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PUBLIC HEALTH
ORIGINAL RESEARCH ARTICLE
published: 21 October 2014
doi: 10.3389/fpubh.2014.00185
Assessment of dietary intake patterns and their correlates
among university students in Lebanon
Pascale Salameh1*, Lamis Jomaa2*, Carine Issa3, Ghada Farhat 4, Joseph Salamé5, Nina Zeidan3and
Isabelle Baldi6for the Lebanese National Conference for Health in University Research Group†
1Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
2Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
3Faculty of Public Health, Lebanese University, Fanar, Lebanon
4Faculty of Health Sciences, University of Balamand, Beirut, Lebanon
5Charité – Universitätsmedizin University Hospital, Berlin, Germany
6Laboratoire Santé Travail Environnement, Université Bordeaux Segalen, Bordeaux, France
Edited by:
Rania A. Mekary, Massachusetts
College of Pharmacy and Health
Sciences University, USA
Reviewed by:
Corrado Romano, IRCCS Associazione
Oasi Maria Santissima, Italy
Dong D. Wang, Harvard School of
Public Health, USA
*Correspondence:
Pascale Salameh, Faculty of
Pharmacy, Lebanese University, Rafic
Hariri Campus, Hadath, Beirut,
Lebanon
e-mail: psalameh@ul.edu.lb,
pascalesalameh1@hotmail.com;
Lamis Jomaa, Department of
Nutrition and Food Sciences, Faculty
of Agricultural and Food Sciences,
American University of Beirut, P.O.
Box 11-0236, Riad El Solh, Beirut 1107
2020, Lebanon
e-mail: lj18@aub.edu.lb
†The Lebanese National Conference
for Health in University Research
Group also includes: Barbour B,
Waked M, Zeghondi H, Gerges N,
Sabbagh MT, Saleh N, and Chaaya M.
Introduction: Unhealthy dietary habits are major risk factors for chronic diseases, par-
ticularly if adopted during early years of adulthood. Limited studies have explored the
food consumption patterns among young adults in Lebanon. Our study aimed to examine
common dietary patterns and their correlates among a large sample of university student
population in Lebanon, focusing on correlation with gender and body mass index (BMI).
Methods: A cross-sectional study was carried out on 3384 students, using a proportionate
cluster sample of Lebanese students from both public and private universities. A self-
administered food frequency questionnaire was used to assess dietary intake of university
students. Factor analysis of food items and groups, cluster analysis of dietary patterns, and
multivariate regressions were carried out.
Results: Three dietary patterns were identified among university youth namely a vegetar-
ian/low calorie dietary pattern (characterized mainly by consumption of plant-based food
while avoiding “western” food, composite dishes, and bread); a mixed dietary pattern
(characterized by high consumption of plant-based food, followed by composite dishes,
bread, and a low consumption of western type food); and finally, a westernized dietary
pattern (characterized by high consumption of white bread and western food, and a
strong avoidance of plant food and composite dishes). We observed significant differ-
ences between males and females in terms of their reported food intake and dietary
patterns. Females were particularly more prone to adopt the vegetarian/low calorie diet than
males (ORa =1.69; p<0.001), while males were more likely to adopt a westernized diet
(ORa =1.51; p<0.001), seemingly in private universities (p=0.053). Students with high
income and obese students (BMI ≥30 kg/m2) were more likely to consume vegetarian/low
calorie diets (p<0.05).
Conclusion: Male university students reported a higher consumption of the westernized
dietary pattern as compared to female university students in Lebanon, while the latter
reported a higher adoption of a vegetarian diet. Health promotion programs are needed
to address the dietary intakes and lifestyle behaviors of young adults in Lebanon to help
prevent obesity and other associated comorbidities.
Keywords: dietary pattern, food categories, gender difference, university students
INTRODUCTION
Unh ealthy dietary habits are among the major risk factors for obe-
sity and related chronic diseases, particularly if adopted during
early adulthood (1,2). They are becoming more frequent due to
the nutritional transition that is affecting populations across devel-
oping countries (3,4), where traditional healthy diets, including
the Mediterranean diet, are being progressively replaced by more
westernized dietary patterns (5,6).
University students seem to be the most affected by this
nutrition transition (7,8); studies from developed countries have
shown that young adults leaving their parents and living away
from home to attend college experience numerous health-related
behavioral changes, including the adoption of unhealthy dietary
habits (9–11). These behaviors are mostly attributed to dras-
tic changes in the environment and resources available, frequent
exposure to unhealthy foods and habits (12),leading to higher con-
sumption of high caloric snacks, fast foods, and lower consump-
tion of fruits and vegetables, i.e., replacing their consumption of
nutrient-dense foods with energy-dense nutrient-poor foods (13);
added to this, skipping meals may also become more frequent (14).
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Salameh et al. Dietary patterns of university students
Studies in the Middle East show that adolescents and adults
eating behaviors are adversely being influenced by the changing
environmental-factors leading to alarming rates of overweight and
obesity and higher metabolic risk factors causing diabetes, hyper-
tension, and other chronic diseases (15,16). In Lebanon, a small
country in the Middle East, the prevalence of overweight and obese
adolescents and young adults was reported to be as high as 21 and
11%, respectively, significantly higher than those reported 10 years
before (17). Previous studies were conducted among university
students in Lebanon; however, these focused mostly on one or
two private universities, showing that the nutrition transition was
associated with higher rates of obesity among youth (18,19).
Gender differences in eating and weight-related behaviors have
been reported in the scientific literature from developed nations
such as Canada (20), France (21), and the United States (22). To
our knowledge, few similar studies were carried out in Middle
Eastern countries that explore gender differences among univer-
sity students. In Lebanon, a previous study conducted on students
from one university showed that females had healthier eating
habits than males and lower rates of obesity (18). Among adults
of Beirut, women had also healthier dietary intakes (23). More-
over, in an earlier study conducted on a sample of all university
students in Lebanon exploring various health risk behaviors, our
research group showed how obesity prevalence differed between
males and females (24). Given these findings, the objective of this
analysis was to define the dietary patterns of university students in
Lebanon, exploring their respective correlates, focusing primarily
on gender and weight status.
MATERIALS AND METHODS
GENERAL STUDY DESIGN
A cross-sectional study was conducted between 2010 and 2011,
using a proportionate cluster sample of students from 16 private
universities and the only public university in Lebanon. Based on
data of student population across various universities from the
Center for Pedagogic Researches in Lebanon (25), a proportionate
sample of 3000 students was targeted to allow for adequate power
for bivariate and multivariate analyses to be carried out.
The study was waived from IRB approval at the Lebanese
University; however, researchers and field worker conducted the
study according to the research ethics guidelines laid down in the
Declaration of Helsinki (26).
Verbal informed consent was also obtained from all sub-
jects prior to participating in the study and completing the
self-administered questionnaire.
PROCEDURE
Random selection of university students was not possible at the
various institutions in Lebanon due to administrative challenges,
thus a convenient sample of students was recruited for this study.
A trained field worker approached students outside their class-
rooms during break hours and explained the study objectives.
Students who expressed interest and provided their oral consent
were handed a self-administered anonymous questionnaire that
included questions related to sociodemographic, anthropometric,
dietary, and lifestyle behaviors. On average, the questionnaire was
completed by participants within approximately 20min. At the
end of the process, the completed questionnaires were placed in
closed boxes and sent for data entry. During the data collection
process, the anonymity of the students was guaranteed. Out of
4900 distributed questionnaires, 3307 (67.5%) were returned to
the field worker, thus the sample size needed for sufficient power
to conduct the analyses was met. Further methodological details
were presented by authors elsewhere (24).
DIETARY INTAKE ASSESSMENT
The self-administered questionnaire used in this study included
numerous questions related to the socio-demographic back-
ground of university students and a short food frequency ques-
tionnaire (FFQ) to assess the usual dietary intake of youth. The
FFQ was composed of 16 semi-quantitative questions covering
different food categories (including the five basic food categories
typically consumed by the Lebanese population) (27). The FFQ
used in this study was adapted from the questionnaire earlier
administered in the Lebanese population (27) and the CDC Global
School Health Survey (28); the finally used items were vegetables
and salads, fruits, olive oil, grains (lentils, peas), fish and seafood,
meats (including cooked meats, poultry, ham, and hotdog), white
bread and derivatives, brown bread and derivatives, rice and pasta,
sweets (cake, ice cream, chocolate, . . .), carbonated beverages, fruit
juices, hot beverages (coffee, tea, Nescafe, hot chocolate, or milk),
cooked vegetables (mainly for composite dishes), fast food [ham-
burger, pizza, Lebanese pizza (known as Man’ouche with thyme
or cheese or yogurt based kechek), and sandwiches], and fried
potatoes and chips. We omitted to ask questions about eggs and
dairy products as separate items, because they would have been
confusing to the students to record in the FFQ given that these
food items are frequently consumed in Lebanon within composite
dishes (eggs, cheese, and yogurt within cooked dishes), fast food
meals (in sandwiches and Lebanese pizzas), or as part of hot bev-
erages (hot chocolate or Nescafe, and hot milk). The FFQ asked
how often each food item, group, or beverage was usually con-
sumed with five possible answers for each of the food categories:
(1) never, (2) two times or less per week, (3) three to six times
per week, (4) at least one time per day, and (5) at all meals. These
five response categories were later merged into four categories for
analysis purposes, namely: (1) never, (2) once or twice per week
(3) three to six times per week, and (4) consumption on daily basis.
ANTHROPOMETRIC DATA
Students involved in this study self-reported their weights
and heights; however, measurements were conducted by a
trained field worker on a subsample of individuals (N=618)
using standardized techniques and calibrated scales. A compar-
ison of self-reported versus measured anthropometrics allowed
us to calculate equations for corrected reported weights
and heights for males and females. The following equations
were used for measuring corrected weights and heights: for
males [corrected weight =(1.003*reported weight) and corrected
height =(0.959*reported height) +7.59] and for females [cor-
rected weight =(0.942*reported weight) +3.14 and corrected
height =(0.943*reported height) +9.42].
A corrected body mass index (BMI) was subsequently cal-
culated as corrected weight in kilograms over corrected height
squared (in square meter). According to the International Clas-
sification of adult weight to height status (i.e., underweight,
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Salameh et al. Dietary patterns of university students
overweight, and obese), BMI values were classified into four
categories for individuals 20 years of age or older: underweight
(BMI ≤18.5 kg/m2), normal weight (BMI between 18.5 and
24.9 kg/m2), overweight (BMI between 25 and 29.9 kg/m2), and
obese (≥30 kg/m2) (29); the method recommended by Cole and
collaborators was used (30).
OTHER DEMOGRAPHIC AND LIFESTYLE VARIABLES
Income level of each student was assessed using the reported
household monthly income divided by the number of individ-
uals per household as a surrogate measure. The obtained number
was subsequently divided into quartiles of income level, according
to which individuals were classified.
In order to assess the physical activity level of students, a ques-
tionnaire was used to calculate leisure time physical activity on the
basis of mean metabolic equivalents (MET) for reported activities
and their frequency and duration in MET – minutes per week; a
higher score indicated greater activity (31). Students were asked
to report about their habitual leisure time physical activities; these
included recreational activities, such as bicycling (MET=8), bas-
ketball playing (MET =8), and walking for exercise (MET =4) as
well as more structured lessons, such as swimming (MET =6),
dancing (MET =6.5), and stretching (MET =2.5). Each student
had a physical activity score that was computed by multiplying an
estimate of the MET for each reported activity by the weekly fre-
quency with which it was performed and an overall average weekly
score was calculated as MET*times per week. Furthermore, time
spent on each activity was multiplied by the MET value of the
activity. The resulting MET-min products were summed to pro-
duce an index of weekly physical activity,expressing the amount of
energy per kilograms body weight expended during the week (31).
DATA ANALYSIS
Statistical analyses were performed using the Statistical Package
for Social Sciences (version 16.0, SPSS,Inc). Student’s t-tests were
conducted to examine differences in height, weight, and BMI
between males and females. Chi-square analyses were used to
compare BMI categories distributions, income level quartiles,uni-
versity types, field of studies, and consumption frequencies of the
different food categories between males and females and some
nominal variables distributions between clusters.
IDENTIFYING DIETARY PATTERNS AMONG UNIVERSITY STUDENTS
In nutritional epidemiology, various statistical methods are used
to derive common eating patterns among specific populations; fac-
torial and cluster analyses are two of the most common methods.
Both methods allow for empirical derivation of eating and dietary
patterns: factor analysis derives patterns based on intercorrelations
between food items/groups, whereas cluster analysis depends on
individual differences in mean intakes when reducing data into
patterns (32). In our study, both methods were used: factorial
analysis allowed for identifying food group patterns based on inter-
correlations between these food components and cluster analysis
allowed for grouping individuals within our sample into mutually
exclusive groups based on their adherence to these food group pat-
terns. Studies using both empirical methods allow for exploring
correlations between derived dietary patterns and various health
outcomes (33,34). The procedure of each is explained in details
below:
First, an exploratory factor analysis was performed to identify
patterns of food categories consumed by university students from
our sample, i.e., to look at food items that were consumed at the
same frequency by individuals. After ensuring sample adequacy
with the Kaiser–Meyer–Olkin (KMO) index and Bartlett’s Chi-
square test of sphericity, factors of food categories consumption
were extracted using the principal component analysis and using
a promax rotation. Factors with Eigenvalues higher than one were
retained; confirmation of adequacy with a Scree plot was per-
formed and interpretability of the results was taken into account.
Items with factor loading ≥0.4 were considered as belonging to
a factor. Reliability analysis was performed by Cronbach’s alpha
values for factors and the total scale.
Second, a cluster analysis was performed with the identified
factor scores reflecting patterns of consumption of food categories
using the K-mean method to identify dietary patterns consumed
by study participants. This method allowed study participants
to be grouped into non-overlapping mutually exclusive clusters
reflecting their dietary patterns. Analysis allowed for 30 iterations
centering results on zero and convergence was only reached using
a three clusters structure, i.e.,thus, three different dietary patterns.
ASSOCIATIONS BETWEEN DIETARY PATTERNS AND PARTICIPANT
CHARACTERISTICS
Association between socio-demographic characteristics of study
participants and the derived dietary patterns were evaluated, using
both bivariate and multivariate analyses. For the latter analysis,we
carried out a multinomial backward logistic regression, using the
full model to show the effect of all independent variables: the
dependent variable was the dietary pattern; the major indepen-
dent variables were gender and BMI, whereas age,university type,
income level, and physical activity were all taken as covariates.
Adjusted odds ratio (ORa) were calculated, after ensuring model
adequacy to data.
RESULTS
CHARACTERISTICS OF THE SUBJECTS
A total of 3307 university students with complete data were
included in the analysis; 60% were females (N=1969) and the
remaining 40% were males (N=1332). The average age of partic-
ipants was 20 years, ranging between 17 and 37 years. Differences
were detected between male and female university students with
respect to their reported income status, distribution between pub-
lic and private universities, and across various fields of studies.
A higher percentage of males were in private universities and
reported higher income levels compared to females. Furthermore,
a higher percentage of males were classified as overweight or obese,
based on the corrected BMI, compared to female university stu-
dents in our sample (38 versus 10%, respectively, p<0.001) (see
Table 1).
DIETARY INTAKE OF UNIVERSITY STUDENTS BASED ON GENDER
Based on the semi-quantitative FFQ, significant differences were
observed between male and female university students with respect
to their consumption of individual food categories regularly con-
sumed by the Lebanese population (14 out of the 16 food items or
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Salameh et al. Dietary patterns of university students
Table 1 | Sociodemographic and anthropometric measurements of university students in the total sample, and by gender (N=3307).
Variable Total (N=3307) Males (N=1332) Females (N=1969) p-Value
Mean (SD)
Age in years 20.37 (1.86)20.66 (2.0)20.18 (1.7) <0.001
Height (cm) 169.82 (9.84)178.3 (7.4)163.9 (6.5) <0.001
Weight (kg) 65.88 (15.57)78.2 (15.1)57.4 (8.8) <0.001
Physical activity (MET-min/week) 1006.72 (1474.16)1593.0 (1868.5)639.9 (1002.3) <0.001
BMI (kg/m2) 22.71 (4.34)24.6 (4.5)21.4 (3.7) <0.001
N(%)
BMI categories
Underweight (<18.5 kg/m2) 297 (9.0%)34 (2.6%)263 (13.9%) <0.001
Normal (18.5–24.9kg/m2) 2219 (67.1%)778 (59.4%)1441 (76.2%)
Overweight (25–29.9 kg/m2) 547 (16.5%)387 (29.5%)160 (8.5%)
Obese (≥30 kg/m2) 139 (4.2%)111 (8.5%)28 (1.5%)
Income level <0.001
Quartile 1 673 (20.4%)239 (19.6%)604 (33.6%)
Quartile 2 741 (22.4%)215 (17.7%)409 (22.8%)
Quartile 3 635 (19.2%)392 (32.2%)441 (24.6%)
Quartile 4 766 (23.2%)371 (30.5%)341 (19.0%)
Public university 1668 (50.4%)491 (36.9%)1175 (59.7%) <0.001
Private universities 1639 (49.6%)841 (63.1%)794 (40.3%)
Field of studies <0.001
Sciences and informatics 665 (20.1%)333 (25.3%)332 (16.9%)
Health sciences 1088 (32.9%)210 (15.9%)876 (44.6%)
Humanities and laws 283 (8.6%)73 (5.5%)210 (10.7%)
Business and economics 733 (22.2%)394 (29.9%)335 (17.1%)
Engineering 274 (8.3%)219 (16.6%)55 (2.8%)
Arts 243 (7.3%)89 (6.8%)154 (7.8%)
groups). Males consumed more fish, white bread, rice and pasta,
carbonated beverages, fruit juice, fast food,and fried potatoes and
chips than females (p≤0.001), while females consumed more
brown bread, meat, grains, olive oil, fruits, and raw and cooked
vegetables (p≤0.001). Only hot beverages and sweets were equally
consumed by males and females (see Table 2).
FOOD CATEGORIES CONSUMPTION PATTERNS
Major factors were extracted using factor analysis of the 16 food
categories in the administered FFQ; these factors reflected food
categories that are consumed with similar frequencies at the indi-
vidual level. Kaiser–Meyer–Olken value was 0.751 (p<0.001 for
Bartlett’s test of sphericity), denoting the sample adequacy for
the analysis. All communalities were higher than 0.3, except for
fruit juice, which was subsequently removed from the factor as it
did not load adequately on any of the extracted factors. Four fac-
tors were then extracted, explaining together 49.31% of the total
variance:
• Factor 1 showed high loadings of fried potatoes and chips, fast
foods, carbonated beverages, and desserts with slightly lower but
still a positive loading of hot beverages such as coffee, tea, and
Nescafe; this factor was termed “western type foods.”
• Factor 2 showed high positive loadings of raw vegetables and
salads, fruits, and olive oil; it was named “plant-based foods.”
• Factor 3 had high positive loadings of rice and pasta, cooked
vegetables, grains, fish and seafood, and a negative loading of
meats; these were deemed to represent “composite dishes” that
were consumed by non-meat eaters.
• Factor 4 was characterized by high positive loading on white
bread and high negative loading on brown bread; it clearly
showed a preference for white bread consumption among study
participants (Table 3).
Moreover, the reliability analysis of the food items gave a mod-
erate value of Cronbach’s alpha (0.463), showing the need for
factors segregation. Thus, for the factors described above, reliabil-
ity was 0.621 for western type foods; 0.597 for plant foods; 0.403
for composite dishes (0.567 without meat); and −1.082 for bread,
respectively. In the latter case, the Cronbach alpha was negative
due to a negative average covariance among items, and the corre-
lation coefficient between brown and white bread was r= −0.352
(p<0.001).
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Salameh et al. Dietary patterns of university students
Table 2 | Dietary intake of university students as assessed by a food frequency questionnaire, in total study sample and by gender.
Food category Total N(%) Males N(%) Females N(%) Chi-square p-Value
Vegetables and salads 31.85 <0.001
Never 53 (1.8)28 (2.4)25 (1.4)
≤2 times/week 627 (20.8)293 (25.2)334 (18.0)
3–6 times/week 770 (25.6)298 (25.6)472 (25.5)
Daily 1563 (51.9)543 (46.7)1020 (55.1)
Fruits 17.62 <0.001
Never 73 (2.4)37 (3.2)36 (2.0)
≤2 times/week 555 (18.5)240 (20.7)315 (17.1)
3–6 times/week 688 (22.9)282 (24.3)406 (22.0)
Daily 1691 (56.2)602 (51.9)1089 (59.0)
Olive oil in food 16.02 0.001
Never 87 (2.9)25 (2.2)62 (3.4)
≤2 times/week 601 (20.0)245 (21.1)356 (19.3)
3–6 times/week 761 (25.3)329 (28.3)432 (23.4)
Daily 1560 (51.8)562 (48.4)998 (54.0)
Grains (lentils, peas.) 15.80 0.001
Never 144 (4.8)57 (4.9)87 (4.7)
≤2 times/week 1424 (47.6)497 (43.1)927 (50.4)
3–6 times/week 1071 (35.8)445 (38.6)626 (34.0)
Daily 354 (11.8)154 (13.4)200 (10.9)
Fish and seafood 73.12 <0.001
Never 305 (10.2)107 (9.3)198 (10.7)
≤2 times/week 2053 (68.6)718 (62.5)1335 (72.4)
3–6 times/week 449 (15.0)205 (17.9)244 (13.2)
Daily 184 (6.2)118 (10.3)66 (3.6)
Meat, hotdog, ham 99.62 <0.001
Never 243 (8.1)155 (13.4)88 (4.8)
≤2 times/week 446 (14.9)191 (16.6)255 (13.9)
3–6 times/week 1259 (42.1)491 (42.6)768 (41.7)
Daily 1046 (34.9)316 (27.4)730 (39.7)
White bread 18.91 <0.001
Never 222 (7.4)63 (5.5)159 (8.6)
≤2 times/week 300 (10.0)96 (8.3)204 (11.1)
3–6 times/week 263 (8.8)113 (9.8)150 (8.1)
Daily 2210 (73.8)881 (76.4)1329 (72.1)
Brown bread 23.05 <0.001
Never 1545 (51.7)649 (56.4)896 (48.7)
≤2 times/week 643 (21.5)228 (19.8)415 (22.6)
3–6 times/week 241 (8.1)98 (8.5)143 (7.8)
Daily 561 (18.8)176 (15.3)385 (20.9)
Rice and pasta 19.81 <0.001
Never 86 (2.9)42 (3.6)44 (2.4)
≤2 times/week 1619 (54.2)614 (53.3)1005 (54.7)
3–6 times/week 926 (31.0)326 (28.3)600 (62.6)
Daily 358 (12.0)169 (14.7)189 (10.3)
Sweets (cake, ice cream, chocolate, etc) 5.56 0.135
Never 72 (2.4)26 (2.3)46 (2.5)
≤2 times/week 876 (29.5)315 (27.5)561 (30.7)
3–6 times/week 758 (25.5)315 (27.5)443 (24.2)
Daily 1267 (42.6)489 (42.7)778 (42.6)
(Continued)
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Salameh et al. Dietary patterns of university students
Table 2 | Continued
Food category Total N(%) Males N(%) Females N(%) Chi-square p-Value
Carbonated beverages 49.42 <0.001
Never 347 (11.7)103 (9.0)244 (13.4)
≤2 times/week 845 (28.5)268 (23.4)577 (31.6)
3–6 times/week 623 (21.0)257 (22.4)366 (20.1)
Daily 1155 (38.9)518 (45.2)637 (34.9)
Fruit juices 38.10 <0.001
Never 321 (10.8)161 (14.0)160 (8.8)
≤2 times/week 1164 (39.1)391 (34.1)773 (42.3)
3–6 times/week 600 (20.2)216 (18.8)384 (21.0)
Daily 890 (29.9)379 (33.0)511 (28.0)
Hot beverage (coffee, tea, nescafe, etc) 4.68 0.196
Never 264 (8.9)100 (8.7)164 (9.0)
≤2 times/week 577 (19.4)245 (21.3)332 (18.2)
3–6 times/week 414 (13.9)160 (13.9)254 (13.9)
Daily 1718 (57.8)643 (56.0)1075 (58.9)
Cooked vegetables 18.60 <0.001
Never 571 (19.2)265 (23.1)306 (16.7)
≤2 times/week 1431 (48.1)522 (45.5)909 (49.8)
3–6 times/week 646 (21.7)236 (20.6)410 (22.4)
Daily 327 (11.0)125 (10.9)202 (11.1)
Fast food (hamburger, pizza, etc) 99.43 <0.001
Never 198 (6.7)57 (5.0)141 (7.7)
≤2 times/week 1742 (58.7)571 (49.9)1171 (64.2)
3–6 times/week 662 (22.3)312 (27.2)350 (19.2)
Daily 367 (12.4)205 (17.9)162 (8.9)
Fried potatoes, chips 7.00 0.072
Never 157 (5.3)62 (5.4)95 (5.2)
≤2 times/week 1094 (36.8)399 (34.7)695 (38.2)
3–6 times/week 836 (28.1)316 (27.5)520 (28.6)
Daily 883 (29.7)372 (32.4)511 (28.1)
DIETARY PATTERNS OF UNIVERSITY STUDENTS
A cluster analysis based on the four factors derived three mutu-
ally exclusive clusters, which form 26.8, 35.4, and 37.8%, of all
participants respectively. As shown in Table 4, the three clusters
were labeled as:
- the “vegetarian/low calorie” dietary pattern (cluster 1 with
N=788): as it had a strong inverse correlation with fac-
tors 1 and 4 (western type foods and white bread, respec-
tively), and a weak but positive correlation with factor 2 (plant
foods),
- the “mixed”dietary pattern (cluster 2, N=1042): had the high-
est scores for factor 2 (plant foods), followed by factor 3 (com-
posite dishes), and factor 4 (white bread),with a low correlation
with factor 1 (western type foods),
- and the “westernized”dietary pattern (cluster 3, N=1112) with
the strongest association with factors 1 and 4 (western type
food and white bread, respectively), and an inverse correla-
tion with factors 2 and 3 (plant foods and composite dishes,
respectively).
CHARACTERISTICS OF STUDY SUBJECTS ACCORDING TO DIETARY
PATTERNS
Correlations between subjects’ characteristics and their dietary
patterns were presented in Table 5. Subjects following a
westernized diet included individuals with a higher weight and
height, but not a higher BMI. We observed that the vegetarian/low
calorie and the mixed dietary patterns were more adopted by
females, whereas the westernized dietary pattern was more com-
mon among males (p<0.001). Lower income level students and
those from the Lebanese public university were more likely to
consume a mixed dietary pattern, while those of higher income
level and in private universities were more likely to consume
either a vegetarian/low calorie or a westernized dietary pattern
(p<0.05). Furthermore, 40% of students (N=418) who follow
the westernized dietary pattern corresponded to individuals who
reported doing no sports at all whereas the 2nd largest group
among westernized dietary pattern consumers (16.7%, n= 175)
reported doing highest level of physical activities, while students
following the vegetarian/low calorie dietary pattern were the most
to report low to moderate physical activity levels compared to
students adopting the two other dietary patterns (p=0.004).
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Salameh et al. Dietary patterns of university students
Table 3 | Pattern loading of the four major factor solutions after
promax rotation.
Food item/
food category
Factor 1
Western
type foods
Factor 2
Plant
foods
Factor 3
Composite
dishes
Factor 4
Bread
Carbonated beverages 0.756
Fried potatoes and chips 0.710
Fast food (pizza,
hamburger)
0.663
Hot beverages (coffee,
tea, Nescafe)
0.520
Desserts 0.451
Fruits 0.799
Vegetables and salads 0.773
Olive oil in food 0.558
Rice and pasta 0.721
Grains/lentils, peas 0.579
Fish and seafood 0.576
Cooked vegetables 0.505
Meat, hot dog, luncheon
meats
−0.431
White bread 0.797
Brown bread −0.734
Table 4 | Classification of university students in the study sample by
cluster analysis using food categories factor scoring.
Cluster 1
N=788
(26.8%)
Vegetarian/
low calorie diet
Cluster 2
N=1042
(35.4%)
Mixed
diet
Cluster 3
N=1112
(37.8%)
Westernized
diet
Factor 1: western food −0.74 0.14 0.40
Factor 2: plant food 0.20 0.77 −0.86
Factor 3: composite dishes −0.20 0.56 −0.38
Factor 4: bread −1.16 0.38 0.47
CORRELATES OF DIETARY PATTERNS
Multivariate analyses were conducted to explore the correlates
of dietary intake patterns of university youth, where the mixed
dietary pattern was taken as a reference. For the vegetarian/low
calorie dietary pattern, we found that females were particularly
more likely to report adopting this pattern compared to males
(ORa =1.62; p<0.001). Similarly, students who adopted this
dietary pattern where from the highest income level compared
to the lowest income level (ORa=1.45; p=0.021) and had the
highest BMI (obese category) versus lowest BMI (underweight
category) (ORa =2.80; p=0.004). Age, physical activity level, and
type of university were not found to be significant correlates of the
vegetarian/low calorie dietary pattern.
With regard to the correlates of the westernized dietary pattern,
we observed that females were less likely to adopta westernized diet
compared to males (ORa =0.64; p<0.001). For physical activity
level, students reporting low to moderate physical activity levels
(first and second quartile) were less likely to adopt a westernized
dietary pattern compared with those who reported no physi-
cal activity [ORa =0.75 (056–1.00) and ORa =0.63 (0.47–0.86),
respectively]. Age, income, and type of university were not found
to be significant correlates for adopting the westernized dietary
pattern among the study population (Table 6).
DISCUSSION
In this cross-sectional study, we present findings on the main
food categories and dietary patterns adopted by a large sam-
ple of university youth in Lebanon. We highlight differences in
dietary intakes among university students and explore correlates
of dietary patterns, focusing primarily on gender and BMI status.
Four main food categories consumed by the study participants
were derived, namely western type foods including fried potatoes,
chips, fast foods, carbonated beverages, and desserts; plant-based
foods including raw vegetables, salads, fruits, and olive oil; com-
posite dishes including grains (rice, pasta, white bread), cooked
vegetables, fish, and seafood, and a low intake of red meat.
University students’ consumption of these food categories was
further explored allowing for dividing the study participants into
three groups referring to three dietary patterns adopted based on
the consumption of the four derived food categories. The first
vegetarian/low calorie dietary pattern was adopted by more than
a quarter of the study participants (26.8%, N=788) and it was
characterized by the low consumption of white bread, wester n type
foods, and a higher consumption of plant-based foods only. The
mixed dietary pattern was adopted by slightly greater than a third
of the university students (N=1042) and was characterized by
the high consumption of plant-based foods, followed by compos-
ite dishes, and bread as well as a low consumption of western type
foods. Whereas the westernized dietary pattern was adopted by the
largest group of students in our sample (38%, N=1112) and was
characterized by the high consumption of white bread and west-
ern foods such as fried potatoes and chips, fast foods, carbonated
beverages and desserts, and the strong avoidance of plant-based
foods and composite dishes.
Identified dietary patterns in our study were relatively simi-
lar to those reported in other studies on the adult population in
Lebanon (35,36). According to a cross-sectional study conducted
on a large national sample of Lebanese adults aged between 20
and 55 years old, four dietary patterns were identified; these were
mainly the western, prudent, and traditional Lebanese, as well as
fish and alcohol dietary patterns. Another case–control study con-
ducted by the same research group on type II diabetic patients
and their age and gender-matched controls showed that Lebanese
adults adopted four similar patterns: refined grains and cereals,
traditional Lebanese, fast food, and meat and alcohol (36). Fur-
thermore, similar patterns were found among adolescents in other
countries, where “vegetable,” “fruit,” “sweet/salty snack foods,”
and “starchy foods” were reported in the US (37), whereas in
Brazil “western,” “traditional,” and “mixed” (38) diets were found.
These differences in identified patterns between different stud-
ies and settings may be due to numerous environmental-factors
including cultural cuisine variations, the availability, affordability,
www.frontiersin.org October 2014 | Volume 2 | Article 185 | 7
Salameh et al. Dietary patterns of university students
Table 5 | Characteristics of university students in the study sample according to the three identified dietary patterns.
Variables Vegetarian/low Mixed Westernized p-Value
Age (years) mean (SD) 20.51 (1.95)20.31 (1.78)20.33 (1.78)0.066
Weight (kg) mean (SD) 64.39 (14.39)64.79 (14.91)66.95 (16.88)0.001a
Height (cm) mean (SD) 168.06 (9.25)169.37 (9.96)170.73 (9.94) <0.001b
BMI (kg/m2) mean (SD) 22.67 (4.08)22.50 (4.58)22.81 (4.51)0.281
BMI classes N(%)
Underweight (<18.5 kg/m2) 60 (8.4%)105 (10.4%)97 (9.1%)0.743
Normal (18.5–24.9kg/m2) 507 (70.8%)709 (70.2%)738 (69.3%)
Overweight (25–29.9 kg/m2) 116 (16.2%)156 (15.4%)180 (16.9%)
Obese (≥30 kg/m2) 33 (4.6%)40 (4.0%)50 (4.7%)
Gender N(%)
Male 182 (29.3%)414 (36.8%)504 (45.2%) <0.001
Female 440 (70.7%)712 (63.2%)610 (54.8%)
Income level quartile N(%)
Quartile 1 124 (23.0%)256 (25.8%)232 (23.7%)0.029
Quartile 2 135 (25.0%)279 (28.1%)240 (24.5%)
Quartile 3 110 (20.4%)218 (21.9%)241 (24.6%)
Quartile 4 170 (31.5%)241 (24.2%)266 (27.2%)
University type N(%)
Public 333 (53.4%)667 (59.2%)590 (53.0%)0.006
Private 291 (46.6%)460 (40.8%)524 (47.0%)
Physical activity levelcN(%)
No sports at all 204 (35.4%)372 (36.4%)418 (40.0%)0.004
Low (≤624) 111 (19.3%)192 (18.8%)152 (14.5%)
Moderate (624–1200) 98 (17.0%)164 (16.0%)132 (12.6%)
High (1200–2160) 91 (15.8%)157 (15.3%)169 (16.2%)
Highest (>2160) 72 (12.5%)138 (13.5%)175 (16.7%)
aWesternized diet is significantly different from vegetarian diet and from mixed diet with post hoc Bonferoni test.
bSignificant difference between all three diet types with post hoc Bonferoni test.
cCalculated according to quartiles of Metabolic Equivalent (MET) multiplied by the weekly frequency and duration of physical activity.
and access to certain types of foods in addition to the nutri-
tion transition status of the countries, the Mediterranean loca-
tion, and the changes that may affect the nutrition environment
that young adults live within their respective settings (39,40).
Other individual-level parameters can also contribute to the dif-
ferences in dietary patterns including age, gender, health status,
food preferences, and the nutrition and health awareness knowl-
edge of the various studied populations (39,40). In our study,
only a select of these individual-level variables were explored as
possible correlates of the dietary patterns adopted by university
students. The dietary patterns we found were adopted differently
by university students.
GENDER AND BMI DIFFERENCES
Our study showed that a higher percentage of males were over-
weight and obese compared to females, while a higher percentage
of females were underweight. These results were comparable to
those reported among similar university student populations in
Lebanon (18,41), and in other countries (42–45): studies have
shown that young female adults are more concerned about their
weight status and body image than males, and may adopt various
restrictive behaviors to limit their caloric intake and avoid weight
gain (41,42). This was further proven in our study where women
adopted vegetarian/low caloric dietary patterns more commonly
than men (70 versus 30%), whereas, the westernized diet was par-
ticularly common for males compared to females (50% more than
females).
As reported in some studies (46,47), the adoption of a west-
ernized diet was not associated with the BMI status of the
young adult population in our study even after adjusting for
other correlates in the multivariate analyses. However, there was
a significant association between BMI status and the adoption
of a vegetarian/low caloric diet, adjusting for other covariates:
obese students adopted the vegetarian/low caloric diet more than
the mixed dietary pattern compared to underweight students
(adjusted OR =2.8, CI =1.4–5.6, p=0.004). There are several
possible explanations as to why obese students reported food
intake that reflects low caloric/vegetarian dietary pattern: obese
students may be attempting to limit their dietary and caloric
intake as a method to lose weight and similar behaviors have
been depicted in the literature (41). Another explanation might
be the fact that this result has been influenced by a possible
underreporting of dietary intake by obese students (48). Thus,
these explanations need to be interpreted with caution since there
are other variables that were not considered in this analysis and
that may affect the association between the adoption of dietary
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Salameh et al. Dietary patterns of university students
Table 6 | Correlates of dietary patters among university students: multivariate analysis.
CorrelatesaUnadjusted OR ORa 95% CI of the ORa p-Value
Vegetarian/low calories diet versus mixed dietb
Older age 1.04 1.04 0.98–1.11 0.168
Income level 0.012
Quartile 1 (reference) 1.00
Quartile 2 0.95 0.93 0.69–1.26 0.630
Quartile 3 1.01 0.94 0.68–1.31 0.721
Quartile 4 1.41 1.45 1.06–1.99 0.021
Body mass index 0.035
Underweight (reference) 1.00
Normal weight 1.25 1.41 0.96–2.07 0.076
Overweight 1.30 1.45 0.90–2.32 0.136
Obese 1.44 2.80 1.40–5.61 0.004
Private versus public university 1.18 1.23 0.96–1.57 0.099
Higher physical activity level 0.651
No activity (reference) 1.00
Quartile 1 1.13 1.21 0.88–1.64 0.237
Quartile 2 1.11 1.19 0.86–1.64 0.304
Quartile 3 1.12 1.05 0.76–1.47 0.759
Quartile 4 1.03 1.23 0.86–1.75 0.260
Female versus male gender 1.36 1.62 1.24–2.12 <0.001
Westernized diet versus mixed dietc
Older Age 0.78 0.98 0.93–1.04 0.534
Income level 0.468
Quartile 1 (reference) 1.0
Quartile 2 0.95 0.90 0.68–1.17 0.422
Quartile 3 1.21 1.06 0.80–1.41 0.693
Quartile 4 1.23 1.12 0.84–1.49 0.458
Body mass index 0.616
Underweight (reference) 1.00
Normal weight 1.13 1.08 0.78–1.51 0.643
Overweight 1.25 0.96 0.63–1.45 0.835
Obese 1.35 1.36 0.73–2.53 0.335
Private versus public university 1.22 1.15 0.92–1.43 0.214
Higher physical activity level 0.038
No activity (reference) 1.00
Quartile 1 Low physical activity 0.73 0.75 0.56–1.00 0.046
Quartile 2 moderate Physical activity 0.74 0.63 0.47–0.86 0.003
Quartile 3 high physical activity 0.96 0.82 0.61–1.09 0.171
Quartile 4 very high physical activity 1.19 0.86 0.63–1.18 0.359
Female versus male gender 0.69 0.64 0.50–0.80 <0.001
aPhysical activity level, body mass index class, and income level are categorical variables; age is a continuous variable.
bN=1392; Nagelkerke R Square=0.036; Hosmer-Lemeshow test p=0.041.
cN=1708; Nagelkerke R Square =0.031; Hosmer-Lemeshow test p =0.363.
patterns and BMI status. These variables may include the nutri-
tion knowledge and health awareness of participating students,
their possible use of weight-loss medications and supplements
that may affect their appetite, their food environment as well
as their household food security status that may affect their
food choices.
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Salameh et al. Dietary patterns of university students
PHYSICAL ACTIVITY
With respect to the level of physical activity of students and as
reported in the literature (47,49), we found that males had sig-
nificantly higher levels of physical activity through leisure time
activities compared to females. Furthermore, a significant associ-
ation was observed between physical activity and dietary patterns
that remained even after adjusting for other covariates. Students
with low to moderate physical activity levels were less likely to
adopt a westernized dietary pattern compared to a mixed dietary
pattern. However, this was not the case with those with highest
levels of physical activity. It is worth noting that students who
reported limited to no physical activity on a weekly basis were
more likely to be adopting the westernized dietary pattern rich
in energy-dense, nutrient-poor foods. This increases our concern
that university students with sedentary behaviors are consuming
unhealthful dietary patterns that increases their risk of weight
gain leading to obesity and its various comorbidities during their
young adulthood years. The link between a lifestyle that combines
the high consumption of westernized fast food diets and sedentary
behavior with increased obesity is well-established in the scientific
literature (50).
SOCIO-ECONOMIC STATUS
The association of dietary patterns with income level showed
that students with low income level were more likely to adopt a
mixed dietary pattern that is considered more traditional, while the
highest income level students adopted the vegetarian/low caloric
diets (plant-based food consumption and low intake of compos-
ite dishes, western foods or breads), even after adjusting for other
covariates. This was further demonstrated with the higher odds
of adopting a vegetarian/low caloric dietary pattern among pri-
vate university students compared to public university students.
Similar findings regarding the association between high socio-
economic status and fruit and vegetable consumption have been
reported in the literature (51). These results are in line with those
published in previous studies in Lebanon that were conducted on
smaller sample sizes of university students (41,52,53), school ado-
lescent populations (45,53), and in other countries witnessing the
nutritional transition (42,54,55).
Several limitations could, however, be stated for this study:
reporting bias is possible given that food consumption frequen-
cies and the weight and height measurements were self-reported
by respondents. Additional differential misreporting may be pos-
sible across socio-demographic groups (56,57) and BMI classes
(58). Food consumption may be differentially reported by males
and females; there is a well-established evidence of underreport-
ing of dietary intakes among females and over-reporting of dietary
intakes among males, which may lead to an additional reporting
bias (57,58). The cross-sectional nature of the study also pre-
cludes causality judgment between dietary patterns and BMI. The
relationship between dietary patterns and the nutritional status
of university youth in Lebanon, in addition to other health and
nutritional parameters, remains to be established by appropriate
prospective studies (59). The nature of the non-random sample in
our study may also introduce a selection bias; self-selected individ-
uals may not represent the whole university students’ population
(59). Even more caution should be exerted in extrapolating the
results to Lebanese youth not enrolled in universities; the latter are
expected to present more unhealthy nutritional habits than the
university population.
Moreover, we may suggest a validation of the FFQ among young
adults from the Lebanese population and the use of portion sizes
and servings in addition to food consumption frequencies for
more precise results, since our semi-quantitative FFQ did not
allow us to estimate portion sizes and caloric intake. Further-
more, the collection of dietary intake by trained researchers with
strong nutrition and dietetics background can further improve the
accuracy of collected data. Further studies that take into account
the abovementioned weak points are recommended. Despite these
limitations, we still think that the high level of unhealthy dietary
patterns, including the adoption of the westernized diet, by our
study population is worth exploring further to identify determi-
nants of food consumption patterns and the associations with obe-
sity, cardiometabolic risk factors among other health outcomes.
CONCLUSION
In conclusion, we found that dietary patterns differed among uni-
versity students; males, particularly in private universities, were
more prone to adopt a westernized diet, while females were
more prone to follow vegetarian/low calorie diets. Health pro-
motion programs and evidence-based educational interventions
are needed to promote healthy eating and active lifestyle behav-
iors among young adults in Lebanon, including university student
population, in an effort to limit obesity-related comorbidities dur-
ing their adulthood years. Furthermore, given the importance
of exploring dietary patterns rather than the intake of individ-
ual nutrients and foods in relation to health, further studies are
needed to explore determinants of dietary patterns among vari-
ous populations, and more importantly, the association between
identified dietary patterns and health outcomes, including obesity
and chronic diseases.
AUTHOR CONTRIBUTIONS
Pascale Salameh designed the study and drafted the manuscript;
Lamis Jomaa carried out the analysis and assisted in drafting and
reviewing the manuscript; Ghada Farhat, Joseph Salamé, and Nina
Zeidan contributed to the discussion, reviewed the final man-
uscript and gave their consent; Isabelle Baldi was the project
principal investigator.
ACKNOWLEDGMENTS
This work was supported by CEDRE program (grant number:
118/2009); CEDRE had no role in the design, analysis or writing
of this article.
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Conflict of Interest Statement: The authors have no conflict of interest to declare.
The Lebanese University ethical committee waived the need for ethical clearance
due to the observational nature of the study and the non-traceability of individuals’
information.
Received: 15 June 2014; accepted: 25 September 2014; published online: 21 October
2014.
Citation: Salameh P, Jomaa L, Issa C, Farhat G, Salamé J, Zeidan N and Baldi I for
the Lebanese National Conference for Health in University Research Group (2014)
Assessment of dietary intake patterns and their correlates among university students in
Lebanon. Front. Public Health 2:185. doi:10.3389/ fpubh.2014.00185
This article was submitted to Child Health and Human Development, a section of the
journal Frontiers in Public Health.
Copyright © 2014 Salameh, Jomaa, Issa, Farhat, Salamé, Zeidan, and Baldi for the
Lebanese National Conference for Health in University Research Group. This is an
open-access article distributed under the terms of the Creative Commons Attribution
License (CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) or licensor are credited and that the original publica-
tion in this journal is cited, in accordance with accepted academic practice. No use,
distribution or reproduction is permitted which does not comply with these terms.
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