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Appetite 55 (2010) 722725

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Appetite
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Eating habits, health attitudes and obesity indices among medical students in northern Greece
Michael Chourdakis, Thrasivoulos Tzellos, Georgios Papazisis, Konstantinos Toulis, Dimitrios Kouvelas *
Department of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, P.O. Box 1532, GR-54006, Thessaloniki, Greece

A R T I C L E I N F O

A B S T R A C T

Article history: Received 13 May 2010 Received in revised form 4 August 2010 Accepted 21 August 2010 Keywords: University students Greece Eating habits Obesity indices Medical students Health attitudes

Medical students represent not only the nal but also the most crucial opportunity for education in the eld of healthy lifestyles and nutritional habits. Eating habits and obesity indices among medical students in southern Greece were described almost a decade ago. However, there is a lack of current, relevant data concerning students living in northern Greece. The purpose of the present study was to evaluate the body mass index distribution and nutritional and health-related behavior among medical students in northern Greece. The participants, 187 males (21.5 1.9 years) and 203 females (21.3 2.2 years), lled out a selfreport questionnaire. Height and weight measurements were obtained. Dietary practices of fast food consumption (more frequent for males) and regular consumption of fruits and vegetables (more frequent for females) were reported. Females seemed to adopt different practices than males when trying to lose weight and were signicantly better informed about the nutrient value of the food consumed. Although the prevalence of overweight (males: 32.1%, females: 8.4%) and obesity (males: 5.9%, females: 1.5%) in the present sample is lower compared to previous data, it remains high according to what would be health promoting. The above ndings suggest a need for further improvement in strategies promoting healthier nutrition habits. 2010 Elsevier Ltd. All rights reserved.

Introduction Obesity is considered a global epidemic, as it is the most rapidly growing form of malnutrition in developed (McTigue, Garrett, & Popkin, 2002) and developing countries (WHO, 2000). Published data demonstrate that obesity is associated with numerous chronic diseases including hypertension, cardiovascular disease (CVD), type-II diabetes, gallbladder diseases and various malignancies (Manson, Skerrett, Greenland, & VanItallie, 2004; Pischon, Nothlings, & Boeing, 2008). Studies conducted in Greece and particularly in the Attica region (central-south of Greece), showed that a considerable proportion of the adult population is overweight (53% vs. 31% for males and females, respectively) or obese (20% vs. 15% for males and females, respectively) (Panagiotakos et al., 2004). During the last 30 years the composition of the Greek diet has shifted towards a diet higher in saturated fat and meat, lower in ber and fruits and higher in processed foods (Karlen, Lowert, Chatziarsenis, Falth-Magnusson, & Faresjo, 2008; Van Diepen et al., 2010). Furthermore, a decrease in the level of physical activity is associated with increased prevalence of overweight, obesity and
The authors express their appreciation to all the students that participated in the study and to G. Leli for her help with data entry. No conicts of interest. No external funds. The authors funded this study. * Corresponding author. E-mail addresses: mhourd@med.auth.gr (M. Chourdakis), ltzellos@googlemail.com (T. Tzellos), gpapaz@med.auth.gr (G. Papazisis), toulis@endo.gr (K. Toulis), kouvelas@auth.gr (D. Kouvelas).

diet-related non-communicable diseases (Lollgen, Bockenhoff, & Knapp, 2009). According to Martinez-Gonzalez et al. (2001) there are noteworthy differences in physical activity levels between different nations, with southern Europeans signicantly less physically active compared with northern Europeans. Along with the Portuguese, the Greeks are the least physically active population in the European Union, with 40% of Greeks reporting to engage in no leisure-time physical activity. University students are important targets for the promotion of healthy lifestyles of the adult population. A number of studies evaluating the nutritional knowledge, eating habits and obesity indices of university students have been conducted (Malinauskas, Raedeke, Aeby, Smith, & Dallas, 2006; Osaka, Nanakorn, Sanseeha, Nagahiro, & Kodama, 1999; Sakamaki, Toyama, Amamoto, Liu, & Shinfuku, 2005), but previous studies in Greece either refer only to females (Farajian, Renti, & Manios, 2008), or have a small sample size (Spanos & Hankey, 2010), presenting data only for central (Papadaki, Hondros, & Kapsokefalou, 2007) or southern (Bertsias, Mammas, Linardakis, & Kafatos, 2003) Greece. There is a lack of evidence about the body mass index (BMI) distribution and nutritional and health-related behavior of Greek students living in northern Greece. Northern Greece is a territory with a slightly different climate (cooler and more humid) and different customs about food habits than the central or the southern part of the country. The purpose of this study was to obtain data about the nutritional knowledge, eating habits, health attitudes and obesity indices of medical students living in this region of Greece.

0195-6663/$ see front matter 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2010.08.013

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Methods Design and participants The study was carried out between March and May 2009 at the Aristotle University of Thessaloniki campus in northern Greece and was approved by the universitys institutional review board for research involving humans. A total of 408 medical students (196 males and 212 females) participated in this study after giving their informed written consent and were asked to ll out a self-report questionnaire. Of the 408 students, 18 were excluded (9 males and 9 females) due to missing data. The nal sample consisted of 390 students (187 males and 203 females), all Caucasians. Self-reported height and weight (and extrapolated BMIkg/m2) were compared to the measured values obtained for weight and height and the calculated BMI. Students were recruited randomly by a trained student accompanied by a professor. Body weights and heights were measured. Weight was measured to the nearest 0.1 kg using a digital scale (Seca 861; Seca Ltd., Vogel & Halke, Hamburg, Germany). Height was measured to the nearest 0.5 cm using a stadiometer, with the participants back square against the wall tape, eyes looking straight ahead (visual axis is horizontal when the top of the external auditory meatus is level with the inferior margin of the bony orbit) (Seca Leicester Height Measure; Seca Ltd., Vogel & Halke, Hamburg, Germany). BMI was calculated as weight (kg) divided by the square of height (m2). In the present study, the BMI classication of the WHO was used (WHO, 1997), classifying overweight as BMI 2529.99 kg/m2 and obesity as !30 kg/m2. A BMI < 18.5 kg/m2 is classied by the Center for Disease Control and Prevention as an underweight condition. Questionnaire A 3-page questionnaire (35 questions) was designed by the authors and was based on a previously published instrument (Sakamaki et al., 2005; Yahia, Achkar, Abdallah, & Rizk, 2008). The questionnaire used was rst described by Sakamaki et al. (2005) and was standardized by the authors for university students population. Yahia et al. (2008) have adopted this questionnaire to study the Lebanon university population without any standardization for Lebanon population, since it contains no country specic dietary habit questions. It included demographic data, eating, drinking and smoking habits (27 questions) and 8 questions related to nutritional knowledge and dietary behaviors were added by the authors. Statistical analysis Statistical analysis was performed using the Statistical Package for Social Sciences (version 12.0, SPSS, Inc.) software. A normality test was performed for all dependent variables. For comparison of quantitative variables, the Independent samples t-test was used

Table 1 Anthropometric and socio-demographic data of the sample. Males (n = 187) N Age (years) Height (cm) Weight (kg) BMI Origin Village Small city Town >50.000 people Athens/Thessaloniki Mother education Primary school High School Lyceum Bachelor degree Post-graduate Father education Primary school High School Lyceum Bachelor degree Post-graduate
a b c d b,c

Females (n = 203) N
b,c

p-Valuea

21.5 1.9 180 6.8 79.2 12.7 24.5 3.5 14 42 68 63 14 9 50 95 19 7 7 38 100 35 7.5 22.5 36.4 33.7 7.5 4.8 26.7 50.8 10.2 3.7 3.7 20.2 53.2 18.6 17 45 78 63 3 9 56 127 8 10 11 50 110 22

21.3 2.2 168 5.8 60.9 8.9 21.5 2.7 8.4 22.2 38.4 31.0 1.5 4.4 27.6 62.6 3.9 4.9 5.4 24.6 54.2 10.8

0.3 <0.001* <0.001* <0.001*

NCd

NCd

NCd

Data considered statistically signicant (*) at p < 0.05. Data for quantitative variables are presented as mean SD. Data for qualitative variables are presented as absolute numberfrequency. NC: not calculated.

for variables following a normal distribution, whereas for others, the MannWhitney U test was performed (Rosner, 2005). All pvalues were two-tailed and differences were considered signicant when the p-value was less than or equal to 0.05. Summary data are expressed as the mean standard deviation (SD). For comparison of categorical data, the chi-square (x2) test (or Fishers exact test for 2 2 data tables) was used (Rosner, 2005). Differences were considered signicant when the p-value was less than or equal to 0.05. Results Characteristics of the sample and BMI categories General characteristics of the population sample are presented in Table 1. Mean age was not signicantly different between males and females. The average height, weight and BMI of males were signicantly higher (p < 0.001) than those of females. Mean BMI was signicantly higher for males. Of the samples population, 61.5% of the males and 84.7% of the females were classied as normal according to BMI, whereas 32.1% of the males and 8.4% of the females fell into the overweight category. Of the remaining students, 5.9% of the males and 1.5% of the females were obese and 0.5% of the males and 5.4% of the females were categorized as underweight (Table 2). Self-reported height, weight and BMI were more favorable than measured values (data not shown). Height,

Table 2 Prevalence of obesity among students based on BMI by gender. Males (n = 187) N Underweight (<18.5 kg/m2) Normal (18.524.99 kg/m2) Overweight (25.029.99 kg/m2) Obese (>30.0 kg/m2)
a b

Mean

SD

Females (n = 203) N % 5.4 84.7 8.4 1.5

Mean

SD

p-Valuea

% 0.5 61.5 32.1 5.9 17.1 22.5 26.9 33.8 1.5 1.3 3.9

1 115 60 11

11 172 17 3

17. 21 26.1 32.1

0.76 1.7 2.4 1.6

NAb <0.001* 0.138 NAb

For means. NA: not applicable due to small sample size. Data considered statistically signicant (*) at p < 0.05.

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Table 3 Alcohol consumption and smoking habits of male and female students. Males (n = 187) N Never drink Active drinkers Frequency of drinking (portions/week) Beer Wine Heavy drinks Never smoked Smoked in the past but quit Active smokers Number of cigarettes/day (for active smokers)
a b c b,c

Females (n = 203) N 51 152


b,c

p-Valuea

32 155

17.1 82.9 2.5 4.6 1.2 1.8 1.4 1.4 60.4 2.1 37.4 15.7 8.4

25.1 74.9 1.2 1.8 1.5 1.4 1.1 1.3 71.9 8.4 19.7 13 5.9

0.223

<0.001* 0.02* 0.11 0.007* 0.21

113 4 70

146 17 40

Data considered statistically signicant (*) at p < 0.05. Data for quantitative variables are presented as mean SD. Data for qualitative variables are presented as absolute number (frequency).

weight and BMI values of males were signicantly higher (p < 0.001) than those of females. Eating habits The pattern of eating habits and other health-related behaviors were compared based on gender. There were no signicant differences between males and females regarding meal regularity, meal frequency, snack frequency or consumption of colored vegetables or fried foods. However, eating habits differed signicantly in fruits (higher in females, p < 0.05) and fast food consumption (higher in males, p < 0.001). Female students had healthier eating habits in terms of daily breakfast intake and meal frequency (p = 0.09). Male students reported having physical activity more frequently than females; however, no statistical signicance was found. Unhealthy eating patterns were observed considering that 45.4% of males and 40.2% of females reported consuming fried food. Fast food consumption occurred more than 3 times a week in 36.9% of males but only in 19.2% of females. Although the majority of males (82.4%) and females (83.2%) seemed to be equally aware of the long-term effects of dietary behaviors on health status, more female students (p < 0.05) are trying to obtain information about the nutrient value of what they consume by reading nutrient labels. Females seem to adopt different practices than males (p < 0.05) when trying to lose weight and 50.7% of the sample used quantity restriction as the rst step towards this goal. Drinking and smoking habits Alcohol consumption was not common among samples population, with only 1.6% of males and 2.0% of females reporting daily intake of alcohol. The majority of both genders reported to consume alcohol less than twice per week (Table 3). For beer and distilled alcoholic beverage intake, males reported higher consumption than females (p < 0.001 and p = 0.11, respectively), whereas females reported higher wine consumption (p = 0.02). Those who had quit smoking were mostly females. Smoking was not common in the studys sample; the majority of males (60.4%) and of females (71.9%) reported that they have never smoked (p = 0.007). The average number of cigarettes per day for active smokers was not signicantly different based on sex. Self-assessment of weight and BMI Fewer males than females (69.5% vs. 79.8%) considered themselves to be normal; more males considered themselves to be underweight (15.0% vs. 9.9% for females) or obese (13.4% vs. 8.9% for females).

Discussion The purpose of the present study was to assess the prevalence of overweight and obesity and to investigate dietary practices and healthy attitudes of medical students in northern Greece. To the knowledge of the authors, there are no published studies regarding the prevalence of overweight and obesity in students in this territory of Greece. Existing information comes from studies either from a different geographic area (Bertsias et al., 2003; Farajian et al., 2008), or from a smaller sample size (Papadaki et al., 2007; Spanos & Hankey, 2010). The present study provides an extension of previous research on university students dietary habits in Greece. Although eating habits of university students have been primarily described almost a decade ago, this is the rst time that such information has been obtained along with measured and self-described weight and height. University students, especially those living away from home, tend to develop unfavorable eating habits (Papadaki et al., 2007), showing a signicant change towards deteriorated, globalized behaviors (Steptoe et al., 2002). According to the present studys results, the prevalence of overweight and obese among students is lower than previously reported in Athens (Panagiotakos et al., 2004) and in Crete (Bertsias et al., 2003). This may be attributed to the extended knowledge during the last decade, coming from published data but also steadily announced in the media, about health-related problems associated with being overweight or obese. Moreover, medical students are thought to be better informed concerning health issues and therefore, they adopt healthier practices. High prevalence rates of overweight and obesity have also been reported in other countries (Arroyo et al., 2004; Lowry et al., 2000; Yahia et al., 2008). The prevalence of overweight and obesity in the present sample may be lower in comparison to other published studies, but it is not low according to what would be health promoting. Overweight and obesity are related to various health problems, such as diabetes, hypertension, and hypercholesterolemia (Eckel & Krauss, 1998; Must et al., 1999). Nevertheless, being overweight at the age of 20 22 years is associated with a substantial incidence of obesity by the age of 3537 years (McTigue et al., 2002). In the present study, the majority of students regularly received at least three meals per day and more than half of the sample reported consumption of vegetables and fruits at least 3 times per week; however, only one in every four males (24.2%) and females (24.6%) reported daily consumption of vegetables. Daily fruit consumption is more frequent among females (36.2%) than males (21.9%). Furthermore, a high proportion of students tended to eat breakfast daily. The above practices constitute healthy diet practices that should be encouraged. However, breakfast regularity in the present study seems to be lower than that in France, in the

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UK or in other European countries (Monneuse, Bellisle, & Koppert, 1997). No signicant difference between males and females was found for breakfast consumption (p = 0.09), although in the rest of Europe as a whole, females eat breakfast more often than do males (Monneuse et al., 1997). Skipping breakfast has been associated with lower nutritional status, with a higher risk of cardiovascular diseases (Calderon, Yu, & Jambazian, 2004) and with the possible development of obesity (Jackson et al., 1990). Furthermore, having breakfast has been associated with a reduction of dietary fat and of impulsive snacking (Schlundt, Hill, Sbrocco, Pope-Cordle, & Sharp, 1992). Daily consumption of snacks was reported to be high in males. However, the frequency of having snacks does not provide safe information about snack size; it must be noticed that students probably had a different snacking pattern according to the perception of their body size. Frequent snacking and/or consuming fried foods can adversely affect students health, given the abundance of energy dense and high-fat ingredients these foods contain (Yahia et al., 2008). In the present study, students were frequent fried food consumers (only about 1/3 of males and females reported rarely eating fried food). Males reported eating signicantly (p < 0.001) more fast food than did females, which is an eating pattern that has been associated with increased risk for developing CVD (Satia, Galanko, & Siega-Riz, 2004). Individuals tend to under-report their weights and over-report their heights (Gorber, Tremblay, Moher, & Gorber, 2007) and a similar trend was also found in the present study. According to our results concerning body gure perception, more females considered themselves to be normal and fewer females considered themselves to be underweight, as compared to males. However, no signicant difference was observed based on gender. Females were signicantly thinner and the percentage of underweight females was almost tenfold higher than that of males (5.4% vs. 0.5%). It is quite possible that some females who are underweight falsely think that they t into the normal category because female students are more likely than males to be inuenced by the media as far as a healthy and attractive weight is concerned (Malinauskas et al., 2006). In addition, females are more likely to engage in unhealthy food restriction behaviors and place higher importance on maintaining a lower ideal body weight, experiencing more stress than males about becoming obese (Pratt & Woolfenden, 2002). Inadequate dietary habits and lack of sufcient physical activity, as shown in industrialized European countries, are related to a high prevalence of overweight and obesity. According to the present studys results, the majority of male and female students were classied into the normal BMI group. However, the prevalence of overweight and obesity, even though lower than that reported in published data, remains high and could lead to adverse mid- and long-term health effects. Universities and, especially, medical schools represent a great opportunity for focused nutritional education. Promoting healthy dietary and weight management practices might be of great importance when developing health education programs (Sakamaki et al., 2005). University students are thought to be a signicant proportion of the socio-economic elite of tomorrow and thus their habits and behaviors are most likely to become the norm (Monneuse et al., 1997). Health educators should promote education and intervention strategies that encourage improved competence in the area of nutrition for healthier dietary behaviors and healthy weight management. Furthermore, it is necessary to target young age groups because the prevalence of overweight and obesity is increasing in youth populations around the world. References
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