European Journal of Cardiovascular Medicine

A balanced diet and an active body and mind are two sides of the same coin called ‘the pink of life’. In today’s fast paced world staying healthy and fit seems to be a herculean task.  According to the World Health Organization, about 11% of men and 15% of women were obese in 2016 and obesity has nearly tripled over the past 45 years ^[1]. In 2015 WHO concluded that the fourth leading risk factor for global mortality (6%) was physical inactivity, of which 5% deaths was due to overweight and obesity ^[2]. Unhealthy dietary patterns, decreased meal frequency and skipping meals are observed more commonly in adolescents ^[3]. Consumption of fried and processed foods, fast foods, sedentary lifestyle, stress, smoking and alcohol may contribute to the development of chronic diseases like cardiovascular diseases, Type 2 diabetes, Metabolic Syndrome and Cancer later in life. Overweight and obesity is also related to poor academic performance, depression, body image dissatisfaction and intake of pills to reduce weight loss ^[4][5]. Physical inactivity attributes to a dramatic rise in the prevalence of many chronic diseases ^[2][6]. Though in most cases they manifest in adulthood, its antecedent risk factors begin early in life ^[7]. In fact, diet and lifestyle modification with intake of fresh fruits and vegetables brings about favorable changes and reduces the risk of many chronic diseases ^[8][9]. Apart from overweight and obesity, underweight is also a matter of concern. Weight misperception is noted among underweight undergraduate students ^[10]. There is inadequate information about the prevalence of underweight among undergraduate medical students.

Many Medical college students were found to follow unhealthy dietary and exercise patterns and many skipped breakfast ^[11]. Lack of time was the most common barrier cited by most students for not following a healthy lifestyle ^[12]. In a questionnaire-based survey among 100 college students in Tamil Nadu, it was found that 57.4% male and 72.7% female students were not aware about the risk factors for obesity ^[13]. However, this survey was not conducted among medical students. A survey in United States reported overweight and obesity to be 25% and 6% respectively. But this study did not find the prevalence of underweight ^[12]. In the United Kingdom, a questionnaire-based study among 268 first year university students revealed weight gain in 55% of students ^14]. A study in Gujarat showed a higher prevalence of obesity of 25.6% ^[15]. In Andhra Pradesh, a study was conducted among 613 medical students to identify the overweight and obese individuals. But this study failed to identify the barriers that prevent a healthy lifestyle ^[16]. Though medical students have a sound knowledge, their lack of application pertaining to their own health is evident through a survey conducted in Karachi, Pakistan ^[17]. However, college students are at a stage in life where their behavior is ‘conducive to change’ ^[18]. So healthy habits cultivated in this youthful age definitely will have a positive impact in the future. Moreover, medical students of today will become doctors of tomorrow and professionals who will be suggesting others to lead a healthy lifestyle cannot afford to miss having one.

There is inadequate information regarding the dietary and exercise patterns, BMI along with its barriers among medical students So, this study was intended to correlate the dietary and exercise habits and BMI and to identify the barriers and gender differences in two hundred undergraduate medical students in Chennai. This study might have implications for physical activity and nutrition counselling to become a part of the medical curriculum and may prevent the overweight and obese individuals from the impending risks. This research may have implications to create more awareness regarding a healthy lifestyle and probably physical education could become a part of medical curriculum, like schools in the near future.

Study design:

This study is a cross-sectional study carried out in a Tertiary health care institution in Chennai, Tamil Nadu.

Sample of the study:

A total of 200 male and female undergraduate medical students were selected. They selected candidates were between the age of 18 and 21 and consented to participate in the research program.

Sample size and sampling technique:

Two hundred UG Medical students were selected by random sampling technique. They were explained the purpose of the study.

Inclusion Criteria:

Both male and female medical students within the age group of 18-21 willing to participate were included in the study.

Exclusion Criteria:

Medical students unwilling to participate, who are sick at the time of survey and those failing to co-operate were excluded from the study.

Data Collection:

The participants were given a self-administered questionnaire comprising of 40 questions, which was divided into four sections. Section 1 consisted of questions on Demographics and Anthropometrics. Section 2 and 3 were designed to understand the dietary and exercise habits respectively. Section 4 had questions to analyze the barriers preventing a healthy lifestyle. The questionnaire was adapted from North Florida’s Survey of diet and exercise of freshman ^[19]. Prior consent for utilizing the questionnaire was obtained. A pilot study was done to a batch of 50 students before starting the research. The participants were given adequate time and the required instructions to fill in their questionnaires.

Anthropometric measurements:

The height and weight of the participants was measured in the Department of Physiology of our college. Weight was measured in standing position and with minimal clothing and height with the help of a stadiometer, both without footwear. The Body Mass Index, sometimes known as the Quetelet Index was calculated by using the standard formula of weight in kilograms divided by the square of height in meters. According to the National Institute of Health, BMI is classified as Underweight (<18), Normal (18.5-24.9), Overweight (25-29.9) or Obese (>30).

The students found to be overweight, obese and physically inactive will be encouraged to take up a sport of their choice or practice yoga and a video about exercise and its benefits will be played. The Dietician of our College will talk to them about the alternate choice of foods they can opt in order to transit to a better and a healthy lifestyle.

Statistical analysis:

The data was entered in a spreadsheet and Data analysis was carried out using Spearman’s correlation co-efficient using SPSS Software version 20. Chi square test was done to correlate the variables. The significance level was set at P<0.05       

Ethical considerations:

The approval of the research proposal was obtained by the Ethical Committee before starting the research. Informed consent was obtained from the participants and the data collected was kept confidential.

This study included 200 participants out of which, there were 61.5% female medical students. The participants belong to an age group of 18-21 (See Table 1). From the calculated BMIs it was observed that more than half the students had normal BMI (58.5%) and 7% were obese. The percentage of students being underweight and overweight was almost equal, 17.5% and 17% respectively.

Dietary Habits

On evaluating Part two of the questionnaire which had questions assessing the food habits, it was observed that more than half the students (65.5%) regularly had meals at mealtime while 3.5% answered seldom, 8.5% sometimes, 22.5% usually to the same. Breakfast was the commonly skipped meal.

When asked about how often they consumed home-cooked foods, 31% answered always, 40% usually, 16% sometimes, 12% seldom and 1% never. It was found that 30% males frequently consume fast foods compared to only 16% females (P=0.05). It was found that 18.5% always, 15% usually and 22.5% students sometimes eat more when stressed. No significance was observed between gender, BMI and eating more during stress. They were asked how often they snack more than thrice a day for which 40.5% answered sometimes, 19% usually and 15% always. About 21% overweight and obese students frequently snacked between meals (P=0.009). There is no significance between gender and snacking often and the type of snack consumed.  There is no significant consumption of alcohol or dietary supplements among the study population.

Exercise Habits

Majority of them exercised less than once per week (P=0.005). Females exercised at a lighter intensity which is equivalent to normal walking while males exercised at moderate and severe intensities (P=0.002). The exercise habits are summarized in Table 2.

*Statistically significant (P<0.05) UW- Underweight (<18); NW-Normal weight (18.5-24.9);  OW- Overweight (25-29.9);  OB- Obese (>30)

Barriers Preventing a Healthy Lifestyle

 The students were asked to rate the healthiness of eating and more than half (57%) the students circled average while 4.5%, 20%, 17% and 1.5% responded poor, fair, good and excellent respectively. They were queried about the reasons for their unhealthy lifestyle and the responses are summarized in table 3.

UW- Underweight (<18); NW-Normal weight (18.5-24.9) OW- Overweight (25-29.9); OB- Obese (>30)

 It was an optimistic response when asked if they wished to have health and wellness activities in campus (75%), health and wellness courses in general curriculum (63%) and nutritional counseling (61.5%). About half of them (47.5%) preferred having health and wellness courses as electives.

The current study has observed 58.5% to have normal BMI, 17.5% overweight, 7% obese and 17% underweight. Shrivastava et al (2013) in a survey among 138 medical students in Kanchipuram has also almost reported similar prevalence of normal BMI (57.9%) overweight and obesity (21.5%) and underweight (20.6%)^[20]. Gopalakrishnan et al (2012) has observed a similar prevalence of obesity (5.2%) and underweight (14.8%) but it has a higher prevalence of overweight (30.7%) among 290 medical students ^[21]. But it should be noted that this survey was conducted in Malaysia and there is expected to be differences in the food habits and culture.

This study disagrees with a survey by Yadav et al (2016) among medical students in Haryana which states that 73% had normal BMI, 22.3% being overweight and a lower incidence of underweight (1.5%) and obesity (3.1%) ^[22]. Also, it was concluded by Rimmi et al (2018) in a recent survey among nursing students in Haryana that majority of them followed healthy dietary habits and had a greater knowledge on healthy consumption^[11]. In this study, more than half the students (65.5%) regularly had meals at mealtime.

About 71% students consumed home-cooked foods while in a study among 215 female medical students 81% consumed home-cooked foods [23]. This difference could be because the latter included only female students while the present study included both sexes.                                                                                                                                                                                                       Breakfast was the commonly skipped meal as also reported by Rimmi et al (2018), Silliman et al (2004) and Shrivastava et al (2013) [11][12][20]. Arora et al (2012) suggested that skipping breakfast was associated with an increased incidence of overweight and obesity among high school students [24]. No significance was observed between gender, BMI and eating more during stress. One the other hand, females with more stress were noticed to show a weight gain (Serlachius et al., 2007) [25]. But this survey was carried out in Denmark where cultural differences would exist.

 It was found that 30% males frequently consume fast foods compared to only 16% females (P=0.05). This finding agrees with that of Silliman et al., 2004^[12]. About 34% snacked more than thrice a day. About 21% overweight and obese students frequently snacked between meals (P=0.009). This was also reported by Elsabagh et al (2016) ^[26].  No gender differences were observed in snacking often and the type of snack consumed in this study while Silliman et al suggested that men preferred fast foods while women preferred cookies^[12].

It was found that 73% of students did not exercise prior to attending medical college of which 65% are males and 78% females (P=0.42). Only 32.5% students currently exercise. This is in accord to another study by Arzu et al (2006) which suggests that only 30.7% are physically active^.[27].More than half (57.5%) reported less exercise since attending college while study by Silliman et al (2004) suggests a lower incidence (42%)^[12].^. Majority of them, 55% males and 76% females exercised less than once per week (P=0.005). This is in line with the study conducted by Elsabagh et al where 59.2% students exercised less than once per week and only 17% routinely exercised^[26].Studies have found that physical inactivity and sedentary lifestyle is linked to having increased BMIs^[28][29].

About 74% females exercised at a light intensity which is equivalent to normal walking and 50% males exercised at moderate and severe intensities (P=0.002). This gender difference was also reported by Silliman et al,2004^[12]. Male students mostly engaged in strengthening exercises while female students preferred aerobic exercise (P=0.000). 23% students exercised to maintain general health, 17% to lose or retain weight, 13% for stress relief, 6% for enjoyment and 41% for other reasons not enlisted. According to Silliman et al the main reason for exercise was also to maintain good health^[12].Students with underweight and normal BMIs exercised to relieve stress while those belonging to overweight and obese categories exercised to maintain or lose weight (P=0.002). Elsabagh et al, on the other hand reported that most of the overweight and obese participants exercised to lose weight while those with normal BMIs exercise for strength and fitness ^[26]. The students were asked to rate the healthiness of eating and more than half (57%) circled average while 4.5%, 20%, responded poor and fair respectively. In the present survey, the students were queried about the reason of their unhealthy food habits for which 45% stated that they “don’t care”. Half of the male students (n=38) said they had no access to healthy choices while about half of the female students stated they don’t care(n=63). Silliman et al has reported “lack of time” as a barrier and has observed gender differences that most women cite “lack of time” and men cite “don’t care” as a barrier. Lack of willpower and lack of motivation are other perceived barriers (Silliman et al., 2004) ^[12]. When asked about the reason for their lack of exercise, majority of them (60%) answered ‘lack of time’(P=0.081) which agrees with many other studies (Allison et al., 1999 and Silliman et al., 2004) ^[12][30]. It was an optimistic response when asked if they wished to have health and wellness activities in campus and in the general curriculum.

This study has observed poor dietary habits and inadequate physical activity among the study population. It has revealed that “don’t care” is the most commonly perceived barrier to unhealthy food habits and “lack of time” to physical inactivity. Nutritional counselling by the Dietician will create more awareness about the importance of having a healthy and balanced diet and will help the students to get rid of the negligence that is keeping them following a healthy diet pattern. But the students have showed interest in health and wellness activities in campus and in the medical curriculum as well. So, if this is implemented, there will definitely be a positive impact in the health of the medical undergraduates and will be of great help in the long run. Also, this study has identified gender differences which could be overcome by gender specific interventions.

1. World Health Organization. Obesity and Overweight. 16 Feb. 2018, https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight.
2. World Health Organization. Global Recommendations on Physical Activity for Health. 2010, https://www.who.int/news-room.
3. Zalewska, Magdalena, and Elzbieta Maciorkowska. "Dietary Habits and Physical Activity of 18-Year-Old Adolescents in Relation to Overweight and Obesity." Iranian Journal of Public Health, vol. 48, no. 5, May 2019, pp. 864.
4. Odlaug, Brian L., et al. "Prevalence and Correlates of Being Overweight or Obese in College." Psychiatry Research, vol. 227, no. 1, 30 May 2015, pp. 58–64.
5. Calzo, Jerel P., et al. "The Development of Associations Among Body Mass Index, Body Dissatisfaction, and Weight and Shape Concern in Adolescent Boys and Girls." Journal of Adolescent Health, vol. 51, no. 5, 1 Nov. 2012, pp. 517–523.
6. World Health Organization. Diet, Nutrition, and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert Consultation. 2003, https://www.who.org.
7. Boreham, C., et al. "Associations Between Physical Fitness and Activity Patterns During Adolescence and Cardiovascular Risk Factors in Young Adulthood: The Northern Ireland Young Hearts Project." International Journal of Sports Medicine, vol. 23, suppl. 1, Apr. 2002, pp. 22–26.
8. Roberts, Christian K., and James R. Barnard. "Effects of Exercise and Diet on Chronic Disease." Journal of Applied Physiology, vol. 98, no. 1, Jan. 2005, pp. 3–30.
9. Boeing, Heiner, et al. "Critical Review: Vegetables and Fruit in the Prevention of Chronic Diseases." European Journal of Nutrition, vol. 51, no. 6, Sept. 2012, pp. 637–663.
10. Gallè, Francesca, et al. "A Cross-Sectional Study Investigating Lifestyle and Weight Perception of Undergraduate Students in Southern Italy." BMC Public Health, vol. 19, 2019, pp. 1–7.
11. Rimmi, Chahal P. K., and Raman H. "A Descriptive Study to Assess the Knowledge and Expressed Practices Among Students Regarding Healthy Eating Habits in Selected Nursing College of Ambala, Haryana." International Journal of Health Sciences & Research, vol. 8, no. 4, Apr. 2018, pp. 110–117.
12. Silliman, Kathryn, et al. "Survey of Dietary and Exercise Habits and Perceived Barriers to Following a Healthy Lifestyle in a College Population." Californian Journal of Health Promotion, vol. 2, no. 2, 1 June 2004, pp. 10–19.
13. Balaji, V., et al. "Awareness of Risk Factors for Obesity Among College Students in Tamil Nadu: A Questionnaire Based Study." Research Journal of Pharmacy and Technology, vol. 10, no. 5, 2017, pp. 1367–1369.
14. Serlachius, Anna, et al. "Stress and Weight Change in University Students in the United Kingdom." Physiology and Behaviour, vol. 92, no. 4, 23 Nov. 2007, pp. 548–553.
15. Chhaya, S., and P. Jadav. "Dietary and Lifestyle Pattern in Relation to Overweight and Obesity Among the Medical and Nursing Students." Nursing, vol. 53, 2012, pp. 21–29.
16. Kumar, C. A., et al. "A Cross-Sectional Study on the Dietary Factors and Their Association with Body Mass Index Among Undergraduate Medical Students in a Medical College." International Journal of Research in Health Sciences, vol. 2, no. 2, 2014, pp. 591–598.
17. Sajwani, R. A., et al. "Knowledge and Practice of Healthy Lifestyle and Dietary Habits in Medical and Non-Medical Students of Karachi, Pakistan." Journal of Pakistan Medical Association, vol. 59, no. 9, Sept. 2009, pp. 650–655.
18. "Executive Summary of the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults." Archives of Internal Medicine, vol. 158, no. 17, 28 Sept. 1998, pp. 1855–1867. doi:10.1001/archinte.158.17.1855.
19. Anding, Jenna D., et al. "Dietary Intake, Body Mass Index, Exercise, and Alcohol: Are College Women Following the Dietary Guidelines for Americans?" Journal of American College Health, vol. 49, no. 4, Jan. 2001, pp. 167–171.
20. Shrivastava, S., P. Shrivastava, and J. Ramasamy. "Assessment of Knowledge About Obesity Among Students in a Medical College in Kancheepuram District, Tamil Nadu." Progress in Health Sciences, vol. 3, no. 1, 2013.
21. Gopalakrishnan, S., et al. "Prevalence of Overweight/Obesity Among the Medical Students, Malaysia." Medical Journal of Malaysia, vol. 67, no. 4, 2012, pp. 442–444.
22. Yadav, S. S., et al. "Assessment of Body Mass Index Among Undergraduate Medical Students—A Cross-Sectional Study from the Medical College of Haryana." International Journal of Medical Sciences and Public Health, vol. 5, no. 4, 2016, pp. 705–708.
23. Majeed, Farah. "Association of BMI with Diet and Physical Activity of Female Medical Students at the University of Dammam, Kingdom of Saudi Arabia." Journal of Taibah University Medical Sciences, vol. 10, no. 2, 1 June 2015, pp. 188–196.
24. Arora, Monika, et al. "Association of Breakfast Intake with Obesity, Dietary and Physical Activity Behavior Among Urban School-Aged Adolescents in Delhi, India: Results of a Cross-Sectional Study." BMC Public Health, vol. 12, 2012, p. 881.
25. Sepulveda, Ana R., et al. "Gender, School and Academic Year Differences Among Spanish University Students at High-Risk for Developing an Eating Disorder: An Epidemiologic Study." BMC Public Health, vol. 8, 28 Mar. 2008, p. 102.
26. Elsabagh, H. M., et al. "Perception and Practices of Healthy Lifestyle in Late Adolescence and Its Impact on Body Mass Index." National Journal of Community Medicine, vol. 7, no. 4, 2016, pp. 311–319.
27. Arzu, D., et al. "Perceived Barriers to Physical Activity in University Students." Journal of Sport Sciences and Medicine, vol. 5, no. 4, 2006, pp. 615.
28. Selvaraj, K., and P. Sivaprakasam. "A Study on the Prevalence of Overweight and Obesity Among Medical Students of Kanchipuram District." National Journal of Research in Community Medicine, vol. 2, 2013, pp. 140–144.
29. Desai, Maya N., et al. "Risk Factors Associated with Overweight and Obesity in College Students." Journal of American College Health, vol. 57, no. 1, 2008, pp. 109–114.
30. Allison, K. R., et al. "Perceived Barriers to Physical Activity Among High School Students." Preventive Medicine, vol. 28, no. 6, 1999, pp. 608–615.