Appetite 55 (2010) 722–725

Short communication

Eating habits, health attitudes and obesity indices among medical students innorthern Greece§

Michael Chourdakis, Thrasivoulos Tzellos, Georgios Papazisis, Konstantinos Toulis, Dimitrios Kouvelas *

Department of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, P.O. Box 1532, GR-54006, Thessaloniki, Greece

A R T I C L E I N F O

Article history:

Received 13 May 2010

Received in revised form 4 August 2010

Accepted 21 August 2010

Keywords:

University students

Greece

Eating habits

Obesity indices

Medical students

Health attitudes

A B S T R A C T

Medical students represent not only the final but also the most crucial opportunity for education in the field

of healthy lifestyles and nutritional habits. Eating habits and obesity indices among medical students in

southern Greece were described almost a decade ago. However, there is a lack of current, relevant data

concerning students living in northern Greece. The purpose of the present study was to evaluate the body

mass index distribution and nutritional and health-related behavior among medical students in northern

Greece. The participants, 187 males (21.5 � 1.9 years) and 203 females (21.3 � 2.2 years), filled out a self-

report questionnaire. Height and weight measurements were obtained. Dietary practices of fast food

consumption (more frequent for males) and regular consumption of fruits and vegetables (more frequent for

females) were reported. Females seemed to adopt different practices than males when trying to lose weight and

were significantly better informed about the nutrient value of the food consumed. Although the prevalence of

overweight (males: 32.1%, females: 8.4%) and obesity (males: 5.9%, females: 1.5%) in the present sample is lower

compared to previous data, it remains high according to what would be health promoting. The above findings

suggest a need for further improvement in strategies promoting healthier nutrition habits.

� 2010 Elsevier Ltd. All rights reserved.

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Appetite

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Introduction

Obesity is considered a global epidemic, as it is the most rapidlygrowing form of malnutrition in developed (McTigue, Garrett, &Popkin, 2002) and developing countries (WHO, 2000). Publisheddata demonstrate that obesity is associated with numerous chronicdiseases including hypertension, cardiovascular disease (CVD),type-II diabetes, gallbladder diseases and various malignancies(Manson, Skerrett, Greenland, & VanItallie, 2004; Pischon, Nothl-ings, & Boeing, 2008). Studies conducted in Greece and particularlyin the Attica region (central-south of Greece), showed that aconsiderable proportion of the adult population is overweight (53%vs. 31% for males and females, respectively) or obese (20% vs. 15%for males and females, respectively) (Panagiotakos et al., 2004).During the last 30 years the composition of the Greek diet hasshifted towards a diet higher in saturated fat and meat, lower infiber and fruits and higher in processed foods (Karlen, Lowert,Chatziarsenis, Falth-Magnusson, & Faresjo, 2008; Van Diepen etal., 2010). Furthermore, a decrease in the level of physical activity isassociated with increased prevalence of overweight, obesity and

§ The authors express their appreciation to all the students that participated in

the study and to G. Leli for her help with data entry. No conflicts of interest. No

external funds. The authors funded this study.

* Corresponding author.

E-mail addresses: mhourd@med.auth.gr (M. Chourdakis),

ltzellos@googlemail.com (T. Tzellos), gpapaz@med.auth.gr (G. Papazisis),

toulis@endo.gr (K. Toulis), kouvelas@auth.gr (D. Kouvelas).

0195-6663/$ – see front matter � 2010 Elsevier Ltd. All rights reserved.

doi:10.1016/j.appet.2010.08.013

diet-related non-communicable diseases (Lollgen, Bockenhoff, &Knapp, 2009). According to Martinez-Gonzalez et al. (2001) thereare noteworthy differences in physical activity levels betweendifferent nations, with southern Europeans significantly lessphysically active compared with northern Europeans. Along withthe Portuguese, the Greeks are the least physically activepopulation in the European Union, with 40% of Greeks reportingto engage in no leisure-time physical activity.

University students are important targets for the promotion ofhealthy lifestyles of the adult population. A number of studiesevaluating the nutritional knowledge, eating habits and obesityindices of university students have been conducted (Malinauskas,Raedeke, Aeby, Smith, & Dallas, 2006; Osaka, Nanakorn, Sanseeha,Nagahiro, & Kodama, 1999; Sakamaki, Toyama, Amamoto, Liu, &Shinfuku, 2005), but previous studies in Greece either refer only tofemales (Farajian, Renti, & Manios, 2008), or have a small samplesize (Spanos & Hankey, 2010), presenting data only for central(Papadaki, Hondros, & Kapsokefalou, 2007) or southern (Bertsias,Mammas, Linardakis, & Kafatos, 2003) Greece. There is a lack ofevidence about the body mass index (BMI) distribution andnutritional and health-related behavior of Greek students living innorthern Greece. Northern Greece is a territory with a slightlydifferent climate (cooler and more humid) and different customsabout food habits than the central or the southern part of thecountry. The purpose of this study was to obtain data about thenutritional knowledge, eating habits, health attitudes and obesityindices of medical students living in this region of Greece.

Table 1Anthropometric and socio-demographic data of the sample.

Males (n = 187) Females (n = 203) p-Valuea

N b,c N b,c

Age (years) 21.5�1.9 21.3�2.2 0.3

Height (cm) 180�6.8 168�5.8 <0.001*

Weight (kg) 79.2�12.7 60.9�8.9 <0.001*

BMI 24.5�3.5 21.5�2.7 <0.001*

Origin

Village 14 7.5 17 8.4

Small city 42 22.5 45 22.2 NCd

Town >50.000 people 68 36.4 78 38.4

Athens/Thessaloniki 63 33.7 63 31.0

Mother education

Primary school 14 7.5 3 1.5

High School 9 4.8 9 4.4 NCd

Lyceum 50 26.7 56 27.6

Bachelor degree 95 50.8 127 62.6

Post-graduate 19 10.2 8 3.9

Father education

Primary school 7 3.7 10 4.9

High School 7 3.7 11 5.4 NCd

Lyceum 38 20.2 50 24.6

Bachelor degree 100 53.2 110 54.2

Post-graduate 35 18.6 22 10.8

a Data considered statistically significant (*) at p<0.05.b Data for quantitative variables are presented as mean� SD.c Data for qualitative variables are presented as absolute number—frequency.d NC: not calculated.

M. Chourdakis et al. / Appetite 55 (2010) 722–725 723

Methods

Design and participants

The study was carried out between March and May 2009 at theAristotle University of Thessaloniki campus in northern Greece andwas approved by the university’s institutional review board forresearch involving humans. A total of 408 medical students (196males and 212 females) participated in this study after giving theirinformed written consent and were asked to fill out a self-reportquestionnaire. Of the 408 students, 18 were excluded (9 males and 9females) due to missing data. The final sample consisted of 390students (187 males and 203 females), all Caucasians. Self-reportedheight and weight (and extrapolated BMI—kg/m2) were compared tothe measured values obtained for weight and height and thecalculated BMI.

Students were recruited randomly by a trained studentaccompanied by a professor. Body weights and heights weremeasured. Weight was measured to the nearest 0.1 kg using adigital scale (Seca 861; Seca Ltd., Vogel & Halke, Hamburg,Germany). Height was measured to the nearest 0.5 cm using astadiometer, with the participant’s back square against the walltape, eyes looking straight ahead (visual axis is horizontal whenthe top of the external auditory meatus is level with the inferiormargin of the bony orbit) (Seca Leicester Height Measure; Seca Ltd.,Vogel & Halke, Hamburg, Germany). BMI was calculated as weight(kg) divided by the square of height (m2). In the present study, theBMI classification of the WHO was used (WHO, 1997), classifyingoverweight as BMI 25–29.99 kg/m2 and obesity as �30 kg/m2. ABMI < 18.5 kg/m2 is classified by the Center for Disease Controland Prevention as an underweight condition.

Questionnaire

A 3-page questionnaire (35 questions) was designed by theauthors and was based on a previously published instrument(Sakamaki et al., 2005; Yahia, Achkar, Abdallah, & Rizk, 2008). Thequestionnaire used was first described by Sakamaki et al. (2005)and was standardized by the authors for university students’population. Yahia et al. (2008) have adopted this questionnaire tostudy the Lebanon university population without any standardi-zation for Lebanon population, since it contains no country specificdietary habit questions. It included demographic data, eating,drinking and smoking habits (27 questions) and 8 questionsrelated to nutritional knowledge and dietary behaviors were addedby the authors.

Statistical analysis

Statistical analysis was performed using the Statistical Packagefor Social Sciences (version 12.0, SPSS, Inc.) software. A normalitytest was performed for all dependent variables. For comparison ofquantitative variables, the Independent samples t-test was used

Table 2Prevalence of obesity among students based on BMI by gender.

Males (n = 187) Mean

N %

Underweight (<18.5 kg/m2) 1 0.5 17.1

Normal (18.5–24.99 kg/m2) 115 61.5 22.5

Overweight (25.0–29.99 kg/m2) 60 32.1 26.9

Obese (>30.0 kg/m2) 11 5.9 33.8

a For means.b NA: not applicable due to small sample size.

Data considered statistically significant (*) at p<0.05.

for variables following a normal distribution, whereas for others,the Mann–Whitney U test was performed (Rosner, 2005). All p-values were two-tailed and differences were considered significantwhen the p-value was less than or equal to 0.05. Summary data areexpressed as the mean � standard deviation (SD). For comparison ofcategorical data, the chi-square (x2) test (or Fisher’s exact test for2 � 2 data tables) was used (Rosner, 2005). Differences wereconsidered significant when the p-value was less than or equal to0.05.

Results

Characteristics of the sample and BMI categories

General characteristics of the population sample are presentedin Table 1. Mean age was not significantly different between malesand females. The average height, weight and BMI of males weresignificantly higher (p < 0.001) than those of females. Mean BMIwas significantly higher for males. Of the sample’s population,61.5% of the males and 84.7% of the females were classified asnormal according to BMI, whereas 32.1% of the males and 8.4% ofthe females fell into the overweight category. Of the remainingstudents, 5.9% of the males and 1.5% of the females were obese and0.5% of the males and 5.4% of the females were categorized asunderweight (Table 2). Self-reported height, weight and BMI weremore favorable than measured values (data not shown). Height,

SD Females (n = 203) Mean SD p-Valuea

N %

11 5.4 17. 0.76 NAb

1.5 172 84.7 21 1.7 <0.001*

1.3 17 8.4 26.1 2.4 0.138

3.9 3 1.5 32.1 1.6 NAb

Table 3Alcohol consumption and smoking habits of male and female students.

Males (n = 187) Females (n = 203) p-Valuea

N b,c N b,c

Never drink 32 17.1 51 25.1 0.223

Active drinkers 155 82.9 152 74.9

Frequency of drinking (portions/week)

Beer 2.5�4.6 1.2�1.8 <0.001*

Wine 1.2�1.8 1.5�1.4 0.02*

Heavy drinks 1.4�1.4 1.1�1.3 0.11

Never smoked 113 60.4 146 71.9

Smoked in the past but quit 4 2.1 17 8.4 0.007*

Active smokers 70 37.4 40 19.7

Number of cigarettes/day (for active smokers) 15.7�8.4 13�5.9 0.21

a Data considered statistically significant (*) at p<0.05.b Data for quantitative variables are presented as mean� SD.c Data for qualitative variables are presented as absolute number (frequency).

M. Chourdakis et al. / Appetite 55 (2010) 722–725724

weight and BMI values of males were significantly higher(p < 0.001) than those of females.

Eating habits

The pattern of eating habits and other health-related behaviorswere compared based on gender. There were no significantdifferences between males and females regarding meal regularity,meal frequency, snack frequency or consumption of coloredvegetables or fried foods. However, eating habits differed signifi-cantly in fruits (higher in females, p < 0.05) and fast foodconsumption (higher in males, p < 0.001). Female students hadhealthier eating habits in terms of daily breakfast intake and mealfrequency (p = 0.09). Male students reported having physical activitymore frequently than females; however, no statistical significancewas found.

Unhealthy eating patterns were observed considering that45.4% of males and 40.2% of females reported consuming friedfood. Fast food consumption occurred more than 3 times a week in36.9% of males but only in 19.2% of females. Although the majorityof males (82.4%) and females (83.2%) seemed to be equally aware ofthe long-term effects of dietary behaviors’ on health status, morefemale students (p < 0.05) are trying to obtain information aboutthe nutrient value of what they consume by reading nutrientlabels. Females seem to adopt different practices than males(p < 0.05) when trying to lose weight and 50.7% of the sample usedquantity restriction as the first step towards this goal.

Drinking and smoking habits

Alcohol consumption was not common among sample’spopulation, with only 1.6% of males and 2.0% of females reportingdaily intake of alcohol. The majority of both genders reported toconsume alcohol less than twice per week (Table 3). For beer anddistilled alcoholic beverage intake, males reported higher con-sumption than females (p < 0.001 and p = 0.11, respectively),whereas females reported higher wine consumption (p = 0.02).Those who had quit smoking were mostly females. Smoking wasnot common in the study’s sample; the majority of males (60.4%)and of females (71.9%) reported that they have never smoked(p = 0.007). The average number of cigarettes per day for activesmokers was not significantly different based on sex.

Self-assessment of weight and BMI

Fewer males than females (69.5% vs. 79.8%) consideredthemselves to be ‘‘normal;’’ more males considered themselves tobe underweight (15.0% vs. 9.9% for females) or obese (13.4% vs. 8.9%for females).

Discussion

The purpose of the present study was to assess the prevalenceof overweight and obesity and to investigate dietary practices andhealthy attitudes of medical students in northern Greece. To theknowledge of the authors, there are no published studiesregarding the prevalence of overweight and obesity in studentsin this territory of Greece. Existing information comes fromstudies either from a different geographic area (Bertsias et al.,2003; Farajian et al., 2008), or from a smaller sample size(Papadaki et al., 2007; Spanos & Hankey, 2010). The present studyprovides an extension of previous research on university students’dietary habits in Greece. Although eating habits of universitystudents have been primarily described almost a decade ago, thisis the first time that such information has been obtained alongwith measured and self-described weight and height. Universitystudents, especially those living away from home, tend to developunfavorable eating habits (Papadaki et al., 2007), showing asignificant change towards deteriorated, globalized behaviors(Steptoe et al., 2002).

According to the present study’s results, the prevalence ofoverweight and obese among students is lower than previouslyreported in Athens (Panagiotakos et al., 2004) and in Crete (Bertsiaset al., 2003). This may be attributed to the extended knowledgeduring the last decade, coming from published data but also steadilyannounced in the media, about health-related problems associatedwith being overweight or obese. Moreover, medical students arethought to be better informed concerning health issues andtherefore, they adopt healthier practices. High prevalence rates ofoverweight and obesity have also been reported in other countries(Arroyo et al., 2004; Lowry et al., 2000; Yahia et al., 2008). Theprevalence of overweight and obesity in the present sample may belower in comparison to other published studies, but it is not lowaccording to what would be health promoting. Overweight andobesity are related to various health problems, such as diabetes,hypertension, and hypercholesterolemia (Eckel & Krauss, 1998;Must et al., 1999). Nevertheless, being overweight at the age of 20–22 years is associated with a substantial incidence of obesity by theage of 35–37 years (McTigue et al., 2002).

In the present study, the majority of students regularly receivedat least three meals per day and more than half of the samplereported consumption of vegetables and fruits at least 3 times perweek; however, only one in every four males (24.2%) and females(24.6%) reported daily consumption of vegetables. Daily fruitconsumption is more frequent among females (36.2%) than males(21.9%). Furthermore, a high proportion of students tended to eatbreakfast daily. The above practices constitute healthy dietpractices that should be encouraged. However, breakfast regularityin the present study seems to be lower than that in France, in the

M. Chourdakis et al. / Appetite 55 (2010) 722–725 725

UK or in other European countries (Monneuse, Bellisle, & Koppert,1997). No significant difference between males and females wasfound for breakfast consumption (p = 0.09), although in the rest ofEurope as a whole, females eat breakfast more often than do males(Monneuse et al., 1997). Skipping breakfast has been associated withlower nutritional status, with a higher risk of cardiovascular diseases(Calderon, Yu, & Jambazian, 2004) and with the possible develop-ment of obesity (Jackson et al., 1990). Furthermore, having breakfasthas been associated with a reduction of dietary fat and of impulsivesnacking (Schlundt, Hill, Sbrocco, Pope-Cordle, & Sharp, 1992).

Daily consumption of snacks was reported to be high in males.However, the frequency of having snacks does not provide safeinformation about snack size; it must be noticed that studentsprobably had a different snacking pattern according to theperception of their body size. Frequent snacking and/or consumingfried foods can adversely affect students’ health, given theabundance of energy dense and high-fat ingredients these foodscontain (Yahia et al., 2008). In the present study, students werefrequent fried food consumers (only about 1/3 of males andfemales reported rarely eating fried food). Males reported eatingsignificantly (p < 0.001) more fast food than did females, which isan eating pattern that has been associated with increased risk fordeveloping CVD (Satia, Galanko, & Siega-Riz, 2004).

Individuals tend to under-report their weights and over-reporttheir heights (Gorber, Tremblay, Moher, & Gorber, 2007) and asimilar trend was also found in the present study. According to ourresults concerning body figure perception, more females consideredthemselves to be normal and fewer females considered themselvesto be underweight, as compared to males. However, no significantdifference was observed based on gender. Females were significant-ly thinner and the percentage of underweight females was almosttenfold higher than that of males (5.4% vs. 0.5%). It is quite possiblethat some females who are underweight falsely think that they fitinto the normal category because female students are more likelythan males to be influenced by the media as far as a healthy andattractive weight is concerned (Malinauskas et al., 2006). Inaddition, females are more likely to engage in unhealthy foodrestriction behaviors and place higher importance on maintaining alower ‘‘ideal’’ body weight, experiencing more stress than malesabout becoming obese (Pratt & Woolfenden, 2002).

Inadequate dietary habits and lack of sufficient physicalactivity, as shown in industrialized European countries, are relatedto a high prevalence of overweight and obesity. According to thepresent study’s results’, the majority of male and female studentswere classified into the normal BMI group. However, theprevalence of overweight and obesity, even though lower thanthat reported in published data, remains high and could lead toadverse mid- and long-term health effects.

Universities and, especially, medical schools represent a greatopportunity for focused nutritional education. Promoting healthydietary and weight management practices might be of greatimportance when developing health education programs (Sakamakiet al., 2005). University students are thought to be a significantproportion of the socio-economic elite of tomorrow and thus theirhabits and behaviors are most likely to become the norm (Monneuseet al., 1997). Health educators should promote education andintervention strategies that encourage improved competence in thearea of nutrition for healthier ‘dietary behaviors’ and healthy weightmanagement. Furthermore, it is necessary to target young agegroups because the prevalence of overweight and obesity isincreasing in youth populations around the world.

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