Promotion of Healthy Habits in University Students: Literature Review

The increase in responsibilities, together with the multiple challenges that students face in the university period, has a direct impact on their healthy lifestyles. This literature review describes the benefits of promoting healthy habits in college, highlighting the fundamental role of prevention and promotion. A systematic review was carried out following the PRISMA recommendations, searching for information in the WOS and Scopus databases. On the other hand, a search was carried out within the existing and available grey literature. The review focused on finding information about physical activity, nutrition, and stress (with an emphasis on resilience and academic burnout) in university students. This bibliographic review includes 32 articles and six web pages, containing information on the benefits of physical activity, healthy habits, and health prevention. The information collected in this study shows that university students are exposed to multiple changes during this period, increasing as the academic years progress. At that time, their habits worsen, with low adherence to the Mediterranean diet, low physical activity, and high levels of stress, specifically increasing cases of academic burnout. The establishment of healthy habits during the university period is necessary, observing an improvement in all the variables studied. Prevention has played a fundamental role.


Introduction
The objective of this literature review is to describe the benefits of promoting healthy habits at university, highlighting the fundamental role of prevention and anticipating the creation of routines that avoid the acquisition of unhealthy habits.
The information collected in this study shows that the increased responsibilities and multiple challenges faced by university students can affect healthy lifestyles, this being a key moment for adherence to healthy routines and habits that will remain in the future [1].
This literature review contains information on the benefits of physical activity, healthy habits, and health prevention.
In this context, this article has focused on three main aspects: physical activity, nutrition, and stress, including burnout and resilience.
Physical activity is essential for health, preventing numerous diseases and contributing to improved quality of life through multiple benefits at different levels, including psychological and physiological [2].Physically inactive students have been shown to exhibit low intrinsic motivation, difficulty in emotion regulation, and alterations in certain dimensions of health-related quality of life [3].However, participation in sports activities promotes social support and well-being [1].Improved healthy lifestyle habits and increased physical activity have been observed with "reward" applications in students [4,5].They are usually measured with two questionnaires with proven validity in university students: PAQ-AD and IPAQ-SF.
Eating habits during the university period undergo significant variations, decreasing the quality of the diet [6].To assess the nutritional status of students, the KIDMED test was used, which measures the quality index of adherence to the Mediterranean diet [7][8][9][10], this being the dietary pattern to be implemented in students, since poor diet predisposes them to situations of obesity and the possible onset of diseases in adulthood [11,12].
The main interventions in this group: promotion of healthy foods in the main meals, together with daily physical activity.According to research by Cuberos et al., 2018 [13], those students with greater intrinsic motivation toward sports practice report healthier habits, so creating motivational climates in this area in the university community may be a fundamental strategy.González-Valero et al., 2009 [11] affirms that this motivational climate plays a fundamental role in physical activity, closely related to greater adherence to the Mediterranean diet.On the other hand, again guided by the research conducted by Cuberos et al., 2018 [13], a certain relationship of stress with nutritional problems has been observed, relating high levels of stress to a worse state of health, with less activity and worse diet quality, stress being another fundamental aspect to be addressed to avoid harmful habits.
Agah et al., 2021 [14], and Ozturk and Tezel, 2021 [15], show us in their research that university students face multiple stressors that can alter their mental health.This stress is especially intensified in the first year of university; specifically, the most stressful time is generated by the examination period [14,15].
Mental health problems in university students are very prevalent, as reported in their research Porru et al., 2021 [16], the association between "effort-reward imbalance" and "overcommitment" being important, as both are directly involved in the psychological distress of university students.The most prominent interventions to optimize academic performance and manage stress in university students are found in the research of Shinde et al., 2021 [17], on mindfulness training; and the research of Ozturk and Tezel, 2021 [15], on laughter yoga, observing that this discipline improves cortisol and stress levels in university students.
In direct relation to stress, we highlight two concepts: resilience and burnout.The first concept, resilience, is defined as healthy integration and adaptation over time in response to adversity and challenges [18].Some college students lack the necessary skills to cope positively with the crises inherent to the college stage [19].For this reason, mental resilience is key to student well-being and performance, and its measurement is important to support mental health and well-being [18,20].
To measure resilience, we have the resilience scale 14 [21], although there are also studies that endorse the resilience scale-10 in university students, self-determination and adaptability being the two key points considered as valid measures in this group in particular [19].
The proactive factors of resilience show perceived self-efficacy and the capacity for adaptive change, while reactive factors are associated with uncertainty, trauma, and enduring change experiences [22].
The second concept we highlight related to stress is burnout, recognized by the World Health Organization (WHO) as an occupational disease in May 2019.In the International Classification of Diseases ICD-11 of 2022, it includes this syndrome as a problem associated with employment or unemployment [23].Burnout has traditionally been associated with work, but in recent years it has been shown that this syndrome is also increasing in academia, specifically in university students [24].The number of studies is still scarce, which highlights the need for research in this group for a better understanding of this profile [25][26][27].To measure academic burnout in university students, the use of the MBI-SS questionnaire is considered appropriate [24,25,[28][29][30][31][32].
The use of the MBI-SS questionnaire reveals a high percentage of students with burnout symptoms [28], and signs of depressive symptoms were even observed in some of them, establishing a relationship between burnout and risk of depression [25,31].
Burnout in students has both individual and environmental explanations, and its prevention would require both organizational and individual interventions [25].As for its associated factors, it has been observed that the frequent use of stimulant substances, together with alcohol and tobacco, increases the risk of burnout [27].
The design of academic burnout prevention programs in university students, with interventions focused on pedagogical and psychological support, is considered fundamental [27,32].It has been observed that intervention based on the promotion of healthy lifestyle habits, focused on physical activity together with relaxation techniques, reduces stress.All activities related to mindfulness, such as yoga, are beneficial.A correct adherence to the Mediterranean diet and the exclusion of negative habits such as the consumption of alcohol and stimulant substances are also beneficial.It is essential to focus on primary prevention, avoiding high levels of stress, promoting healthy lifestyles, and recommending the reduction in triggering risk factors [33][34][35][36].

Materials and Methods
This review was based on the PRISMA methodology [37].

Review Questions
• What healthy habits are necessary to promote in university students?
• What are the benefits of establishing healthy habits during college?

Eligibility Criteria
In order to guide the information search process, the PICO strategy [38] was used:

•
Intervention: promoting healthy habits in university students.

•
Comparison: studies showing improvements in students with habit change.

•
O/Results: benefits of establishing healthy habits in a permanent way during the university period.

Sources of Information
In order to obtain the information, two search strategies were used: on the one hand, a search was carried out in the WOS and Scopus databases.
In relation to the consulted grey literature, specifically the website of the Ministry of Health and Consumer Affairs, the section on citizen-health promotion and prevention-benefits of physical activity was explored.The other web pages consulted addressed healthy habits: minervamedica.it and eu-osha.eu.In addition, pages related to health prevention were reviewed: prevention of occupational hazards-prlceoe.es(Ministry of Labor, Migration and Social Security), discapnet.es(prevention of occupational hazards), and dirdascalia.es(burnout as an occupational disease) [39][40][41].

Search
In order to focus the search for information in relation to the subject of the review, different key words were chosen according to the variables studied, having in common: "university student" and "intervention".
To develop the search strategy, controlled language was used through Health Sciences Descriptors (DeCs), subsequently combining them with the Boolean operators "AND" and/or "OR".Table 1 shows the database search strategy.

Data Extraction Process
The inclusion criteria were as follows: • All studies were conducted between 2007 and 2023.
• The studies were in Spanish or English.
• The studies focused on university students.
The exclusion criteria were as follows:

•
Duplicates. • All studies that had a direct relationship or some kind of link to the COVID-19 pan- demic.All studies related to the COVID-19 pandemic were discarded because all students' habits and stress levels were altered at that time.The entire population, including university students, was exposed to previously unknown levels of stress and our routine was affected, so studies related to that event were not representative for this review.

Selection of Studies
In order to assess the quality of the selected articles, they were analyzed by means of a series of checklists developed by the Joanna Briggs Institute (JBI) [42][43][44][45].
In the present work, we made use of checklists created for the evaluation of articles with experimental and quasi-experimental design, cross-sectional studies, prospective studies, research articles, randomized controlled trials, and systematic reviews [46].
The articles were selected following the word frequency queries, highlighting the following: physical activity, nutrition, university students, and academic burnout.
As for coding, we were also guided by the following keywords: physical activity, nutrition, university students, and academic burnout.

Item Management
Mendeley was used as a bibliographic manager in order to organize the selected articles, allowing for the elimination of all duplicate studies, being used at the same time for the writing of citations and bibliographic references.

Results
With the search criteria indicated above, we found 82 articles and 12 web pages.Following the inclusion and exclusion criteria explained above, the final result was 32 articles and six web pages.

Discussion
In this literature review, a total of 32 articles were selected in order to describe the benefits of promoting healthy lifestyle habits to university students.
As reflected by Boone et al. (2021) [1], in their study conducted at a US University, increased stress is a natural component expected in college life, with participation in extracurricular activities being a means to enhance the students' well-being by promoting social support, considering this as an important form of stress prevention.
The results show that students who have a higher intrinsic motivation to participate in sports and perceive a climate of involvement in the task report healthier habits.This highlights the importance of creating motivational climates related to physical activity [11].As referenced by Faílde-Garrido et al. (2021) [3], physically inactive students show Based on the information on authorship, research design, objectives, intervention performed, results, date of publication, country, and journal, the summary of the documents included in the review are shown in Table 2.
According to the typology of the resources obtained through the bibliographic search carried out with the criteria explained above, the studies found were cross-sectional studies, prospective studies, randomized controlled trials, and systematic reviews.
Table 2. Presentation of selected documents.Summary of the documents included in the review, highlighting information on authorship, year, journal, and country of publication, as well as the main objectives, the intervention carried out, the results of interest, the research design, the researchers, quality and main prevention guidelines extracted by the study variables.[8].

Variable
Behavioral Sciences.Switzerland.
To show whether there are differences between Mediterranean diet and physical activity in university students in Romania and Spain using KIDMED and PAQ-A.
The study was conducted on a sample of 567 participants, 147 students from Romania, and 427 students from Spain.The KIDMED questionnaire and the PAQ-A questionnaire were used.
It was determined that there are no differences between adherence to the Mediterranean diet and the level of physical activity between the two countries.The objectives of this study were to assess burnout using the MBI-SS, identify factors that may predict burnout, and evaluate the effectiveness of wellness initiatives to reduce burnout in college students.

Cross
The MBI-SS was administered to all US undergraduate medical students.Factor analysis and internal consistency of the MBI-SS were evaluated.Mean MSBI-SS subscale scores were calculated for burnout, cynicism, emotional exhaustion, and academic efficacy.
Burnout in medical students was validated using the MBI-SS.
After a complete reading of all the documents, the information contained in them was grouped according to the study variables initially identified, which were as follows: Physical activity: The selected studies indicate that a lack of physical activity hinders the regulation of emotions and affects the quality of life, thus being essential for health, preventing diseases, and obtaining benefits at psychological and physiological levels while able to measure them by means of the questionnaires PAQ-AD and IPAQ-SF [1,[3][4][5]47].Physical activity is the fundamental pillar of stress prevention in university students, promoting coping strategies and improvements at multiple levels.
Nutrition: It has been shown that, during the university period, eating habits undergo significant variations after assessment of nutritional status, highlighting the need to promote the Mediterranean diet, to avoid obesity and possible disease in adulthood.Interventions in this area focus on promoting a healthy diet together with the daily practice of physical activity.Finally, this highlights the link between poor diet and higher levels of stress [6][7][8][9][10][11][12][13].Again, stress prevention is associated with a correct adherence to the Mediterranean diet, increasing this prevention with the help of physical activity.A good connection between nutrition and physical activity favors the improvement at multiple levels of the state of university students, improving stress levels and reducing academic burnout [48].
Stress: The selected studies show the increase in stress in university students especially in the first year, facing multiple factors that alter their mental health.Mindfulness and yoga may be the main interventions to try to decrease the level of stress [14][15][16][17].

•
Resilience: A lack of skills has been observed in university students who face crises inherent to the university period in a negative way, and resilience is a key factor in the well-being and performance of students.Therefore, it is essential to measure it and for this purpose we have the Resilience Scale-14 and the Resilience Scale-10 [18][19][20]22].

•
Burnout: An increase in this pathology has been observed in university students, although the number of studies in this area is still scarce.The MBI-SS questionnaire is used for its measurement, showing a high percentage of students with burnout symptoms and even, in some of them, symptoms of depression.The design of academic burnout prevention programs is essential, with interventions focused on psychological and pedagogical support, implementation of healthy habits based on physical activity, correct adherence to the Mediterranean diet, and relaxation techniques [23][24][25][26][28][29][30][31][32][33][34][35][36]49].

Discussion
In this literature review, a total of 32 articles were selected in order to describe the benefits of promoting healthy lifestyle habits to university students.
As reflected by Boone et al. (2021) [1], in their study conducted at a US University, increased stress is a natural component expected in college life, with participation in extracurricular activities being a means to enhance the students' well-being by promoting social support, considering this as an important form of stress prevention.
The results show that students who have a higher intrinsic motivation to participate in sports and perceive a climate of involvement in the task report healthier habits.This highlights the importance of creating motivational climates related to physical activity [11].As referenced by Faílde-Garrido et al. (2021) [3], physically inactive students show lower intrinsic motivation, with worse emotional regulation and worsening in health-related quality of life.These results from this study can be useful when designing and implementing programs aimed at promoting health and physical activity, with special attention to physically inactive young populations.In this aspect, Cuberos et al. (2018) [13], in their study conducted on university students in Spain, corroborates these findings.Students who have greater intrinsic motivation to participate in sport and perceive a climate of involvement in the task, report healthier habits, coinciding with González-Valero et al. (2019) [11], who also conducted their studies on university students in Spain, re-emphasizing again the importance of creating motivational climates related to sport, considering physical activity as a healthy component and an aid to self-improvement learning as well.In this area, Lemola et al. (2021) [4], who conducted their studies in a UK University, and Reynolds et al. (2021) [5], who focused on students at a University of New Wales in Sydney, agree that mobile applications provide useful information and especially that exerciseincentive applications could increase physical activity levels.Both studies have reported satisfactory results, with improvements in adherence to physical activity through the use of incentive apps.
In all these studies focused on physical activity, satisfactory results have been reported with improvements in multiple aspects of students' lives.This can be extrapolated to an international context since, being studies carried out in different parts of the world, the results coincide.
One of the most outstanding aspects in relation to nutrition in university students is that their diet is of low quality, with an intermediate-to-low adherence to the Mediterranean diet, with several authors agreeing on the need to establish nutritional education campaigns for university students [6,9,10].This theory based on the need to establish educational campaigns makes sense when reviewing the article by Vega et al. (2014) [12], which performs an evaluation using the KIDMED questionnaire pre-and post-teaching in Spanish university students, based on health education, collecting significant variations after teaching about the Mediterranean diet.In this sense, Atencio-Osorio et al. (2020) [7] evaluated the psychometric properties of the KID-MED questionnaire in Colombian university students, demonstrating its reliability and validity.On the other hand, Badicu et al. (2018) [8] conducted a study in students from Romania and Spain using the KIDMED questionnaire and the PAQ-A, determining that students from both sites have low adherence to the Mediterranean diet and low performance in physical activity.
Another point to highlight in relation to stress in university students, as indicated by Porru et al. (2021) [16], in their study of Italian university students, is that one in three university students manifests severe psychological distress, showing the need for longitudinal studies to delve into the cause of this symptomatology and focusing on the prevention of severe psychological distress with the decrease in effort-reward imbalance and overcommitment.
As reported by Kajjimut et al. (2021) [26], who conduct their studies on university students in Africa; Dahlin and Runeson (2007) [25], in their study conducted on university students in Stockholm; Lane et al. (2020) [34], studying university students in Dublin; Merlo and Rippe (2021) [35] and Nteveros et al. (2020) [36],who focus on university students in Cyprus, university students experience some degree of burnout, which increases as the academic years progress.They agree that it is important to know the predictors of burnout and its relationship with life habits, sleep quality, and mental health, as the toxic effects of stress can affect the student's cognition, learning, and empathy.This burnout has both individual and environmental explanations, and Dahlin and Runeson (2007) [25] and Merlo and Rippe (2021) [35] agree on the importance of prevention and of addressing early signs, highlighting the importance of a model to reduce risk factors focused on primary, secondary, and tertiary prevention.Kajjimut el al (2021) [26] highlights burnout prevention based on interventionist measures, and Ntveros et al. (2020) [36] focuses prevention on improving healthy habits in general.
In this context, Shinde et al. (2021) [17], who conducted their study on students at a Midwestern university, and Ozturk and Tezel (2021) [15], show how mindfulness training and laughter yoga reduce stress and stress-related symptoms in university students considering both preventive disciplines on stress.[30] agree on the validity of the MBI-SS scale to measure burnout in university students.
In direct relation to academic burnout, the importance of resilience is highlighted, identifying the attributes of individuals who seem to cope more adaptively with stressful situations and experience better overall well-being.These results could be useful in identifying students at risk for increased vulnerability to stress and burnout, in order to provide them with appropriate resources and support [20].De la Fuente et al. (2021) [22], who conducted their study on Spanish university students, focus on resilience, positivity, and coping strategies as predictors of engagement in the context of burnout in university students, making proposals for therapeutic intervention for prevention in different student profiles, considering the work on resilience fundamental to withstand experiences of change.Jardim et al. (2021) [19], who studied Portuguese university students; and Sigley-Taylor et al. (2021) [18], who focused on Australian university students, highlight the importance of defining resilience and its implications in students.
Despite the disparity of interventions and recommendations, after analysis of the results, it was determined that academic burnout is significantly associated with resilience and optimism, highlighting the need to implement academic burnout prevention programs [32] based on health coaching, relaxation, and physical activity, together with cognitive behavioral therapy if necessary [14,33].
Likewise, prevention on burnout in university students and the importance of resilience in the occurrence of burnout can be contextualized internationally, since the reviewed studies have been conducted in multiple countries and to students from all over the world, reporting similar results.

Limitations
One of the main limitations of the present work has been the lack of studies focused on university students, mainly on academic burnout.
In this context, and given that burnout is considered an occupational disease, its scope of study is focused more on adults, and the literature focused on university students is still scarce.
It is also worth noting as a limitation the lack of studies with results focused on longterm interventions; concrete improvements have been observed but reports over several months are still to be explored.
Likewise, and continuing in the context of stress, multiple studies have been found that relate stress to the COVID-19 pandemic, which should be discarded.

Conclusions
The aim of this literature review is to describe the benefits of promoting healthy habits during the university period, highlighting the fundamental role of prevention and promotion.
The information collected in this study shows that university students are exposed to multiple changes during this period, which increase as the academic years progress.At that time, their habits worsen, with low adherence to the Mediterranean diet, low physical activity, and high levels of stress, specifically increasing cases of academic burnout.
Regarding physical activity, it has been observed that daily sport levels favor the general wellbeing of students as well as offering social support.Hence the need for interventions based on the promotion of health and physical activity in this population group, reporting satisfactory results in the design and implementation of programs aimed at promoting health and physical activity, with improvements in multiple aspects and considering it fundamental in the prevention of stress and promotion of well-being.
In relation to nutrition, university students have a low adherence to the Mediterranean diet.An improvement in this domain is observed in students having received health education in university, reporting better adherence to the Mediterranean diet, this adherence being increased when combined with greater physical activity.
High levels of stress and the appearance of academic burnout, together with resilience, improved with interventions based on physical activity, health coaching, and relaxing activities.Again, prevention is a fundamental part, and cognitive behavioral therapy models have been observed to prevent stress in college students; severe psychological distress is diminished when the effort-reward imbalance and overcommitment are controlled.Physi-cal activity improves stress and academic burnout; training programs decrease stress and improve life satisfaction.Multimodal programs focusing on relaxation, physical activity, and balneotherapy have shown short-term stress reduction.Coping mechanisms with work on resilience report positive results.
After reviewing all the literature, we can conclude by indicating that it is necessary to establish healthy habits in the university period, reporting multiple benefits with improvements in stress, favoring its reduction and achieving levels of satisfaction in multiple spheres of life, highlighting the fundamental role of prevention and promotion, helping to create routines that anticipate the establishment of harmful habits and the maintenance of healthy habits in the future.

Figure 1 .
Figure 1.Literature review flowchart PRISMA.Results.With the search criteria, we found 82 articles and 12 web pages.Following the inclusion and exclusion criteria explained above, the result was 32 articles and 6 web pages.Source: own elaboration.

Figure 1 .
Figure 1.Literature review flowchart PRISMA.Results.With the search criteria, we found 82 articles and 12 web pages.Following the inclusion and exclusion criteria explained above, the result was 32 articles and 6 web pages.Source: own elaboration.

Table 1 .
Database search strategy.