Social and Psychosocial Factors Affecting Eating Habits Among University Students in Syria: A Cross-Sectional Study


 Background: Syrian eating habits are trending towards westernized patterns that are high in carbohydrates, fats, and meat. This accompanied by an increasingly sedentary lifestyle has affected young adults’ dietary habits. As a consequence, obesity and overweight young adults are significantly increasing in prevalence. This study aims to assess the pattern of eating habits and their relation with psychosocial factors among university students. The objective of this study is to identify factors associated with eating habits and psychological factors.Methods: A cross-sectional study was conducted among Syrian Private University students using a self-administrated questionnaire. The questionnaire consisted of 3 sections: socio-demographic characteristics, eating habits, and psychosocial factors. Hierarchical multivariate linear regression was used to obtain factors associated significantly with eating habit score and psychological factors.Results: Of 728 students included in the study 398 (54.7%) were females. Overweight and obese participants represented 154 (21.4%) and 49 (6.8%) respectively. 316 (43.4%) were smokers and 135 (18.5%) drank alcohol. Only 233 (32%) and 306 (42%) had meals and breakfast regularly respectively. Participants’ mean total of eating habits was 5.96 (SD ± 1.95). Multivariate analysis revealed smoking, exercising, living with family, and “eat because of feeling happy” were factors significantly associated with eating habits score and psychological factors (p<0.05). Conclusions: Most of the students demonstrated healthy eating habits. The identified socio-demographic factors associated with eating habits can be used to provide lifestyle modification advice via health promotion programs targeted at these specific groups.

unhealthy eating habits, for example, students tend to adopt unhealthy eating patterns including skipping meals, disfavor homemade food, snack, opt for cheap quick food, and consume fast food (11)(12)(13). This raises health concerns when unhealthy habits obtained at this young period remain in later adult life (14,15). The poor eating habits acquired in university life have been attributed to stress, high workload, and tight schedules (16). Psychological factors such as bad coping strategies during stressful situations including university exams have been found to seriously damage students' eating behaviors (17,18).
Studies among medical students have highlighted inadequate eating habits and their relation to university stress (19,20). Therefore, promoting healthy eating habits across young people is essential to ensure healthy wellbeing (10). Raising awareness regarding healthy eating diets through university nutritional campaigns has been advised to prevent NCD (21, 22).
During the Syrian war, a massive downfall in the agricultural sector was recorded. Different factors contributed to this collapse. Many lands/regions/governorates had been taken from government control, and bombed, rendering them unsuitable for cultivation. The shortage of electricity, the imposed sanctions, and the destruction of infrastructure by the terrorist attacks also contributed to the collapse of Syria. All the above have resulted in the decrease of the agricultural labor force forcing local farmers to emigrate from the country. 2014 marked a reduction by 47.53% and 64.18% of wheat and olive production respectively (23). This severely affected Syrian nutritive intake where 12.4 million people are food insecure, and 1.3 million are severely food insecure (24).
While some studies have been conducted to assess eating habits and dietary intake among countries in the Middle East (19,25), only a few studies focused on the dietary intake of adolescents in Syria (26, 27).
The Syrian studies revealed bad eating habits such as skipping breakfast, binge night eating, and an inadequate intake of fruits, vegetables, meat, and dairy products (26, 27). Thus, we aimed to assess eating habits and psychological factors among students in a Syrian university. The objectives of this study are to evaluate the association of eating habits with socio-demographic characteristics and to identify factors associated with eating habits, and psychological factors among students in a Syrian university.

Methods:
Study setting, and participants: This online cross-sectional study was conducted in December 2020 using a convenience sampling method among university students of the Syrian Private University (SPU) in Damascus, Syria. Students were asked to participate voluntarily. They were informed all of their responses were recorded anonymously, response to all questions was not mandatory, and were allowed to opt-out of the survey at any time. The aims and objectives of the study were explained to students in a written form attached to the questionnaire. The sample size calculated was 357 based on a margin of error of 5%, and a con dence interval of 95%, for a population of 5,000 students using a sample size calculator. Ethical approval was obtained from the Institutional Review Board (IRB), Faculty of Medicine, Syrian Private University.

Study instruments:
A self-administered self-completed English-language validated questionnaire on eating habits was adopted from previously published studies (19,20,25). The questionnaire contained 3 sections: 1-Socio-demographic information included 10 questions on age, gender, faculty, marital status, nancial status, living circumstances, body mass index (BMI), smoking status, alcohol consumption, and exercise.
3-Psychological factors that in uence the dietary eating habits of respondents were assessed using a 6item scale. The validated compulsive eating scale (CES) was used to measure uncontrolled eating patterns among university students (28).

Statistical analysis:
Data were analyzed using the Statistical Package for Social Sciences version 25.0 (SPSS Inc., Chicago, IL, United States) and reported as frequencies and percentages (for categorical variables) or means and standard deviations (SD) (for continuous variables). The BMI was calculated as weight in kilograms divided by height in square metres (kg/m2). Students' BMI were divided into 4 groups: < 18.5 kg/m2 was categorised as underweight, 18.5 -24.9 kg/m2 was categorised as healthy weight, 25 -29.9 kg/m2 was categorised as overweight, and > 30 kg/m2 was categorised as obese. Each item of eating habits was scored (1) if the response was healthy or (0) if unhealthy. All items were summed and the total score was obtained (minimum = 0 and maximum = 10). Thus, a higher score on eating habits indicated better eating habits. The t-test was applied to compare the mean eating score against socio-demographic variables (gender, faculty, marital status, exercise, and alcohol consumption). The chi-square test was applied to assess the relationship between the mean eating score and psychological factors. One-way analysis of variance (ANOVA) was applied using f-test to compare mean eating scores against socio-demographic variables (study year, nancial status, living circumstances, BMI, and smoking status). Hierarchical multivariate linear regression was used to obtain factors associated signi cantly with eating habit score. Age, faculty, smoking, drinking alcohol, exercise, and accommodation status were entered in the rst step. In the second step, psychological factors affecting eating behavior were entered. Multicollinearity was checked between independent variables. Statistical signi cance was set at p < 0.05.
Association between eating habits and socio-demographic characteristics: The mean total score of eating habits for all participants was 5.96 ( ± 1.95), ranging between 0 and 10.
The mean eating score was compared with socio-demographic characteristics. A series of one way ANOVA analyses and t-test analysis revealed that mean eating scores differed signi cantly across the study year (p = 0.037), accommodation status (p < 0.001), practicing sport (p = 0.001), and smoking (p < 0.001). Students in the sixth year had the highest score 6.55 (± 2.24) compared with other year group mean scores, while students in the fth year had the lowest score 5.67 (± 2.08) compared with other year group mean scores (p = 0.037). Students living with their families 6.26 (± 1.89) showed a higher mean score compared to those living with friends 5.16 (± 1.73) or alone 4.81 (± 1.85) (p < 0.001). Students practicing sports >3 times/week 6.37 (± 1.93) showed higher scores than those who played sports <3 times/week 5.81 (± 1.94) (p = 0.001). Students who never smoked 6.25(± 1.86) had higher mean scores than current smokers 5.59 (± 2.02) and previous smokers 6.08 (± 1.55) (p < 0.001) ( Table 4).
Association between eating habits and psychological factors: The mean score of eating habits was compared with those who answered "yes" or "no" on psychological factors questions. No signi cant difference was found between those who ate because of feeling lonely (mean score = 5.91 ± 1.99), and those who did not (mean score = 5.99 ± 1.92) (p = 0.580).
Factors associated with eating habits in the hierarchical multiple linear regression factors: Socio-demographic variables entered in the rst step were age, faculty, smoking status, alcohol consumption, exercise, and accommodation. In the second step, psychological factors were entered: "eat because of feeling lonely", "feel out of control when eating", "eat so much until stomach hurts", "eat because of feeling upset or nervous", "eat because of feeling bored", and "eat because of feeling happy".
In the rst step non-smokers (p < 0.001), exercise (p = 0.002), and living with family (p < 0.001) were factors signi cantly associated with higher eating habits scores (Table 6). While in the second step results indicated that non-smokers (p < 0.001), exercise (p = 0.007), living with family (p < 0.001), and "eat because of feeling happy" (p = 0.014) were associated with higher eating habits score. The total model was signi cant (p < 0.001) and accounted for 13.2% of the variance (Table 7).

Discussion:
Our results revealed that only 32% of students ate regular meals daily. This is lower compared with undergraduates from China (83.6%), Lebanon (61.4%), Malaysia (57.6%), and Saudi Arabia (50.5%). The urge to change these irregular eating habits through health promotion programs is well-recommended in the literature (19,20,25).
Constant snacking is a widespread habit adopted by youth (27, 37). Meanwhile, excessive snack eating may lead to both impairment weight loss and even weight gain (38).
Our results revealed that 64.7% of students consumed vegetables at least three times a week. This nding is higher compared with Saudi Arabian medical students, where only 20.4% ate vegetables daily, but lower than Malaysian medical students (81.8%), who consumed more than three portions of vegetables a week (19,20). The majority of respondents (57.6%) consumed fruit at least three times a week, this nding is similar to Malaysia (48.5%), but higher compared with undergraduates from Saudi Arabia (11.9%) (19,20). Despite our results, a signi cant portion of students are not consuming enough vegetables and fruits. This may be due to the unaffordable expenses of buying such food when agriculture has been reduced signi cantly as a result of war (23).
Merely 31.8% of the students reported eating fast food at least three times a week. This nding is higher than a previous Syrian report where 14% of adolescents ate fast food at least four times a week (27). Fast food consumption ranged between 21.2% and 49% among undergraduates (19,20,25,32). Students choose to eat fast food due to its avor, easy access, convenience, and low price (39). making healthier meals more attainable by young people is necessary when the usual student diet is high in fat (40). Most participants (77.6%) reported eating with their family or friends more than three times a week. The result is in line with reports from Malaysia (81.8%), Saudi Arabia (78.3%), and Lebanon (76.8%) (19,20,25).
The association between eating habits score and participants socio-demographic revealed that healthier scores are high in nal year undergraduates compared with rst year undergraduates. This nding is in accordance with previously reported studies (19,25). Students living with family reported healthy eating scores compared with students living alone or with friends. Students who practice regular exercises and have never smoked scored higher than non-athletic students and smokers or ex-smokers. Saudi Arabian medical students also showed higher eating scores in students who live with their family, play sports, and never smoked (19). These results suggest that following a healthy lifestyle elicits a healthier eating behavior.
In our study, students who reported yes because they "eat until their stomach hurts" scored lower than those who did not. The nding concurred with previous studies in Saudi Arabia and Malaysia (19,20). Reports have shown that unrestrained eating habits among undergraduates indicate compulsive eating behavior (20). Furthermore, students who reported yes because they "eat when feeling happy" had higher eating habits scores. Other studies reported lower eating scores because of feeling lonely, upset or nervous, and bored among medical students (19,20). These suggest that a healthy mental state goes hand in hand with a healthy eating lifestyle.
Although social media have become part of people's lives with a signi cant impact especially on younger adults, obtaining online health information has a negative effect on attitude toward eating habits (41). Data on healthy eating diets have become scarce. This study presented many factors affecting eating habits among Syrian undergraduates. These will help understand the causes of adopting unhealthy eating habits and encourage local governments to take strict actions. Measures that must be taken include creating promotional programs on healthy eating, provide an approach to encourage the consumption of healthy, safe, and affordable foods, reduce access to consumption of calorie-dense and nutrient-poor foods, and raise awareness about the importance of healthy eating habits to prevent obesity and NCD.
Like any study, there are a few limitations to be listed. The results of this study are limited to a sample of students from just one university which may not be representative of all university students in Syria. Moreover, students attending SPU are usually of high socioeconomic standards; therefore, samples from different universities may provide a more comprehensive image of university students mulling over nancial status.

Conclusion:
Socio-demographic and psychological factors were signi cantly affected by the eating habits of the university students. Results of this study may help to create a foundation for possible interventional programs on healthy eating habits promotions across different regions. Understanding the bad eating habits may help Syrian public health authorities, university authorities, food providers, and health promotion o cers plan out the required nutritional education needed by students across Syria.

Declarations:
Ethics approval and consent to participate: This study was approved by the Institutional Review Board (IRB) at Syrian Private University. Written consent was obtained from all participants. Participation in the study was voluntary and participants were assured that there would be no victimization of anyone who did not want to participate or who decided to withdraw after giving consent.     1 Bad: income does not provide essential needs for the family. 2 Average: income provides essential needs for the family but no more. 3 Good: income provides essential needs and luxury requirements.