Assessment of Lifestyle, Eating Habits and the Effect of Nutritional Education among Undergraduate Students in Southern Italy

Background: The years spent at university represent a critical period that can influence both the quality of lifestyle and the eating habits of subsequent adulthood, and also, in the long term, the health of the individual. The aim of this study was to investigate the lifestyle of university students living away from home. Methods: Each subject recruited for the study was given a questionnaire to obtain general information, eating habits and physical activity levels before (T0) and after six month of training seminars (T1). Blood pressure, body composition and questionnaire responses were investigated. Results: The main findings of this study are a significant decrement in blood pressure; an increment in physical activity practice; an increased number of subjects who pay attention to the calorific value of food and also an improvement in BIA parameters. Conclusions: In conclusion, this study demonstrated the challenges that university students face in leading a healthy lifestyle and caring for their nutritional needs, particularly when they are away from their families. No intervention specifically targets young adults, even though much emphasis is placed on the promotion of a healthy lifestyle based on a varied and balanced diet and sufficient exercise. Our study showed that it is possible to improve lifestyle through educational events aimed at making students aware of the health risks deriving from unhealthy lifestyles.


Introduction
The "healthy lifestyle" (HL) is a way of living, characterized by a methodical approach to behavior management across various domains [1]. Although there have been significant advancements in the prevention and management of chronic diseases, it is widely acknowledged that lifestyle factors, such as smoking, eating habits, stress management, and inactivity, play a significant role in the onset and progression of many chronic diseases [2]. Although clinicians may advise behavioral modifications such weight loss, quitting smoking, and exercising or engaging in physical activity (PA), convincing patients to follow this advice can be difficult [3]. However, even when efficient pharmaceutical, behavioral, in-person social interaction and academic achievement and lead to relationship problems. Studies on smartphone use have shown that among smartphone users, 45.8% feel anxiety when they are not holding their smartphone, 27.1% spend too much time using their smartphone, and 22.6% have repeatedly attempted to reduce their smartphone use but have failed. Moreover, 21.0% of smartphone users reported difficulties with school or work due to excessive smartphone use. Further, these percentages were higher for individuals in their teens and twenties. Considering that addiction is a phenomenon characterized by tolerance, withdrawal symptoms, dependence, and social problems, the research described above suggests the concept of "smartphone addiction" [10]. In fact, data have revealed that the relationship between mobile phone addiction and numerous psychological and behavioral difficulties, including stress, anxiety and depression, might be mediated by interpersonal problems [18]. According to the interpersonal theory, people who are addicted to their mobile phones typically neglect real-world social networking, which leads to a lack of social resources and lower levels of physical activity [19]. In order to understand smartphone addiction, knowledge of risk and protective factors for such addiction is essential [20,21]. A person's risk of obesity and cardiovascular problems may increase if they engage in little physical activity [22]. On the other hand, it has been hypothesized that physical activity can be used to reduce and regulate body fat [23]. More generally, regular exercise was shown to be an efficient way to lower a variety of health risk factors, particularly those connected to metabolic syndrome and cardiovascular diseases [24]. In order to maintain a suitable level of cardio-respiratory fitness, the American Academy of Sports Medicine specifically advises people to engage in at least 150 min per week of moderate intensity cardiovascular exercise and at least 75 min per week of strenuous intensity training. Also advised is resistance exercise 2-3 days per week [25]. Human health has long been a major concern, and research in the fields of medicine, biology, psychology, education, and social and philosophical inquiry have all focused on this issue. The ability to maintain health, prevent sickness, and lead a healthy lifestyle has always been correlated with the level of social development. It takes some instructional effort during sports and health and fitness activities to help children develop the understanding and belief that health is the highest value in a person and must be consistently kept. Given that one of the objectives set by the World Health Organization by 2020 is to promote a healthy lifestyle [26] and one of the key strategies for promoting health is to adopt a healthy lifestyle, it is important to design interventions to change unhealthy lifestyles and promote the dimensions and behaviors associated with health-promoting lifestyles. One of the approaches available for educational interventions in health promotion is the intervention mapping approach. This approach evaluates and intervenes on health-related problems from a problem solving and ecological perspective. Students are a large part of their community and the social capital of that community. On the one hand, studying the promotion of students' lifestyles is effective in designing promotional interventions to promote healthy behaviors of these individuals. On the other hand, students with healthy lifestyles can become role models for other people in society [26].
Therefore, considering the situation of students who live outside their own households, and the importance that lifestyle has on health, the aim of this study was to evaluate the lifestyle and eating habits and the effect of nutritional education among undergraduate students in southern Italy.

Participant
For this study 80 subjects (age range: 18 to 28) were enrolled (in Table 1 are reported the anthropometric parameters and blood pressure values). However, the second evaluation was carried out on only 70 subjects, as 10 dropped out. All subjects were students at the University of Foggia and were recruited at ADISU Puglia (Agency for the Right to University Study) in cooperation with the Department of Clinical Experimental. All recruited subjects joined the "Lifestyle and Planet life: improving your life while saving the planet" project. To achieve this goal, a pilot study was conducted, which aimed to detect the physical activity level and lifestyle at the ADISU Residences. No exclusion criteria were applied for this investigation. Participants were provided with comprehensive information regarding the project and were assured that they were free to withdraw from the study at any time. All students provided written informed consent before the beginning of the investigation and after having had a detailed explanation of the tests. The study was approved by the Institutional Ethics Committee of the University of Foggia on 22 May 2018, no.440/DS, and conducted according to the ethical principles of the Declaration of Helsinki.

Study Design
Each subject recruited for the study was given a questionnaire (Appendix A) to obtain general information, eating habits and physical activity levels before (T0) and after (T1) six months of training seminars. The training seminars were carried out via an electronic platform. The seminars focused on the following topics: nutrition and reduction of risk factors, physical activity and correct lifestyles. However, after the sixmonth training period, the number of subjects who underwent T1 measurements dropped to 70. Using Google forms (with the possibility of multiple answers), a questionnaire was administered under the supervision of researchers involved in the investigation. The questionnaire consisted of two multiple choice questions on physical activity levels, in which students could choose whether they practiced sports and, in the event of a positive answer, they could choose weekly attendance. Moreover, blood pressure was measured in each student at T0 and T1 by a team of doctors using a manual sphygmomanometer (Sfigmomanometer Aneroide Erka Perfect). Furthermore, before (T0) and after (T1) training seminars, each student was subjected to body composition analysis using a Quantum V Segmental Bioelectrical Impedence Analyzer (A-Wave, Santeramo in Colle, Bari, Italy). The topics covered during the training seminars concerned nutritional education, the composition of foods in terms of macronutrients and micronutrients, and the beneficial effects of physical activity, especially in the prevention and treatment of non-communicable diseases, such as obesity and cardiovascular diseases. Statistical analysis was performed using GraphPad 6 Software, Inc., Boston, MA, USA, for Windows, version 6.01, Dotmatics, R&D scientific. The data are presented as mean (M) ± standard deviation (SD), and statistical significance was set at p < 0.05. The Shapiro-Wilk test was used to check the normal distribution of variables. The paired samples t-test was performed to investigate the differences between T0 and T1 if data were normally distributed and the Wilcoxon test was performed if data were not normally distributed. The chi-square test was performed to investigate differences in questionnaire answers.
The percentage of subjects who tried to lose weight increased (Question 9). In fact, it went from 51% at T0 to 60% at T1; however, no significant differences emerged (Chisquare, df = 1.640, 1; z = 1.281; p > 0.05). Regarding question number 10, the percentage of subjects who declared that they paid attention to the caloric value of food increased from 63.75% to 78.0% (Chi-square, df = 4.104, 1; z = 2.026; p < 0.05).
The percentage of subjects who tried to lose weight increased (Question 9). In fact, it went from 51% at T0 to 60% at T1; however, no significant differences emerged (Chi-square, df = 1.640, 1; z = 1.281; p > 0.05). Regarding question number 10, the percentage of subjects who declared that they paid attention to the caloric value of food increased from 63.75% to 78.0% (Chi-square, df = 4.104, 1; z = 2.026; p < 0.05).

Discussion
The main purpose of this study was to evaluate the effect and impact of a training period focused on improving lifestyles. The main findings of this study are: (1) a significant decrement in blood pressure; (2) an increment in physical activity practice; (3) an increased number of subjects who paid attention to the calorific value of food; (4) a percentage decrease in subjects who declared they consumed sweets during the week; (5) a percentage decrease in subjects who declared they consumed red meat during the week; (6) a percentage decrease in processed meat consumed per week; (7) a percentage increase in subjects who declared they consumed legumes during the week; (8) a percentage increase in fruit consumed per day; (9) an improvement in BIA parameters. Our study, in addition to providing an overview of the lifestyle of students who live away from home, seems to show the effectiveness of training events as a tool to achieve improvement in lifestyles. Finally, regarding questions 20 (vegetables consumed per day), 21 (olive oil consumed per day), 22 (cereals consumed per day), 23 (glasses of water drunk every day), 24 (glasses of wine drunk every day), 25 (salt consumed every day), 26 (snacks consumed during meals), 27 (sugar intake) and 28 (hours spent watching TV a day), the results showed no significant differences between T0 and T1.

Discussion
The main purpose of this study was to evaluate the effect and impact of a training period focused on improving lifestyles. The main findings of this study are: (1) a significant decrement in blood pressure; (2) an increment in physical activity practice; (3) an increased number of subjects who paid attention to the calorific value of food; (4) a percentage decrease in subjects who declared they consumed sweets during the week; (5) a percentage decrease in subjects who declared they consumed red meat during the week; (6) a percentage decrease in processed meat consumed per week; (7) a percentage increase in subjects who declared they consumed legumes during the week; (8) a percentage increase in fruit consumed per day; (9) an improvement in BIA parameters. Our study, in addition to providing an overview of the lifestyle of students who live away from home, seems to show the effectiveness of training events as a tool to achieve improvement in lifestyles.
The results of our study are in line with previously published results by WHO [27]. In fact, given that the 2010 Global Recommendations on Lifestyle for Health state that one in four (27.5%) adults and more than three quarters (81%) of adolescents do not meet the recommendations for physical exercise and diet [28], there is an urgent need to increase the priority and investment in services that promote a healthy lifestyle [3]. These statistics also show that gender differences are significant and that participation levels have not increased globally over the past 20 years. Inequalities in involvement by age, gender, socioeconomic level and geography are also frequently seen in national data, which highlights the urgency of increasing financial support for health [4]. For current and future generations to remain healthy throughout their lifespans, proper diet is crucial. A balanced diet lowers the risk of chronic diseases while promoting healthy growth and development. Adults who follow a healthy diet have a lower risk of obesity, heart disease, type 2 diabetes, and several malignancies. They also live longer. People with chronic diseases can control their conditions and prevent complications by eating healthfully.
When there are no healthy options, consumers could select for items that are higher in calories and less nutritious. People from low-income areas and some racial and ethnic groups frequently do not have easy access to establishments that provide inexpensive healthier foods. Consequently, it is important to encourage people of all ages to eat healthily [29]. A healthy diet, according to the WHO (2016), should, for example, include a high intake of fruits, vegetables, and whole grains, as well as a low intake of saturated fats, salt, and processed carbohydrates [30]. Given that many healthy behaviors are formed and established during the transition from adolescence to young adulthood, this time may be a crucial moment for health promotion measures, including the promotion of good eating. Furthermore, excessive weight gain has been observed among young adults, particularly university students [31][32][33]. The transition from high school to university also coincides with new living conditions, which could cause eating habits to change [34]. However, few researchers have examined potential shifts in eating habits post matriculation.
Sport was the recreational activity students engaged in the most, despite doing so less frequently than the weekly average recommended for the maintenance of good health [14], which is consistent with other studies describing a lack of regular sport activities [14] and a decline in all forms of physical activity in correlation with the start of university [15]. According to an important investigation conducted in Southern Italy [11], students who live alone spend less time engaging in sports and other leisure activities overall [35].
From a nutritional standpoint, most respondents, particularly students living away from home, acknowledged that their eating habits had altered while they were attending college. It has been emphasized in other contexts how challenging it is for students to maintain appropriate eating routines [36]. The various factors that affect people's eating choices include changes in lifestyle, the comfort and convenience of fast food, taste, their immediate physical and social environment, gender, attention to weight, and beliefs [37]. Other studies indicate that college students have adopted unhealthy eating habits, particularly with regard to low consumption of fruits and vegetables [38,39], milk and dairy products [40], fish [41], eggs, pulses [42], meat [43], sausages, and sweets [37][38][39][40].
College students from various backgrounds and with various dietary habits are affected by the difficulties of adopting a diet that complies with the Guidelines [32,37,[40][41][42].
Although many students are influenced by the shift in eating patterns, those who lived away from their families are primarily impacted [43][44][45]. University students who lived with their parents consumed significantly more fruits, vegetables, legumes, and fish than those who did not live with their parents, which may be explained by the fact that they were not directly involved in meal planning and preparation while the family offered ongoing encouragement for making healthy food choices [46]. According to other studies [36,47], students who leave their families have a diet that deviates significantly from the ideal model of the Mediterranean diet in terms of their consumption of fruits, vegetables, pulses, and fish, while also consuming more ready-made foods and fries [48,49]. This is particularly true of students who are living on their own. These young people's eating habits may be related to a variety of factors, including their first-ever complete independence [48], lack of expertise in meal planning and preparation, lack of time [49], or financial constraints that compel them to spend less on food [46].
The results of our study seem to suggest that attending university, especially away from the family, could play a role in the onset of unhealthy lifestyles, and that these could, at least in part, be modified through training events aimed at sensitizing this population during this moment of their life.

Conclusions
In conclusion, this study demonstrated the challenges that university students face in leading a healthy lifestyle and caring for their nutritional needs, particularly when they are away from their families. No intervention specifically targets young adults, even though much emphasis is placed on the promotion of a healthy lifestyle based on a varied and balanced diet and sufficient exercise.
Our study showed that it is possible to improve lifestyle through educational events aimed at making students aware of the health risks deriving from unhealthy lifestyles.
However, although our study provided important results, there are some criticisms that will need to be investigated in the future. In particular, the sample should be increased to seek gender homogeneity; moreover, students who live in families alongside those who live in university residences should be encouraged to accurately evaluate the effect of the latter. In conclusion, it can be said that it would be appropriate to provide training and support programs in universities for students to improve their lifestyle. In fact, good nutrition is essential to keeping current and future generations healthy across the lifespan. Adults who eat a healthy diet live longer and have a lower risk of obesity, heart disease, type 2 diabetes, and certain cancers. New discoveries in health research happen every day, but one clear message remains consistent: optimal nutrition is imperative to human health. Research shows that an unhealthy diet is one of the major risk factors for a range of chronic diseases, including diabetes, cancer, cardiovascular diseases, and other conditions linked to obesity. This is a study that comes from a pilot project that allowed us to obtain a statistical report on the university population of Foggia. Being a pilot project, this could be extended to other Apulian and national universities. Furthermore, because of the educational initiatives implemented during the project, improvements were highlighted both in the anthropometric parameters evaluated in the population and in the levels of physical activity, as well as through the effectiveness of the programmed training events, demonstrating that education on a healthy lifestyle and monitoring of body composition have a fundamental role in the conduct of a healthy lifestyle for the prevention of non-communicable diseases.