Background : During recent years, nutritional knowledge and eating habits of university students have received a great deal of attention, globally. University students especially those living away from home may experience significant environmental changes that exert a negative influence on the quality of their diet. The aim of this study was to explore dietary habits of nursing students in the area of Athens. Method and material : The sample of the study consisted of 435 Nursing students in Technological Educational Institution of Athens. Data were collected by the completion of a self report and anonymous questionnaire designed after elaborate literature review on dietary habits of university students. All statistical tests (x2 and Fischer exact test) were considered to be significant at an alpha level of 0.05 and were performed with the Statistical Package for Social Sciences software version 19.0. Results: The study results showed that 88.7% of students preferred home-cooked meals and 11.3% preferred ready meals. In regard to the frequency of consumption of ready meals (souvlaki, pizzas and fast food) 58.6% reported 'rare' consumption while 41.4% 'moderate' consumption. Female students had family made food, 'often' p=0,013 while males ate 'often' ready meals outside home, p=0,030. Female eating habits differed significantly in consumption and frequency of green vegetables compared to male, p=
Dietary habits, smoking,university students
During last decades, a remarkable change in dietary habits has been noticed in Greece. The new dietary pattern includes increased consumption of animal products and low intake of fruits and vegetables is usually called 'Western diet' which significantly differs from the healthy 'Mediterranean diet' that involves high intake of fresh fruits, vegetables, olive oil and fish [1,2].
Eating changes, lack of physical activity and sedentary life have significantly contributed to the increase of various diseases, mainly cardiovascular diseases, diabetes mellitus and obesity. More in detail, according to estimates for 2008, over 50% of both men and women in the WHO European Region were overweight, and roughly 23% of women and 20% of men were obese. Based on the latest estimates in European Union countries, overweight affects 30-70% and obesity affects 10-30% of adults. Apart from personal, family and social disastrous consequences, obesity is also related to financial implications. For instance, obesity in adults accounts for up to 6% of direct health costs and more than 12% in indirect costs of shortened lives, reduced productivity and lowered incomes [3-5].
Taking into account that eating habits are established from childhood, it is emphasized that obesity in childhood is leading to adolescence obesity and finally to adult obesity . As a result, nutritional knowledge of university students and their food consumption pattern have received global attention. Indeed, the transition of young people from school to university has many health implications that are significantly related to food consumption patterns and associated nutritional risks .
It is widely known that dietary habits usually change when young enter university. Interestingly, moving away from home, implies lack of time and knowledge in cooking and other food choices such as fast food which involves high saturated fat and meat, less fiber and fruits and mainly processed food. Moreover, university students are used to irregular meals, high-energy fat snacks along with drinks or sweets. It is not rare, that meals are often skipped by students while the management of food preparation is avoided. At the same time, the healthy way of living is disrupted by the studying hours that may vary every day [7-10]
It is worth noting that, food consumption patterns vary among university students from European countries when living away from family home. For example, in Greece, students adopt positive changes such as decrease in whole-fat dairy products, white bread and margarine but they simultaneously decrease their consumption of fresh fruit, cooked and raw vegetables, oily fish, and increase their sugar and fast food intake . Polish female students living had significantly less percentage of energy provided by total fat and higher percentage of energy from carbohydrate compared to those who reside with their parents . Irregular meal patterns and the consumption of high-energy snacks tend to become common in most European countries .
Nursing uuniversity students is a particular interest age group for adopting healthier practices and being deep informed concerning health issues. Moreover, they are the future professionals whose role in health promotion can lead to many positive health outcomes.
The purpose of this study was to explore dietary habits of nursing students in the area of Athens.
Method and material
The sample studied consisted of 435 Nursing students in Technological Educational Institution of Athens. All participants were invited in their classrooms to participate in the study. Data were collected by the completion of a self report and anonymous questionnaire distributed by the researchers after being informed that all the answers were confidential and given their consent.
The questionnaire consisted of 18 open and closed questions which were included after elaborate review of the literature related to eating patterns and health habits of university students. More in detail, there were included questions regarding the frequency of consumption of fruits, vegetables, legumes, meat, fish as well as questions about the preparation of meals, eating ready meals, alcohol intake, sweets consumption and finally the smoking habits of students. Participants answered these questions according to the following scale: at least one, two, three, four, five, six, seven times a week and rarely. Apart from the above questions, there were also included socio-demographics variables. The method of the collection of data was a convenience sampling. The study was approved by the Nursing department of TEI.
The statistical analysis was conducted by the use of the statistical software SPSS 19. All reported p values were compared to a significant level of 5%. Chi-square tests were utilized to identify the relationships between gender and dietary habits of students.
Limitations of the study
The study sample is not representative in Greece, but a convenience sample. This method of sampling limits the generalizability of the results. Furthermore, the results can not be generalized since are coming from nursing students that have knowledge about health. Another limitation of the present study could be that dietary habits were measured only by self reports.
The sample studied consisted of 435 nursing students, of whom 16,6% were males and 83,4% females. The study results showed that 69% of the students had a breakfast. 36.1% of the participants reported drinking milk at breakfast, 31.5% reported drinking milk in combination with cereals while 23.9% reported toast and 6.7% butter consumption.
About other liquid intake with breakfast, 17.5% had coffee and 16.1% juice. In terms of fruit consumption, our findings showed that 36.1% of the students consumed fruits daily, while 13.2% of participants consumed 'rarely' or 'never'. 39.2% of the participants consumed vegetables daily while 4.5% reported 'rare' consumption. Regarding the meat consumption rate, 73.8% of students consume meat 2-4 times a week while 17% of students consumed fish 2-3 times a week.
Regarding the consumption of legumes 72.5% of students consumed 1-2 times a week and 14.7% reported 'rarely' or 'not at all' consumption. Fast food consumption was reported by 47.6% of students with frequency 1-2 times a week, while 31.7% of students consumed ready food 'rarely'.
37.7% of the participants reported consumption of sweets with a frequency of 2-3 times per week while of 13.1% reported 'rare' consumption of sweets during the week. Specifically preferences of students are presented in table 1.
80% of the participants reported preparation of food by the mother while 90.3% reported that food was prepared within the family with a frequency of 5-7 times per week.
88.7% of students preferred home-cooked meals and 11.3% preferred ready meals. In regard to the frequency of consumption of ready meals (souvlaki, pizzas and fast food), 58.6% reported 'rare' consumption while 41.4% 'moderate' consumption. Souvlaki was the main preference of meals, in a proportion 64.1% of the students.
Taste was the major determinant for the choice of food. 65.7% of the students choose food based on taste and not based on how healthy it is (Table 1 &2).
From the descriptive analysis, it was found that 33.1% of students used tobacco, of whom 59% started before the age of 17. Finally, 29% did not consume beverages, while 20% of students consumed alcohol with a frequency of 2 -3 times a week (Table 3).
Statistical analysis of the data showed no statistically significant difference between males and females in taking breakfast, p=0,411. Regarding the preference of the snack from the canteen, the results showed that males often preferred to consume pizza, pastry, toast, cheese, with a statistically significant difference than females, p=<0,001, while there was no statistically significant difference in the 2nd, 3rd and fourth preference, p=<0,05.
Regarding the frequency of consumption of fruits, no statistically significant difference was found between males and females students, p = 0,676, while both groups consumed largely fruits 94.4% and 95.6% respectively.
However, eating habits differed significantly in consumption and frequency of green vegetables, higher in females, p=<0,001 and p=0,015, respectively. Regarding meat consumption it was found that males consumed meat 'very often' with a statistically significant difference than females, p=0,004 while no difference was found between the two groups in terms of fish, p=0,179 and legumes, p= 0,308.
Female students often had family made food, p= 0,013 while males often ate ready meals outside home, p=0,030. No statistically significant difference between groups was found in the type of food when eating outside home, p = 0,549 and in the frequency of consumption of sweets, p= 0,686 (Table 4).
Regarding the consumption of alcoholic beverages males consumed more often than twice a week, p=0,001 (Table 5).
Male students reported higher use of tobacco, and more specifically, 36.1% of male students reported use of tobacco versus to 32.% of female.
The results of the present study showed that 69% of the students had breakfast, of which 17.5% had coffee with breakfast and 16.1% juice. 36.1% of the students consumed fruits daily, 39.2% consumed vegetables daily, 73.8% consumed meat 2-4 times a week, 72.5% consumed legumes 1-2 times a week, 47.6% consumed fast food and 37.7% consumed sweets. In regard to the frequency of consumption of ready meals (souvlaki, pizzas and fast food), 58.6% of the participants reported 'rare' consumption while 41.4% 'moderate' consumption.
It is widely accepted that university students especially those being away from home, usually adopt unhealthy dietary habits. More in detail, students in the United States and in Europe after their entry to the university usually experience failure to follow healthy diet especially in terms of fruits and vegetables and meat [7-10].
Papadaki et al.,  who explored the effect of living away from family home on the dietary habits of a group of Greek undergraduate students showed that they decreased their weekly consumption of fresh fruit, cooked and raw vegetables, oily fish, seafood, pulses and olive oil, whereas they increased their sugar, wine, alcohol and fast food intake. Interestingly, in this sample of Greek University students, moving away from family home, assuming responsibility for food preparation and purchasing for the first time seemed to affect their dietary habits. Another equally important factor that exerts a significant negative influence on the consumption of fruit and vegetables, meat and fish is the fact that university students often face limits in their budget. Moreover, it is observed increase in weight and fat gain in students being at first year in university that is mainly attributed to unhealthy diets .
According to Cervera Burriel et al., 12 university students are in critical period for the development of life styles which important for their future health. The main factors that affect their dietary habits are eating behaviour of other students, alcohol consumption, economic situation and the ability of cooking. Moreno-Gómez et al.,  reported that dietary pattern of the university student population was characterized by a low consumption of cereals and tubers, fruits, vegetables, olive oil, legumes and nuts, and a high consumption of processed meat, sweets, snacks, soft drinks and pastries. Likus et al.,  who explored dietary habits in first year medical students showed that 25% of students did not eat breakfast, 45.6% snacked in between main meals and 25% ate just before bedtime. Only 29% ate fruit and vegetables daily and 12% never had fish. Energy drinks were consumed by 39% of students daily and also 40% daily drank sweetened beverages. Irazusta et al.,  showed that the energetic intake of the nursing students was deficient including low carbohydrates and high fat and protein. Chen et al.,  found that nursing students who skipped breakfast frequently had more negative health promotion behaviors than those who attended breakfast more regularly. These results indicate that school achievement is negatively affected when nursing students omit breakfast.
The results also showed that 80% of the participants reported preparation of food by the mother while 90.3% reported that food was prepared within the family with a frequency of 5-7 times per week. Interestingly, food shopping and preparation plays a significant role on forming dietary habits as well as in planning meals. An alternative solution for students is eating at the canteen. Guagliardo et al.,  showed that only one third of students ate regularly at university canteens at midday during the week. Eating regularly at the canteen was associated with increased self-reported consumption of meat, fish, fruit and vegetables, independently of social and demographic variables.
From the descriptive analysis, it was found that 33.1% of students used tobacco, of whom 59% started before the age of 17 years old while 20% of students consumed alcohol with a frequency of 2 -3 times a week.
Haddad et al.,  showed that the prevalence of smoking among university students was 28.6% (50.2% among males and 6.5% among females). The same researchers also showed friends as the main source of the first smoking, which most often occurred after 15 years of age (82.3%). Similarly, Khader et al.,18 showed that reported prevalence of current smoking in university students was 35.0% (56.9% for males and 11.4% for females). The most important factors associated with increased smoking were male sex, higher income, lower academic attainment and higher number of friends or family members who smoke. Chalmers et al.,  who explored student nurses' attitudes, beliefs and personal behaviour in relation to tobacco isues showed that 22.1% smoked daily or in social situations. Although 91.4% of the smokers reported that they wanted to quit, few were actively engaged in the quitting process (16.9%). Vitzthum et al.,  showed that 41.9% of nursing students were daily or occasional smokers while the majority of smoking students were willing to quit and has already undertaken several attempts. Öztürk et al.,  who explored smoking status of nursing students showed that 9.5% were smoking. The difference between smoking ratios of male and female students was significant and increased with increase in the number of friends who smoke. They also showed that smoking mostly increased at times of exams (42.5%).
Students of health sciences courses deserve special attention in relation to smoking because they will become behavioral models conveying the basic concepts of health into the community .
Statistical analysis of the data showed that eating habits differed significantly in consumption and frequency of green vegetables, higher in females. Regarding meat consumption it was found that males consumed meat very often with a statistically significant difference than females. Female students often had family made food while males often ate ready meals outside home. Chourdakis et al.,  showed that eating habits differed significantly between the gender in regard to fruit consumption (higher in females) and fast food consumption (higher in males). More in detail, daily fruit consumption was more frequent among females (36.2%) than males (21.9%). Female students had healthier eating habits in terms of daily breakfast intake and meal frequency. Male students reported having physical activity more frequently than females. Fast food consumption occurred more than 3 times a week in 36.9% of males but only in 19.2% of females. 82.4% of males and 83.2% of females seemed to be aware of the long-term effects of dietary behaviors’ on health status. Skemiene et al.,  who compared the dietary habits between first-year and third-year medical university students showed that first-year and third-year female students used vegetable oils more frequently, used more vegetables and complied with dietary regimen more often than male students. The same researchers also showed that medical students, especially males, used excessive amounts of animal fat.
Nutrition interventions in university students should be encouraged to promote healthier diets and lifestyles. Equally essential is the achievement of adequate institutional programs aimed at reducing the number of smokers. Indeed, integration of lifestyle programs in nursing education is essential to promote the long-term health of future nurses who will serve as positive patient role models [24,25].
According to the findings of the study, nursing students move away from a traditional Mediterranean diet. Health promotion programs should be ή encouraged in the nursing curriculum in order to establish a healthier life style.