determinants of students’ food choices include their personal characteristics and beliefs,

their social life and environment, the university environment, the local food settings, the living

arrangement and their exposure to advertising. Individual traits such as taste, self-control, time

management, meal preparation skills, convenience, religious beliefs and previous eating habits

can all positively or negatively affect eating habits (Deshpande et al., 2009; Boek et al., 2012;

Deliens et al., 2014). Limited access to healthy food and high food prices constitute additional

reasons for unhealthy food choices (Deliens et al., 2014). Family, friends, partners and peers play

a significant role, as young people tend to consume more fast-food and sugar-sweetened

beverages if their family and friends do so (Pelletier et al., 2014). This might be due to role

modelling as studies found associations between parents’ and adolescents’ dietary intakes

(Hanson et al., 2005).

Living arrangements might also impact students’ food choices. Data from a cross-

sectional study among 2,402 first-year students from Germany, Denmark, Poland and Bulgaria

revealed that those living away from their parents consumed less fruit, vegetables and meat (El

Ansari et al., 2012). The authors of the study speculated that financial limitations (e.g. cost of

meat), lack of parental control and time needed to prepare meals (e.g. cook vegetables) might

explain these findings. However, another study found that living away from home was positively

correlated with meal preparation skills, without affecting dietary habits of students (Pelletier et
al., 2014). On the other hand, residents in student accommodation halls seem to be frequent

buyers of savoury snacks, desserts and sugary beverages (Nelson and Story, 2009) while those

who purchase frequently food and beverages from the campus area seem to skip breakfast and

consume high amounts of fat and added sugars (Pelletier and Laska, 2013). This might be

explained by the high number of vending machines and the quality of food served in university

residencies. Food advertisement exposure was also related with increased consumption of

unhealthy and energy dense snacks in a study including university students (Zimmerman and

Shimoga, 2014). Finally, data from student focus groups reported that perceived stress affects

students’ eating habits towards healthier or unhealthier choices (Deliens et al., 2014).

2.5 Eating Behaviors Among Universities Students

It has been well documented that universities students do not meet the recommendations

for nutrients when using comparative standards such as the DRI’s and the recommendations put

forth by the Dietary Guidelines for Americans (Anding et al., 2001; Brunt and Rhee, 2008; Davy

et al., 2006; Hendricks et al., 2004; Silliman et al., 2004; Huang et al., 2003). According to

previous literature, a typical universities student’s diet is high in sugar, fat, and sodium, and low

in fruits, vegetables and dairy products (Anding, et al., 2001; Brunt and Rhee, 2008; Davy et al.,

2006; Hendricks, et al., 2004; Silliman, et al., 2004; Huang, et al., 2003). The diets of

universities students become a major concern as adapting poor dietary habits can have long term

health consequences that affect quality of life, such as the development of cardiovascular

disease, diabetes, hypertension, and obesity (Engeland et al., 2004).

An earlier study conducted by Anding and colleagues (2001) assessed universites

students’ dietary habits by utilizing a population of 60 females from three aerobic classes at the

University of Houston, Texas. Participants completed a questionnaire that collected information

on height and weight, physical activity, and food intake using a 3 day food record. The results of

this study were compared with the recommendations found in the Dietary Guidelines for

Americans 1995 (USDA, 1995). The study showed that participants failed to meet the minimum

recommendations for bread and grains, fruit, vegetables, and dairy products. Of all 60 8

participants, only 9 participants consumed 5 or more servings of fruits and vegetables. Mean

total fat intake per day was 37%, while the recommendation was 30% or less per day (U.S.

Department of Agriculture and U.S. Department of Health and Human Services, 1995). Daily

sugar intake also exceeded the Dietary Guidelines which limits sugar to 10% of calories (U.S.

Department of Agriculture and U.S. Department of Health and Human Services, 1995).

Daily sugar intake for the participants averaged 19.7% of total calories, with only 8% of

participants consuming less than 10% sugar from total calories. Sodium consumption was also

high among the participants within this study. The Dietary Guidelines for Americans 1995

recommended that Americans limit sodium consumption to 2,400 mg (U.S. Department of

Agriculture and U.S. Department of Health and Human Services, 1995). The participants within

this study consumed an average of 3,204 mg of sodium per day with an average of 57% of the

participants consuming over 2,400 mg of sodium per day (Anding, et al., 2001). Within that

same year, Debate, Topping, and Sargent (2001) found similar results. Utilizing a population of

630 U.S. universites students, researchers distributed a questionnaire collecting data on nutrition

intake, weight status, and dietary practices. BMI was calculated using self-reported height and

weight and nutritional intake was assessed using 24 hour recall. Results of the study showed that

only 18% of the participants consumed five or more servings of fruits and vegetables per day.

Furthermore, only 7% of participants consumed six or more grain products per day and 53%

consumed two or more dairy products per day (Debate, et al., 2001).
 A year later, Hiza and Gerrior (2002) also found that universites students were not

meeting dietary recommendations by using the Interactive Healthy Eating Index. The Interactive

Healthy Eating Index is a tool that provides an overall picture of an individual’s diet variety and

9 compliance to the Dietary Guidelines for Americans. Utilizing a population of 100 students at a

university, researchers found that universities students did not meet recommendations for fruits,

dairy, and protein (Hiza, and Gerrior, 2002). In 2012, universities students still were not meeting

recommendations. The American Universities Health Association National Universities Health

Assessment is a nationally recognized research survey distributed to universities students

biannually to collect data regarding alcohol, tobacco, and drug use, sexual health, weight,

nutrition, and exercise, mental health, and personal safety and violence. According to the

American Universities Health Association National Universities Health Assessment, only 6.4%

of students consumed five or more servings of fruits and vegetables per day (American

Universities Health Association, 2012).

In 2013, this figure had not changed as only 6.3% of students consumed five or more

fruits and vegetables servings per day (American Universities Health Association, 2013).

Chronologically throughout time, researchers have found that universities students are not

meeting dietary recommendations. This trend continues on even when dietary intake is assessed

according to BMI and living arrangements.

2.6 Importance of healthy eating by University Students

Healthy eating is particularly vital for children and young adults, as not only does it affect

intellectual and cognitive development, but it also engenders habits and behaviours that have

increasingly greater risk as the individual ages; cardiovascular disease for example can take 33

decades to develop and is pre-disposed to by a lifetime of risk factor indulgence (Lobstein et al.,
2004). Dietary habits can also have immediate short- and middle-term consequences on health,

such as occurs when genetically-predisposed individuals develop coeliac disease due to modified

and abundant gluten in modern processed western diets (Gujral et al., 2012).

Given the interest and public health relevance of eating behaviours, many people have

sought to determine the factor that influence weight status and eating behaviours in young adults,

as the transition to adulthood (when an individual has a good level of academic and life

understanding) has been identified as a critical time for correcting deleterious behaviours

(Lobstein et al., 2004). This can be of particular relevance to young adults leaving home for

university or employment, where time constraints, new commitments and new experiences are

forthcoming (Lobstein et al., 2004). Since living away from home is a vulnerable time in a young

life, and a major contributing factor to weight gain, strategies for promoting healthy lifestyle

behaviours in this population are vital.

2.7 Nutrition Education Approaches by University Students

A variety of nutrition interventions which target obesity have been reported. However

there is limited evidence as to the most successful approach. Such programmes have included

educational programmes for children, young adults and also their parents to change dietary

habits. The modes of distributing such knowledge also need consideration, to ensure that the

message is spread using a medium or a method that effectively reaches the target population, be

it the children and young adults or their parents. Thus, understanding of the level of awareness of

what constitutes the healthy diet and of the barriers and facilitators to implementation of such

diet in any particular population or culture are necessary for developing successful educational

approach to tackling overweight and obesity among today’s young 34 adults. Social networks is

an effective tool which is explored further as a method of communication education messages.

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