Assessment of food consumption, smoking, alcohol use, and physical activity by sex and major of study among a sample of college students in Jordan

This study aimed to assess the food frequency and health-related risk behaviors based on gender and major of study (health and non-health majors) in a sample of undergraduate university students. A cross-sectional study was conducted among 708 undergraduate university students (37.4% males; 62.6% females) with a mean age of 20.88(SD = 2.20), ranging from 18 to 37 years from five universities. A self-reported questionnaire was administered in the university classrooms to collect data. Results showed that 47.3% of students reported consuming fruits and vegetables (38.1%), and 54% reported consuming unhealthy foods at least once in the preceding 24 h. About 16% of the students were cigarette smokers, 17% were waterpipe smokers, and slightly more than 4% were alcohol consumers. Significant associations were found between the participants based on their sexes, and study majors (P < 0.001). Male students smoked and consumed alcohol at significantly higher rates than female students. As with regards to the physical activity in the preceding week, students had not carried out any stretching activities (52.8%), strengthening activities (62.4%), cycling (35%), or taken part in any physical activity classes (68.4%). The rates of physical activity were significantly higher among male students than female students (p < 0.001). The results showed that non-health major students differ from those in health majors in the consumption of cigarettes (p < 0.001) and waterpipe smoking (p = 0.027). Students in non-health majors were more likely than students in health majors to have carried out stretching activities (p = 0.021) and participated in physical activity classes (p = 0.02). Our findings highlighted the importance of identifying health-related risk behaviors among university students to develop a health-promoting intervention tailored to a specific group of students considering their sex and study majors.


Introduction
Health-risk behaviors such as smoking, alcohol use, physical inactivity, and low fruit and vegetable consumption are prevalent in adolescence and early adulthood, constituting most university student population [1]. Health-risk behaviors are activities carried out by persons with a recurrence or intensity that increase the risk of injury or disease [2]. study's nature, purpose, potential risks, and procedures. Completed questionnaires were put in an envelope and were collected by the principal investigators (PIs) in the classroom.

Instruments
The Arabic version of the self-report questionnaire developed by Salameh et al. [37]. was used to collect data from the students. This instrument comprises four different sections.

Sociodemographic information
This section consists of five items on gender, major of study (healthcare-related or non-healthcare-related), marital status, level of study, and type of university (i.e., public or private).

Food consumption in the last 24 h
This section contains seven items asking respondents to report the frequency with which they consumed seven food items (fruit, fruit juice, green salad, cooked vegetables, burger and sausage, French fries or potato chips, and cookies or cake) the previous 24 h. Items are measured on a three-point scale (i.e., No, Yes, once, and Yes, twice or more).

PhysicalActivity and sedentary behaviors
This section includes fourteen items that assess sedentary and physical activity. The first and second questions asked students whether they participate in sports (yes/no) and how many times per week. The second section (which included eight activities such as watching television, computer use, studying/school or work, quiet activities, walking, and riding public transportation) asked students to indicate how many hours per day they did any of the listed activities. These activities were graded on a three-point scale: 1 (less than 1 h), 2 (1-2 h), and 3 (more than 2 h). Question nine asked students to estimate how many hours they sleep per day. There are three options: 1 (less than 7 h), 2 (7 h), and 3. (more than 7 h). In questions 10 to 14, students were asked how many times per week they did activities that made them sweat (e.g., stretching, muscle strengthening, walking, and cycling for at least 30 min). These activities were graded on a three-point scale of 1 (never), 2 (once), and 3 (more than two times).

Toxic substance consumption
This section assesses respondents' cigarette/waterpipe smoking habits and alcohol consumption. The items are scored on a threepoint scale (i.e., No, Tried but stopped, and Yes).

Analysis
The statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 25 (SPSS Inc., Chicago, IL, USA). Descriptive analyses were conducted for all study variables, including frequencies, percentages, means, and standard deviations. Independent sample t-test and the chi-square test were used to compare the groups. A p-value of <0.05 was set as the level of significance.

Characteristics of study participants
A total of 766 students were invited to participate, 708 of whom completed the questionnaire and were included in the final analysis, and 58 were excluded due to incomplete responses. Of the 708 students, 647 (91.4%) were from public universities, and 61 (8.6%) were from private universities. About 443 of the total sample were female (62.6%), 179 (25.3%) were in their first year of university, 123 (17.4%) were in their second year, 219 (30.9%) were in their third year, 187 (26.4%) were in their fourth year or above. Most of the participants (90%, n = 637) were single. The mean age was 20.88(SD = 2.20), ranging from 18 to 37. About 506 (71.5%) were majoring in subjects unrelated to healthcare (i.e., science, computer science, engineering, humanities, law, business and economics, arts, or Islamic sciences). Only 202 (28.5%) were in healthcare majors (i.e., medicine, nursing, or pharmacy) ( Table 1).

Food consumption in the last 24 h
Overall, 54.4% of the students were found to have consumed French fries or potato chips in the preceding 24 h, and 54% were found to have consumed cookies, doughnuts, pie, or cake at least once in the initial 24 h. About 52% of the students had not consumed vegetables, 48.2% had consumed green salad, and 47.3% had consumed fruit at least once in the preceding 24 h. Interestingly, 66.9% of the students indicated that they had not consumed hamburgers, hot dogs, or sausages in the initial 24 h (Table 2).
There was a significant association between students' sex and fruit consumption. Female students consumed more fruits than male students (p = 0.044) ( Table 2). However, there was no significant association in food consumption based on study major (i.e., health vs. non-health) ( Table 3). Table 4 displays the consumption of toxic substances among the total sample based on gender. Overall, 15.5% of the students were cigarette smokers, 16.7% were waterpipe smokers, and only 4.4% were alcohol consumers. The mean age at which the participants had started consuming toxic substances was 16.63(SD = 2.48) years for cigarette smoking, 17.64(SD=1.87) years for waterpipe smoking, and 18.03(SD = 1.49) for alcohol consumption.

Physical activity and sedentary behaviors
Regarding physical activity, 58.2% of the students reported practicing sports, 15.0% doing sports regularly, 16.7% walking for more than 2 h per day, and 13.4% carrying out moderate activities for more than 2 h per day. Among the participating students, 9% reported spending more than 2 h watching television, 19.9% using the computer, 29.2% studying, and 19.1% commuting.

Table 2
Association of sex on food consumption among a sample of college students in Jordan. Food  Approximately 26.6% of the participants reported getting less than 7 h of sleep per night. As with regards to the participants' sedentary behaviors in the preceding week, 52.8% of the students had not carried out any stretching activities, 62.4% had not carried out any strengthening activities, 35% had not done any cycling, and 68.4% had not taken part in any physical activity classes (Table 6). In comparison to female students, male students were more likely to engage in sports activities (73.2% vs. 49.2%, p < 0.001), sweat due to physical activity (37.0% vs. 26.2%, p = 0.001), and carry out stretching exercises (24.9% vs. 10.2%, p < 0.001) in the preceding week. Male students were more likely than female students to spend more than 2 h in transportation (25.3% vs. 15.3%, p = 0.003) and walk for more than 2 h per day (20.4% vs. 14.4%, p = 0.008). However, female students were more likely than male students to spend 2 h or less per day watching television (28.0% vs. 19.6%, p = 0.042), to spend more than 2 h per day studying (32.1% vs. 24.5%, p = 0.045), and to sleep for more than 7 h per night (40.6% vs. 27.5%, p = 0.002) ( Table 6).
Students in health majors were more likely than students in non-health majors to spend more than 2 h per day studying (44.6% vs. 23.1%, p < 0.001), to spend more than 2 h per day using the computer (25.7% vs. 17.6%, p = 0.007), and to sleep for more than 7 h per night (42.1% vs. 33.2%, p = 0.005) ( Table 7). However, students in non-health majors were more likely than students in health majors Note. *Cell entries for health and non-health major are percent for study major. a χ 2 test for independence.

Table 4
Association of sex on toxic substance consumption among a sample of college students in Jordan. to have carried out stretching activities (18.0% vs. 9.9%, p = 0 0.021). They participated in physical activity classes (20.0% vs. 11.4%, p = 0.02) more than twice in the preceding week (Table 7).

Discussion
This study aimed to assess university students' food consumption, physical activity, smoking, and alcohol use based on sex and major of study. Our findings showed that more than half of the participating students were found to have consumed French fries or potato chips, cookies, doughnuts, or pie or cake at least once in the preceding 24 h. This finding aligns with previous national surveys conducted among Jordanian students [38] and Lebanese students [37]. The results of this study can be explained by the availability and accessibility of fast food in and around the university environment. University students have a limited variety of nutrients because the food choices in the university environment are not usually the healthiest options, which increases the risk of weight gain and chronic diseases among students.
The present study also revealed that 48% of the students had consumed fruit and green salad at least once in the preceding 24 h. Although this may seem a high percentage for our sample, previous studies have suggested it reflects fruit and vegetable consumption frequency but not portions. Therefore, it is likely that the participating students consumed less fruit and vegetables than the nine daily servings recommended by the American College Health Association guidelines [39]. The result is consistent with a survey of 6727 American college students, which found only 8.5% reported eating five or more servings of fruit and vegetables daily [39].
Therefore, university students often consume fast food more frequently than fruit and vegetables. A study found that the most influencing fruit and vegetable intake during emerging adulthood is the favorable test preferences, availability of fruit and vegetables, and perceived time barriers to healthy eating [29]. University students often struggle with time management between the commitments of study responsibilities, work, engaging in other social activities, and the low availability of fruit and vegetables in the university environment where the students spend a lot of their time. It seems that university students do not consider having a healthy diet the main priority. They do not have the self-regularity skills required for maintaining a nutritious diet, such as controlling their shopping and preparing meals [40].
Moreover, the results of this study revealed no significant differences between students in food frequency by gender and major of study. Similar results were found by Salameh et al. [37] among students in Lebanon that the major of study is not a determinant factor in the food consumption of university students.
The transitional stage from adolescence to young adulthood can explain the insignificant differences between students by gender, in which all students share similar challenges in a new environment. This transition from school to the university creates an environment that negatively affects food consumption. The increase in academic requirements, stress, limited time management skills, the quality of the food served in the cafeteria, and changes in family support led to changes in university students' food consumption.
Regarding consuming toxic substances (cigarettes, waterpipe, and alcohol), our results indicated that 16% of the students were cigarette smokers, 17% were waterpipe smokers, and 5% were alcohol consumers. These findings are similar to those reported by previous studies [10,21,40]. Compared to cigarette smoking and alcohol consumption, water pipe smoking was highest among the students. This may be attributed to waterpipe smoking being perceived as less harmful than cigarette smoking and is socially acceptable and expected behavior [41].
In this study, the low prevalence of alcohol consumption reflects the Islamic beliefs widely adopted in Jordan. Alcohol consumption is prohibited in Islam, stigmatized, and considered socially unacceptable in Arab culture. Therefore, alcohol consumers are condemned by society [10]. However, due to the topic's sensitivity, the participants' answers regarding alcohol consumption may have been impacted by self-reporting bias.
In the current study, the prevalence of the consumption of toxic substances was higher among male students than female students. This finding corresponds with the results of many previous studies [20,21,37,42]. A survey conducted in Germany found that male university students were more likely than females to take drugs and consume alcohol. However, no gender-based differences in the rates of regular cigarette smoking were reported [43]. The results of a qualitative study indicated that society considers female smoking inappropriate and views female smokers as disreputable and out of control [44].
On the other hand, male smoking positively reflects masculinity, strictness, relaxation, and authoritativeness. Traditional middle eastern cultures view male smoking as more acceptable than female smoking [45]. Also, male students are often permitted to stay out late, have friends over when their parents are not home, and have a room where they can spend unsupervised. Spending long durations of time unsupervised increases the likelihood of toxic substance consumption among males [46]. However, the prevalence of toxic substance consumption among female students may be underestimated due to reporting bias.
The current study found cigarette and waterpipe smoking prevalence rates higher among non-health majors than among health Note. *cell entries for males and females are percent for sex. a χ 2 test for independence. b Cell entries are frequencies and percentages of all respondents.
majors. Meanwhile, no significant association between alcohol consumption and the significance of the study was identified. Previous studies have indicated that students from healthcare faculties are more likely to adopt healthy behaviors, such as avoiding toxic substance consumption, than non-healthcare faculties [28,29]. This can be explained by promoting healthy behaviors in many of the courses taught in healthcare faculties [28]. A previous national study found the prevalence rates of smoking among students from faculties of law and religious studies to be the lowest compared to those among students from other faculties [20]. Moreover, this study showed that the mean age of starting cigarette smoking was 17 years. This finding is consistent with the study among Jordanian students [20]. Another study among Jordanian students reported that the age of starting cigarette and water pipe smoking ranged from 18 to 21 years. While the average age of starting cigarettes, waterpipe, and alcohol among Lebanese university students ranged from 14.4 to 16.4 years, which is younger than that of the current study. Most smokers start smoking before 18 years of Table 7 Association of study major on physical activity and sedentary behaviors among a sample of college students in Jordan.

Behavior
Health major* n = 202 Non-Health major* n = 506 P a value age, and the initial exposure to smoking at a younger age is documented as a risk factor for heavier smokers as adults. This study revealed that 58% of the participating undergraduate students practiced sports regularly, similar to the rate reported among students in Lebanon [37]. Despite the availability of numerous options for physical activities at university, students often do not have the time to regularly participate in physical activity programs. In our study, male students reported practicing sports more frequently than females. Previous studies support this finding [37,47]. This result may be explained by the fact that females face barriers that prevent them from exercising, such as difficulty exercising in the streets and poor access to sports centers [25]. Females also have lower self-efficacy and negative beliefs about their physical abilities [48].

Limitations
There were some limitations in this study. The use of self-reported instruments is subjected to social desirability responses, which may underestimate 'students' responses to the alcohol and substance use questions. Although we have a representative sample of undergraduate students from five public and private universities, the findings' generalizability is limited to students in other Jordanian institutions. Further, approximately two-thirds of the participants (63%) were females, explaining the gender-based differences regarding health-risk behaviors. In this study, the main concern was to examine the main risk behaviors associated with increased risk of non-communicable diseases and harm students' physical and mental health. However, some other risk behaviors are important to identify in future research. In our analysis, gender and study majors were used as covariates; other socio-demographic variables may be necessary for determining group differences.

Conclusion
Our findings revealed several patterns of health-risk behaviors among undergraduate students in Jordan. Specifically, most students were likely to engage in health risk behaviors, such as inadequate fruit and vegetable consumption, insufficient physical activity, smoking, water pipe, and alcohol use. There were significant differences between students based on their gender and study majors in how they engaged in health-related risk behaviors. Specifically, male students and students from non-health majors were more likely to engage in health-related risk behaviors. Our findings highlight the need for strengthening health services targeting health-promoting and protective behaviors and preventing health-risk behaviors among university students. More campus health promotion initiatives and programs are needed to target smoking, alcohol use, food consumption, and physical activity. The distinction between students in adopting health-related risk behaviors calls for tailored interventions considering students' gender and their study majors. Integrating health-promoting behaviors and health-related risk behaviors into the curriculum for undergraduate students, particularly those majoring in health-related fields is important.

Author contribution statement
Nahla Al Ali: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.
Fatima Khazaaleh: Conceived and designed the experiments; Performed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Data availability statement
Data will be made available on request.