Background
Prevention of overweight and obesity, and its related diseases [
1], has become a worldwide challenge [
2]. According to US literature, university is a critical period for weight gain [
3‐
5]. During the transition from secondary school to university, students need to adapt to a new environment [
6,
7]. When students fail to adapt adequately this could have negative consequences towards their health behaviours and subsequent weight status [
7]. Eating behaviour (next to physical activity and sedentary behaviour) is an important factor influencing students’ weight. According to studies conducted in US universities, students were not eating the recommended amount of fruit and vegetables, and were consuming increasing amounts of high-fat foods [
8‐
10]. Furthermore, Butler et al. [
9] reported significant decreases in the amount of bread and vegetables consumed during the first year of university and significant increases in percentage fat intake and alcohol consumption in US students. Unhealthy eating and excessive alcohol consumption may contribute significantly to energy intake and may therefore facilitate student weight gain [
11]. The same pattern of weight gain in university students is emerging in Europe [
12]. However, European literature on dietary intake in university students is scarce. In a Greek study [
13] university students showed significantly higher intake of total and saturated fat and lower intake of poly and monounsaturated fat, folate, vitamin E and fibre, compared to the American Heart Association guidelines. Crombie et al. [
3] warned that these health behaviours may not only occur during the years at university but may remain throughout adulthood as well. Therefore, prevention programs countering unhealthy eating habits in university students are needed, in order to prevent an increasing prevalence of overweight and obesity in later life.
To develop effective obesity prevention strategies it is important to get insight into factors influencing eating behaviours in university students. Early theories explaining health behaviour mostly focused on the individual within its social context [
14,
15]. According to Ajzen’s Theory of Planned Behaviour [
14], behaviour can be explained through intention. These intentions are being determined by attitudes toward the behaviour, social or subjective norms and perceived behavioural control [
14]. The Social Cognitive Theory of Bandura [
15] on the other hand, focuses on the interaction between personal (self-efficacy), behavioural (expected result) and social (modelling and social support) factors to explain health behaviours such as eating behaviour. Next to these psychosocial determinants, many researchers [
16‐
18] are convinced of the uttermost importance of the environmental influence on eating behaviours. According to Brug et al. [
16] the environment has obviously changed during the last decades, whereas opportunities to eat energy-dense foods are omnipresent. Egger et al. [
17] suggested that the increasing obesogenic environment is the driving force for the increasing prevalence of obesity rather than any ‘pathology’ in metabolic defects or genetic mutations within individuals. Individuals interact in a variety of micro-environments or settings (e.g. schools, workplaces, homes, (fast food) restaurants) which, in turn, are influenced by the macro-environments or sectors (e.g. food industry, government, society’s attitudes and beliefs) [
18]. Ecological models consider the connections and the continuous interactions between people (intrapersonal) and their (sociocultural, policy and physical) environments [
19‐
21]. Based upon the latter two theories Story et al. [
19] proposed a framework including individual (intrapersonal), social (interpersonal) environmental, physical environmental and macro levels, to understand factors influencing eating behaviours.
Only few qualitative studies, using focus group discussions, have examined determinants of eating behaviour in university students. Lack of discipline and time, self-control, social support, product prices (costs) and limited budgets, and the availability of and access to (healthy) food options were reported as important influencing factors of students’ eating behaviours [
22‐
25]. All of these studies were conducted in the US and either not included students of all study disciplines [
22,
23] or did not specify students’ study backgrounds [
24,
25]. In addition, all studies included predominantly freshman students. However, including students of all study disciplines as well as students with more university experience (i.e. older students) could contribute to a wider range of experiences and opinions. Furthermore, no previous studies have included questions asking for recommendations towards intervention strategies aiming to improve healthy eating behaviours in university students. To the best of our knowledge, no European (qualitative or quantitative) studies on determinants of eating behaviour in university students have been conducted so far. Many differences in lifestyle, environment and culture (e.g. fast food culture) can be observed between North-American and European students. Continental differences as such might not only influence students’ eating behaviour but also the enablers and barriers to engage in healthy eating practices. Hence, there is a need for European studies investigating determinants of eating behaviour in university students. Therefore, the purpose of this study was to explore which factors influence Belgian (European) university students’ eating (incl. drinking) behaviour, using a qualitative research design. Furthermore, we aimed to collect ideas and recommendations in order to facilitate the development of effective and tailored intervention programs aiming to improve healthy eating (incl. drinking) behaviours in university students.
Discussion
The purpose of this explorative study was to identify determinants of eating (incl. drinking) behaviours in Belgian (European) university students. Furthermore, we aimed to collect ideas and recommendations in order to facilitate the development of effective and tailored intervention programs aiming to improve healthy eating (incl. drinking) behaviours in university students. Similar to Story’s framework [
19] combining Bandura’s Social Cognitive Theory [
15] with Sallis’ ecological model [
21] explaining health behaviour, we identified four major levels of determinants: individual (intrapersonal), social environment (interpersonal), physical environment (community settings) and macro environment (societal). Furthermore, some university specific characteristics were found to be influencing students’ eating behaviours as well.
Similar to US literature [
22‐
25], many self-regulatory processes, including intrinsic (e.g. food preferences) and extrinsic (e.g. health awareness, guilt) motivations, self-discipline, self-control, time management, etc. have been mentioned by our participants to be influencing eating behaviour in university students. Our results further indicate that these latter determinants become more important after the transition from secondary school to university when independency subsequently increases. In a qualitative study of Cluskey et al. [
25], university students who reported greater independency and more responsibility for food and meal preparation prior to college, felt to have achieved more stability in their eating behaviours at college. Therefore, LaCaille et al. [
23] suggested that future interventions should aim at strengthening students’ self-regulation skills around eating as part of the overall transition to university or college. Such self-regulation and self-management skills can help students to make more healthy decisions and to maintain a healthful lifestyle throughout adulthood [
24]. Moreover, the systematic review of Kelly et al. [
29] evaluating the effectiveness of dietary interventions in college students suggested that approaches involving self-regulation strategies have the potential to facilitate changes in students’ dietary intake.
Although in the study of Cluskey et al. [
25] US students most agreed that intrinsic motivation was needed for successful changes in healthful behaviour, our results indicate that the environment should be organised as such, ‘forcing’ students to make healthful food choices. Students’ food choices are influenced by the availability and accessibility of healthy foods and cooking supplies [
22]. Therefore, our participants suggested that offering more healthy menus in the student restaurant as well as providing campus vending machines with more healthy products could contribute to making more healthful food choices. It has been shown that food availability and accessibility of fruits and vegetables is strongly and positively related to fruit and vegetable consumption in children [
30]. In addition, students in the current study mentioned that the appeal of (on-campus) foods often determines food choices. This suggests that making healthy products offered around campus more appealing might contribute to more healthy eating behaviours in university students.
Students in the current study believed they are continuously challenged by competing demands, including academic responsibilities and involvement in extracurricular and social activities. As mentioned by Nelson et al. [
24], healthy food choices may become low priorities when compared to other commitments. Therefore, as described by our participants, students might be more likely to buy foods that are fast, convenient and inexpensive. Marquis et al. [
31] showed that college students often prioritize cost and convenience over health. Moreover, previous studies found that price is one of the most influential individual factors (next to taste) in determining food choice in both adults and adolescents [
32‐
36]. In our study, participants felt that offering more healthy (on campus) foods at a lower cost would contribute to more healthful food choices. Intervention studies in other populations have shown that price reductions increase purchases of lower-fat products and fruits and vegetables in cafeterias, workplaces and school vending machines [
34,
36]. Given the importance of price in university students’ food choices, this might even be a more effective strategy in this population.
Similar to previous research in adolescents [
37], participants felt that perceived benefits (e.g. improving health status, higher vitality) of healthful eating behaviour can influence food choices as well. Students also believed that dietary knowledge should be a first step towards the awareness on healthy eating behaviour. Cluskey et al. [
25] mentioned that university students lack the knowledge and skills to make healthful food choices as well as to prepare healthy foods, which makes it difficult to adapt healthfully to college or university life. It was suggested by our participants that all students should be given a health education class.
In this study, students mentioned that parents and household influence their food intake. A review study on environmental influences on food choices [
38] indicated that adolescents’ dietary intake is being influenced by their family members. Parents serve as models for eating behaviour and transmit dietary attitudes throughout the upbringing of their offspring [
38]. The latter suggests that especially university students living with their parents might experience similar parental influences. Besides family influences, our participants believed that friends and peers influence their eating behaviour as well. Contento et al. [
39] reported that attitudes, encouragement, and behaviours of friends and peers influenced adolescents’ food choices. In a natural experiment assessing peer effects on weight, it was shown that the amount of weight gained during the freshman year was strongly and negatively correlated to the roommate’s initial weight [
40], suggesting that peers are influenced by each other’s eating behaviours.
Living arrangements (residency) and exams were mentioned to be influencing students’ eating behaviours. It has been shown that living arrangements can affect university students’ dietary intake [
41‐
43]. In a study in four European countries students living at parental home consumed more fruit and vegetables than those who resided outside of their family home [
43]. In addition, in a natural experiment, Kapinos et al. [
44] showed that students assigned to dormitories with on-site dining halls gained more weight and exhibited more behaviours consistent with weight gain (e.g. males consumed more meals and snacks) during the freshman year as compared with students not assigned to such dormitories. Living arrangements might be moderating the relation between eating behaviour and its determinants rather than causing eating behaviour as such. According to MacKinnon [
45], a moderator affects the strength of the relation between two variables. E.g. living in a student residence may moderate the relation between parental influence and eating behaviour, i.e. parental control will decrease when students live away from home. Results of the current study suggest that the relation between parental control and eating behaviour might be stronger in students living at home compared to those living away from home. Also, when living in a student residence (and receiving a weekly based allowance) our results revealed that food prices become more important when making food choices, i.e. students have to pay attention to ‘what’ they buy. Thus, a stronger relationship between food prices and eating behaviour might be observed when students live away from home in comparison to those living with their parents. Exams can have a similar moderating effect on the relation between e.g. time and eating behaviour. Our results show that during exam periods students will spend as little time as possible on cooking.
When comparing with the limited US literature, it should be noticed that, despite similarities between this study and other US studies (e.g. lack of time, unorganised living), some determinants can be region or culture-specific. For example, students in the present study referred to the abundant availability of fast food and one-dollar-menus in the US, in comparison to Europe. Focus group discussions with US university students pointed out that all-you-can-eat formulas of on-campus dining facilities had a negative impact on their healthy eating behaviours [
23,
25]. In contrast to US universities our universities do not dispose of all-you-can-eat dining possibilities. Furthermore, unlike US colleges/universities, Belgian universities do not have on-campus dormitory dining halls where campus meal plans for students are provided.
Our results also indicate that what may be a barrier for one student may be perceived as an enabler by another. For example, with regard to the physical campus environment, some students felt that the student restaurant was a barrier to healthful eating behaviour, whereas others believed it enabled students to make healthy food choices. Therefore, with regard to future intervention programs, we should modify perceptions of physical environment as well, rather than the objective environment on its own.
Furthermore, our results indicate that physical and social environments are continuously interacting with self-regulatory processes and thus individual eating behaviours. It could be that a certain stimulation at the individual level might not be changing one’s eating behaviour when acting in a non-beneficial social and/or physical environment, and vice versa. Therefore, intervention strategies based on multilevel approaches may be most effective [
21].
This qualitative research methodology, using focus groups, is an important strength of this explorative study. As Sallis et al. [
46] suggested, qualitative research allows us to understand not only the ‘what’ but also the ‘how’ and ‘why’. Using an inductive thematic methodology allowed the research team to construct a student-specific framework. Furthermore, in contrast to in-depth interviews, the more ‘naturalistic’ approach (i.e. closer to everyday conversation), including dynamic group interaction [
28], allowed us to get better insight into the mechanisms behind university students’ eating behaviours. On the other hand, some participants might have been intimidated by the group setting which might have limited a greater sharing of their thoughts.
A first limitation of this study is that we used student volunteers. We have to take into account that participants were probably interested in this topic, which might have resulted in a selection bias. However, sample characteristics showed sufficient variety in BMI and perceived health status. Secondly, whereas we might expect differences in behaviours according to gender [
47] or year in school, we chose to use mixed-gender focus groups including students of different study years and disciplines, allowing us to create interaction between both genders with a variety of study experience and backgrounds, which in turn generated a greater diversity in opinion within each focus group. Thirdly, focus groups were conducted at one university, which has a campus outside the city centre. Because of university specific environmental differences (e.g. size, structure, region, etc.), the applicability of the study’s findings to other student populations is limited to the psychosocial level, whereas future studies should further explore the physical environmental issues within a variety of other Belgian or European universities. Finally, because of the abovementioned setting limitation and the explorative nature of this study no conclusions can be drawn concerning the importance of each determinant and the generalizability of our results. The purpose of using focus groups is to generate a rich understanding of participants’ experiences and beliefs [
48,
49] and not to generalize results [
50]. In addition, no quantification was used because numbers and percentages convey the impression that results can be projected to a population, and this is not within the capabilities of qualitative research [
50]. Also, the issue raised most frequently is not necessarily the most important, even when it is raised by a larger number of people [
50]. In other words, each idea or opinion should be equally appreciated. Therefore, future studies, using a larger representative sample size, should focus on providing quantitative evidence regarding the importance and value of each determinant, making it also possible to differentiate according to gender, year in school, study discipline, or other student characteristics. Subsequently, future tailored interventions could focus on those factors students experience as most determinative in their current eating behaviour.
Conclusions
To the best of our knowledge, this is the first European study examining perceived determinants of eating (incl. drinking) behaviour in university students and collecting ideas and recommendations in order to facilitate the development of effective and tailored intervention programs aiming to improve healthy eating (and drinking) behaviours in university students. An ecological framework of determinants of university students’ eating behaviour was developed. Students were found to be influenced by individual factors, their social networks, physical environment, and macro environment. Furthermore, the relationships between determinants and university students’ eating behaviour seemed to be moderated by university characteristics, such as residency, student societies, university lifestyle and exams. After the transition from secondary school to university, when independency increases, students are continuously challenged to make healthful food choices. They have to be self-disciplined, have self-control and thus often have to prioritize healthy eating over other (university specific) social activities in order to prepare a healthy meal. In addition, students have to make these healthful food choices within a university specific setting (e.g. living in a student residence, having exams), depending on the availability and accessibility, appeal and prices of food products. Moreover, during this choice making process, students are either controlled or lacking control by their parents as well as influenced by friends and peers. Recommendations for university administrators and researchers include providing information and advice to enhance healthy food choices and preparation (e.g. via social media), enhancing self-discipline and self-control, developing time management skills, enhancing social support, and modifying the subjective as well as the objective campus food environment by e.g. making healthy foods price-beneficial and by providing vending machines with more healthy products. Our results should be considered a first step into the development of tailored and effective intervention programs aiming to improve university students’ eating behaviours.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
TD participated in the design of the study, collected all data, performed the data analyses and drafted the manuscript. IDB participated in the design of the study and revised the manuscript critically. PC and BD participated in the design of the study, contributed to the interpretation of data and revised the manuscript critically. All authors read and approved the final manuscript.