nutrients

Article
College Students and Eating Habits: A Study Using
An Ecological Model for Healthy Behavior
Giovanni Sogari 1,2, * , Catalina Velez-Argumedo 3 , Miguel I. Gómez 2 and Cristina Mora 1
1 Department of Food and Drug, University of Parma, 43124 Parma, Italy; cristina.mora@unipr.it
2 Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, NY 14850,
USA; mig7@cornell.edu
3 Tecnológico de Monterrey, EGADE Business School, San Pedro Garza García 66269, Mexico;
catalina.velez@gmail.com
* Correspondence: giovanni.sogari@unipr.it




Received: 15 September 2018; Accepted: 20 November 2018; Published: 23 November 2018


Abstract: Overweightness and obesity rates have increased dramatically over the past few decades
and they represent a health epidemic in the United States (US). Unhealthy dietary habits are among
the factors that can have adverse effects on weight status in young adulthood. The purpose of
this explorative study was to use a qualitative research design to analyze the factors (barriers and
enablers) that US college students perceived as influencing healthy eating behaviors. A group of
Cornell University students (n = 35) participated in six semi-structured focus groups. A qualitative
software, CAQDAS Nvivo11 Plus, was used to create codes that categorized the group discussions
while using an Ecological Model. Common barriers to healthy eating were time constraints, unhealthy
snacking, convenience high-calorie food, stress, high prices of healthy food, and easy access to junk
food. Conversely, enablers to healthy behavior were improved food knowledge and education, meal
planning, involvement in food preparation, and being physically active. Parental food behavior and
friends’ social pressure were considered to have both positive and negative influences on individual
eating habits. The study highlighted the importance of consulting college students when developing
healthy eating interventions across the campus (e.g., labeling healthy food options and information
campaigns) and considering individual-level factors and socio-ecological aspects in the analysis.

Keywords: young adults; focus group; USA; interventions; overweight; qualitative studies

1. Introduction
Overweightness and obesity rates have dramatically increased over the past few decades and
they represent a health epidemic in the United States, as well as in many other areas of the world [1–3].
According to a scoping review of risk behavior interventions in young men, Ashton, Hutchesson,
Rollo, Morgan & Collins [4] identified obesity as a serious health risk with an incidence rate of obesity
reaching 29% of the population aged 20–39 years old [5,6]. Physical inactivity and unhealthy dietary
habits are among the main behaviors that potentially have adverse effects on weight status in young
adulthood, and consequently, the future health of adults [3,7].
As reported by the World Health Organization (WHO) [8], the adult disease burden is due to
health risk behaviors that start during adolescence (e.g., unhealthy eating practices). For example,
most of the United States (US) population does not consume the recommended daily amount of fruit
and vegetables, nuts, and seeds. On the other hand, the consumption of added sugars, processed
meats, and trans fats is higher than the recommended daily intake [9]. It has been shown that after
the transition from adolescence to young adulthood, when independency increases, young adults are
continuously challenged to make healthful food choices [2,10]. Along with unhealthy eating behaviors,

Nutrients 2018, 10, 1823; doi:10.3390/nu10121823 www.mdpi.com/journal/nutrients

Nutrients 2018, 10, 1823 2 of 16

a new series of weight-related behavioral patterns begins throughout this period, such as excessive
alcohol consumption and a low level of physical activity.
Substantial life-changing transitions happened when young adults finish high school to start
college or a working life [10]. According to the literature [11–13], university is a critical period for
young adults regarding food choices and their relationship with weight gain. Some studies have even
shown that college students tend to gain more weight than those who do not attend university [14].
In order to design and support healthy nutrition campaigns (e.g., less meat options) across campuses,
it is critical to improve knowledge of dietary behaviors in the university-age population [15].
In the last decades, there has been growing interest in the development and implementation of
health promotion interventions in the workplace [16]. Studies exploring eating behavior in children [17],
adolescents [18,19], and young adults [20] have been done in recent years; however, theories to explain
such behaviors are still moving from the nascent to the mature stage [21].
Recently, the so-called Ecological Model has been considered as an acceptable framework to link
individual and social behaviors with environmental determinants, to reduce serious and prevalent
health problems [22].
The aim of this study is to explore the barriers and enablers of healthy eating behaviors among
US college students, using focus groups that foster open discussion between a small number of
participants. This study is the first stage of a larger research project called “CONSUMEHealth. Using
consumer science to improve healthy eating habits”, funded bythe European Union’s Horizon 2020
research and Innovation programme (Marie Sklodowska-Curie grant agreement No 749514).

2. Materials and Methods

2.1. Focus Groups

We selected focus group interviewing as a key methodology for the study, the elements of which
include participant observation, formal and informal interviewing, filming, and recording, among
others [23]. Focus groups are used to obtain insights and in-depth information on why and how people
think (perceptions, attitude, opinions, experience) about a topic of interest [24] used to unlock the
complexity of the decision-making process [25] and unencumbered by what we expect to find [26].
In our study, a focus group was suitable, since we were aiming to obtain cultural insights from a
group of individuals, and to explore their beliefs and behaviors [27], allowing for us to examine the
context of healthy eating behaviors [16,28]. Various studies have demonstrated that focus groups are
an appropriate research method to study eating habits, particularly among students [2,29]. Since the
definition of this population was not just a matter of age, but of lifestyle and identity, a focus group
could help us to better understand the meanings of healthy eating behaviors and its contexts.

2.2. Participants
Eligible participants were college students aged 18 to 25 years, who were transitioning from
adolescence to young adulthood, who lived in the USA, and who were enrolled at Cornell University
in the town of Ithaca (New York, NY, USA). Similar to previous studies [29], no first-year university
students were included in the study, due to their limited college experience. In addition, we excluded
students from nutrition classes or any other disciplines that might transmit a greater overall knowledge
or awareness of healthy eating. The final group consisted of students from different disciplines
(humanistic and scientific). These young adults were recruited via flyers that were distributed across
the University facilities, and via email using a college student database. In the advertisement sheet,
a link to an online survey was provided to facilitate recruitment, and to give subjects the essential
statement outline of the study (aim, benefits, and risks that are associated with time, incentives, other).
One advantage of our approach was that it allowed us to recruit participants from different disciplines
and years of study. In addition, we chose to have mixed-gender groups, which could produce a
greater variety of responses and better discussion [29]. The interview guideline was designed to take
Nutrients 2018, 10, 1823 3 of 16

participants on a journey, starting from a broader concept of health, to more specific questions on past,
present, and future diet behavior practices.

2.3. Procedure
The recruitment of participants was carried out using an online system at Cornell University.
A recruitment rate of between six and eight participants per focus group session was planned, in order
to have at least four people in each focus group session, therefore, an over-recruitment of two students
was planned in the case of ‘no-shows’.
Following the literature [29], a semi-structured question guide was developed to identify the key
questions for the research problem (eating habits, physical activity levels, and weight change). Enough
flexibility and side-questions allowed for open discussions within the group, to obtain more in-depth
information from participants.
Projective techniques were used both at the beginning of the sessions for “ice-breaking”, and
later on to understand better emotional connections and cognitions towards the topic of interest [30].
Specifically, the photograph response test technique was used, which consists of showing a series of
photographs that are related to the topic under investigation. A stimulus (images of obese/overweight
individuals) was presented to the group, and the participants were asked to answer with the first
words that came to their mind.
As reported by Guerrero and Xicola [24], the integration of different qualitative techniques (e.g.,
projective stimuli as in this study) within the same focus group was considered to be a mixed approach.
The study was approved by the Institutional Review Board (IRB) of the Office of Research Integrity
and Assurance of Cornell University (Protocol ID: 1709007406).

2.4. Data Collection Outline

During the online prescreening registration, all of the participants completed a short questionnaire,
providing self-reported socio-demographic information, physical activity, height, weight status, and
perceived body image.
Before beginning the focus group, an information sheet about the study and a consent form
for anonymity and confidentiality were signed by each participant. Drinks and a few snacks were
provided in order to make the environment as much comfortable as possible. In addition, the room
that was used to carry out the discussions was modified to look like a living room of a house.
As suggested in the literature [28], each focus group lasted around 90 min, and it was held in
a comfortable and quiet place. The sessions were video-audio recorded with the permission of the
participants, and were facilitated by a well-trained and experienced moderator (female moderator
with five years of experience in focus groups in the field of food, both in the public and private context).
The principal investigator was an observer, and stayed in another room that was connected with audio
and video recording systems during the focus group discussion. The moderator directed the flow of
the discussion, and ensured that all of the important issues were covered. We opted for small groups
(4–6 people), which was considered to be more appropriate when the topic of investigation is seen as
complex and personal [31]. Both the principal investigator and the moderator did not have any type of
relationship with the participants; we strongly believe that no bias or conflict of interest exist between
the research team, the subjects, and the focus of the study.
The semi-structured questions guide (Table 1), as developed following Krueger and Casey [27],
aimed to investigate the main factors influencing eating behaviors among college students. First,
a projective technique was first used for “ice breaking”, and to facilitate the group discussion. At the
beginning, all of the participants were asked to list “five healthy eating habits” and “five unhealthy
eating habits”, and afterwards to read the list out and share it with group. In this way, the whole
group was actively involved in the discussion, and participants became acquainted with, and felt
connected with each other. The main questions focused on factors influencing students’ health and
weight-related behaviors. Before ending each of the focus group sessions, the moderator and principal
Nutrients 2018, 10, 1823 4 of 16

investigator decided whether further questions were needed. At the very end of the focus group, all
of the subjects chose to either receive a monetary payment ($ 15) or university course credit (1.5) for
their participation.

Table 1. Short version of the Focus Group questions guide.

Question Type Questions

Presentation of the research topic and participants (demographic characteristics
Opening and warm-up questions
and some general eating habits like “what do you have for breakfast?)
Could you list five habits related to healthy and unhealthy eating?
Introduction/Projective techniques
Could you mention the first types of food/food products you consider healthy?
How do you think the concept of healthy eating has changed?
Transition questions (to move into
Were you involved in cooking preparations in the past?
and between key questions)
What changes happened in your cooking habits since you started college?
What different eating behaviors do you have between eating out and at home?
What is for you the meanings of the word “healthy” and “unhealthy”?
What is your eating behavior to stay healthy?
What are the consequences of having a healthy eating behavior?
Main key questions
How may have the community (e.g., colleges)
impacted on your healthy and unhealthy habits?
How can a parent/guardian positively/negatively
influence on children’s eating behavior?
Projective technique
(i.e., showing images of What comes into your mind (e.g., thoughts) when you see these images on obesity,
overweight/underweight overweightness, and a healthy body weight?
adults/children)
Are there any other opinions related to the topic? Is there anything else you would
Ending
like to share?

2.5. Data Analysis

In the field of health studies, the use of focus groups for research is a relatively recent
phenomena [28]. The information resulting from focus groups is usually analyzed throughout a
process of categorizing and coding the data in a systematic manner.
At the end of the six focus group sessions, the audio tapes were transcribed verbatim in Microsoft
Word by an independent transcription agency, and they were double-reviewed by two researchers.
Second, the data collected were analyzed by the principal investigator and two research assistants
who were trained in qualitative analysis. All quotes were encoded using the computer-assisted
qualitative data analysis software Nvivo11 Plus Version 11 (QSR International Pty Ltd., Melbourne,
Australia) [32]. This software helped the researchers at the stage of data analysis, marking, and coding
the transcription, and helped them to identify the relations between categories (concepts, themes, and
ideas) and individuals [28].
An inductive thematic approach, which is useful for identifying core meanings that were relevant
to the research objects, was used for data analysis, in which quotes were coded and categorized into
themes and subthemes [25,33]. These themes were organized into individual, social, and environmental
categories using an Ecological Model framework [16,22], and were successively described. A Microsoft
Excel package was used to analyze the characteristics of the sample using responses from the
questionnaire (descriptive statistics).

3. Results

3.1. Descriptive Results

In our study, six focus group discussions were conducted until saturation of new information was
reached. The final sample consisted of 35 students (23 females), with a mean age of 20.4 ± 1.5 years
and a mean body mass index (BMI) of 23.2 (SD ± 4.52), which was calculated as weight (kg) divided
Nutrients 2018, 10, 1823 5 of 16

by height squared (m2 ). Most participants considered themselves to have a healthy weight status,
and few of them indicated current or past eating disorders. The characteristics of the sample are
summarized in Table 2. Participants were also from a variety of study disciplines and different college
years (from junior to senior). This variety in participant characteristics enormously contributed to
gather more insights (e.g., diverse experiences and opinions) into the relationship between behaviors
and healthy eating.

Table 2. Characteristics of focus group participants (n = 35).

Group Characteristics Responses % Mean ± SD

White/Caucasian 80
Asian (excluding South Asian) 11
Race/ethnicity
African American 6
South Asian 3
Gender (female) 66
Age (years) 20.4 ± 1.5
Body Mass Index (BMI) 23.2 ± 4.5
Business 42.9
Scientific 34.3
Field of study
Humanistic 14.3
Info not provided 8.5
Job 42.9
Students with an extra job No job 40
Info not provided 17.1
Physical activity
No exercise 15.2
Exercise 1 time per week 21.2
Exercise 3 times per week 42.4
Exercise 5 times per week 21.2
Self-assessment weight status
Underweight 9.1
Normal weight 66.7
Overweight 21.2
Population Area (size of the city)
<5000 inhabitants 15.1
Between 5000 and 50,000 inhabitants 27.3
>50,000 inhabitants 57.6

3.2. Qualitative Results

Following the literature [31], the researchers reviewed the transcript line-by-line encoding and
classified the text. As a first step, the questions that were enclosed in the script were used as initial
categories, then during a rigorous and systematic reading of the transcript, the main categories started
to emerge [33]. The researchers used an inductive coding method to find meaningful messages to
categorize into main themes and sub-themes.
The information was then analyzed in conjunction with the Ecological Model conceptual
framework. The importance of the Ecological Model in the social sciences is the consideration
of interactions between the people’s behavior and the environment (sociocultural, policy, and
physical) [16,29].
With the results from this model, we developed a list of factors influencing healthy eating
behaviors among college students, based on content analysis of the focus groups (Figure 1). We adapted
a model by Deliens, Clarys, Bourdeaudhuij & Deforche [29], and then developed the following main
levels for the analysis: individual (intrapersonal), social (interpersonal relationship), and university
environment (community settings), and some main attributes of the students (e.g., gender). The most
 interactions between the people’s behavior and the environment (sociocultural, policy, and physical)
[16,29].
With the results from this model, we developed a list of factors influencing healthy eating
behaviors among college students, based on content analysis of the focus groups (Figure 1). We
adapted a model by Deliens, Clarys, Bourdeaudhuij & Deforche [29], and then developed the
following
Nutrients 2018, 10,main
1823 levels for the analysis: individual (intrapersonal), social (interpersonal relationship), 6 of 16
and university environment (community settings), and some main attributes of the students (e.g.,
gender). The most significant quotes by respondents were reported to illustrate each (sub)theme. We
also decided
significant quotes to incorporate some basic
by respondents were information
reportedoftothe participants
illustrate eachby(sub)theme.
using an ID forWe
the also
quotes:
decided to
e.g., FG1_F21
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(Focus Group 1, Female,
Figureage 21 years
1. Factors old). healthy eating behaviors of college students.
influencing

Barriers and
enablers to a healthy
diet

Individual level University Social level

Healthy eating: meaning, environment and
Parental feeding behavior
perception, and consequences student life
Diet at home, school, and
Eating habits (healthy and eating out
unhealthy)
Friends and media
Food preferences pressure
Healthy activities
Food preparation and
knowledge
Time, price, and state of mind
Source: Authors’ creation

Figure
3.2.1. Individual Factors influencing healthy eating behaviors of college students.
Level1.(Intrapersonal)
3.2.1. Individual Level
Intrapersonal (Intrapersonal)
factors are represented mainly by attitude, behavior, self-concepts, and skills [16].

Intrapersonal factorsMeaning,
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fulfil your daily nutrition requirement, even though I obviously don't do that” (FG1_F20).
eating clean. So, lots of fresh veggies and fruits and some sort of protein” (FG1_F20); however, they were also
There was a gap between having knowledge and actually practicing it: “… now I feel like I'm more
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daily nutrition requirement, even though I obviously don’t do that” (FG1_F20).
There was a gap between having knowledge and actually practicing it: “ . . . now I feel like I’m more
aware of it (healthy eating), I just don’t pay attention to it” (FG5_F21). In addition, they highlighted how
the meaning of healthy eating had changed over the past decades: “when I was a kid, I definitely thought
it was more ... just eating less, ... now I understand that it’s more eating the right things, and not necessarily
eating less, but just eating different stuff ”(FG1_F21).
During the focus groups, the term “healthy” itself proved to be quite elastic: “I think about getting
a lot of balance” (FG3_M23) and it was perceived to have changed overtime: “before, it was all about
portion control, eating smaller things, but now, it’s focused more on eating healthy things” (FG1_F20). Most
participants considered their generation to be more health-aware and more health-conscious than the
previous ones. However, others believed that today, it is harder for people to eat healthy because there
is so much fast food available. For someone whose parents taught them during childhood, healthy
Nutrients 2018, 10, 1823 7 of 16

eating remained an important factor for the future: “my mom told me when I was a kid, healthy eating is if
your plate is colourful, so sometimes when I went through that little phase where I was trying to eat really well
at the dining halls I’d be like, carrots, orange, tomatoes, red, I’d get a bowl of blueberries, blue. You’d try to get
every colour on your plate and that’s healthy” (FG5_F19).
Participants were aware of the long-run consequences of not maintaining a healthy diet: “It’s
risk for diseases, increasing your risk of dying earlier” (FG4_F19); “you have less health problems, for the most
part, that are related to your diet. You probably have more energy, honestly, because processed stuff sort of slows
you down” (FG1_F20). In particular, a male participant reported: “I think that America has this epidemic,
which is obesity. And I know that leads to a whole bunch of complications, especially the demographic that I am.
I understand that our life expectancy isn’t as high as other demographics, and that’s due to obesity, diabetes,
heart disease and stuff like that” (FG2_M20).
They also considered “eating healthy” as something that was related to a lifestyle with positive
consequences to the general mindset of the individual: “I think healthy is feeling good about yourself,
having energy, and not being exhausted all day” (FG2_F18); “I think healthy goes beyond just food, you
have to be mentally healthy and physically healthy” (FG2_F19); “I tend to like healthy food, it makes me feel
better” (FG6_M22). More generally, people related the concept of being healthy to both physical and
psychological status: “I think being healthy is both your physical appearance and your mindset . . . exercised
and eating food, as well as balancing it out with your mental state” (F2_M20).
We used a projective technique to create more interaction and interest on the topic. Images of
overweight/obese people were shown, and participants were then asked what thoughts came into
their mind. Most participants felt uncomfortable with describing these images. Some of them thought
that being heavily overweight or obese could be attributed to not having control over their own
lifestyle: “I feel bad for them, because I know the probably inside, they are not happy with themselves, but it’s all
your personal choice” (FG3_M19). At the same time, there was a feeling both of sadness for them, but
also a willingness to not judge other people’s weight status. Only one person mentioned that body
image was a motivator in maintaining healthy eating: “I want to be in a good shape, and I think that’s what
motivates me” (FG4_M21).

Eating Habits (Healthy and Unhealthy)

Every participant was asked to list five healthy and five unhealthy eating habits on post-it notes
and then share it among the groups (Table 3). First, snacking was associated most of the time with
unhealthy eating, as mentioned by several participants: “I’m trying to eat a heavier breakfast so that I snack
less throughout the day” (FG1_F21); “I have snacks late night, mostly, if I’m going to snack at all, it’s generally
junk food” (FG4_M19). Only a few of them tried snacking with an healthy option: “I don’t mindlessly
snack, but when I do snack, it’s always something healthy like nuts or fruit” (FG4_F19). Some participants
did not seem conscious of having three meals a day, but preferred to have smaller snacks consistently
throughout the day and being portion-aware: “I try to eat like four to five times a day like smaller meals
as opposed to just like breakfast, lunch and dinner” (FG3_M23). Regarding drinking habits, surprisingly,
alcohol consumption was not mentioned as an unhealthy drinking habit; but more attention was
focused on the most common daily drinks (i.e., water, coffee, and soda). One female participant said:
“I like carbonated drinks, like sugary drinks that I should probably stay away from” (FG1_F21). Many people
were aware that a high sugar-sweetened beverage intake was associated with greater weight gain.
The participants were asked about why American consumers do not follow the dietary guidelines
given by the United States Department of Agriculture (USDA). Most of them mentioned that nowadays
there is a greater availability of unhealthy foods: “I think there’s a lot more junk food now than there
was then, and it’s also way cheaper than getting healthy food” (FG1_F20); “I think junk food is way more
accessible than going out to get healthy food” (FG1_F21); “sometimes people just don’t have access to food in
their neighbourhood” (FG6_M22).
Nutrients 2018, 10, 1823 8 of 16

Table 3. Top 12 self-reported healthy and unhealthy eating habits of the participants.

Healthy Eating Habits Frequency (n) Unhealthy Eating Habits Frequency (n)
Consumption of fruit and vegetables 26 Irregular meals 25
Sweet food (i.e., dessert, ice-cream, candy,
Drinking water 13 21
chocolate)
Balanced diet 12 Unhealthy snacks 15
Portion control 8 High salty and fat food (i.e., fried food) intake 13
Having breakfast 8 Overeating 10
No sweet food 8 Skipping breakfast 10
Over protein consumption (i.e., too much meat,
No oils/fat (e.g., less sauces) 7 5
eggs)
No processed food (i.e., whole food) 7 Eating disorders 5
Regular meals 7 Low water consumption 5
Protein consumption 7 Drinking soda 4
Self-prepared meals 6 Low fruit and vegetable consumption 4
Healthy snack (i.e., nuts) 5 Coffee consumption 3
Other Other
Notes: “Other”: eating habits that have been mentioned only one or two times. The researchers decided not to
report them.

Food Preferences
Food preferences are highly complex, personal, and influenced by a broad variety of factors,
especially physiological. Even if health seemed to be important for everyone, when choosing food,
students did not take health into consideration as the most important factor, but usually pleasure and
taste. As one participant said: “I think unhealthy food just tastes better. I don’t know, if a food tastes good to
me, I have thoughts of, "Is this unhealthy?" Because I feel like healthy food just doesn’t taste as good” (FG2_F19).
Likeability as a first factor for choosing food was confirmed by another student: “I think unhealthier
food just tastes better to everybody” (FG2_M20). Another participant highlighted the importance of the
pleasure of eating: “I really like pasta, like a lot, it’s pretty much what I eat every day. I put hot sauce on
everything” (FG5_F19).

Healthy Activities
Almost all of the participants mentioned that they had been very busy since they started tertiary
education, and that this was a barrier to maintaining a healthy lifestyle. They remembered that
exercising was as a big part of family time: “ . . . me and my two brothers and my dad, we started going
to the gym. So we’d go to the gym like every weekend” (FG2_M20); “I play a lot of soccer with my dad”
(FG3_M19). It is clear the role of parents in incentiving activities to stay healthy: “my parents were
also very encouraging of me and my other siblings with doing sports” (FG6_M21). Nowadays, due to time
constraints associated with being a college student, it was more difficult to stay active. The statement
“not keeping junk food in the house” was repeated by several students as a way to avoid the temptation of
eating unhealthy foods, as was having small snacks throughout the day rather than designated meals.
They were also aware about overeating, and few of them believed themselves to be good at controlling
portion sizes: “I try to get individual packages, so I have portion control” (FG2_F18).

Food Preparation and Knowledge

In order to eat healthy, consumers must have some knowledge about food, healthful products,
and the composition of a meal, among others. During the focus groups, participants were asked about
changes that they had made in their cooking habits since they had moved from home. Some of them
realized how negative the changes were in terms of eating healthy: “the first time I lived outside of home
wasn’t good. I ate out twice a day, every day, which is really unhealthy and really expensive. So now I’m trying
to cook more, which is good. I feel like I’m healthier when I’m cooking it myself ” (FG1_F21). Others confirmed
how expensive it is to eat out frequently: “Well I didn’t cook at all when I was at home. So just off campus,
it’s cheaper to cook than eating out every night, so I’m just trying to cook more” (FG1_F21).
Students were asked their involvement in preparing food when living with their parents,
the majority declared to have never helped in the kitchen or only during holiday meals. One participant
Nutrients 2018, 10, 1823 9 of 16

shared a personal experience: “Only for Thanksgiving or Christmas I would usually make a dessert or
something like that. Cake or cookies” (FG6_M21).
When asked to elaborate more on a healthy diet and give examples, few students had a vague
idea of what the Mediterranean diet was about: “I’ve definitely heard of it before, but I don’t ... is it like,
only eating certain Greek, Mediterranean ingredients?” (FG2_F19), and most of them had not even heard
of the term before.

Time, Price and State of Mind

The transition from living at home to the college experience was considered to be stressful. Most of
the participants mentioned a problem with stress eating, especially when studying; as one participant
said: “ . . . I definitely snack too much when I’m stressed” (FG4_F19). Another one: “I work too much. I don’t
take the down time to exercise. I like to snack a lot. I use food to regulate my mood” (FG6_M22). Almost all
participants believed that they did not have enough time to prepare healthy meals. The “lack of time”
appeared to be an important barrier: “I don’t have time to be going to the grocery store to just get fruit and
healthy things” (FG1_F20). Time constraints also made students skip meals: “ . . . then sometimes I will
eat at random hours during the day, including sometimes I’ll have to skip lunch if I just don’t have enough time,
which I can see the effects, it just makes me really tired, it’s not good for working out” (FG4_F19).
Also, the relative perception of the high costs of buying healthy food (i.e., fruits and vegetables)
was one of the main barriers to a varied diet [2,34]. For many students: “junk food is way cheaper than
getting healthy food”; as one female participant specified: “it can be hard to afford healthy food, because
no matter what healthy eaters say about how easy is to find cheap, healthy food, it’s always probably gonna be
cheaper to find heavily processed junk food” (FG1_F20). Another female participant with Asian origin
confirmed with her personal experience that: “it’s very abnormal in America that the fruit and the vegetables
are much expensive than the meat, because back in China the vegetables and fruits are very cheap, so everyone
can have access to that” (FG5_F24).

3.2.2. Social Level (Interpersonal Relationships)

Social relationships in early adulthood are predominantly formed with roommates and friends at
college, as well as with family members, even if with a lower frequency with the latter. The perception
of social pressure was a strong determinant in supporting and maintaining a healthy diet [35]. As one
participant said in relation to healthy eating: “What you eat and who you’re around is really influential”
(FG2_F20). Another one confirmed this point: “Seeing if someone’s eating really unhealthy, you can be
like: "I’m going to be the one to eat healthy tonight", or if everyone’s eating healthy, you feel more inclined to
eat healthy” (FG2_F20). Sometimes, it was also the influence of the partner that could make a person
change their dietary habits.

Parental Feeding Behavior

Respondents were asked about how parents can negatively and positively impact a child’s eating
behavior. They agreed that it was difficult for kids and adolescents to learn about eating healthy if their
parents did not influence and teach them: “I think as a child, you look up to your parents a lot, so instead of
verbally saying, "Eat healthy, blah blah blah . . . " you actually have to show it” (FG2_F19).
One student explained that sometimes there was a risk that the parents were too busy to take care
of their children’s diet: “If parents are too busy or they don’t have the income and also the time, if they’re
working too many jobs, you know, they’ll just get packaged food or processed foods and that could definitely have
a very negative effect” (FG6_M21). As a result, the parents prefer to give them money to buy food away
from home and most of them choose junk food or fast food: “if I’m with my friends, I can kind of get away
with my mom not knowing what I’m eating. So I tend to eat what I can’t eat at home, so always unhealthy”
(FG1_F21).
These young adults believed that parents should give a good example (i.e., not going to a fast
food place). Most of the students mentioned the role of the mother as a relevant figure for giving good
Nutrients 2018, 10, 1823 10 of 16

recommendations: “my mom has always ingrained the healthy eating thing in me” (FG1_F20); “when I was
younger ... even now, my mom only has healthy food available for me. And if I ever shop with her, she doesn’t let
me buy snacks or sweets” (FG1_F21). The participants who mentioned that their parents were good at
cooking, and liked preparing foods from different cultures, also realized that they should not be really
picky in their food choices. Others reported that their parents used some tricks to make their children
to eat healthy food: “I think my parents just seasoned my vegetables so it would taste better. And that way I
wouldn’t really have to think about me eating vegetables” (FG4_M20). Other students experienced a more
ambiguous and controversial approach with food: “We weren’t allowed to leave the table until I finished
my food” (FG4_F21); in this case, sometimes their mothers were part of the "Clean Plate Club”, a club
where parents are used to asking their children to finish everything on their plates.

Dietary Aspects of Home, School, and Eating Out

Respondents were asked what different eating behaviors they had between eating out and at
home. Even if young adults ate in a variety of different settings, especially after living with their
parents, the number of times eating out strongly increased. For instance, eating at home was usually
correlated with higher fruit and vegetable intakes. However, many participants said that eating out
was a kind of relief where all food desires could be satisfied: “I tend to eat what I can’t eat at home, so
always unhealthy” (FG1_F21); “when I’m eating out "I might as well treat myself" and treat myself for nothing”
(FG4_F21); “when I lived at home, I would always eat really healthy, so whenever I go out, I tend to eat a lot of
junk food” (FG1_F21). One participant’s personal experience confirmed that: “usually when I go out with
my friends or family, I eat just such trash food. And restaurant food to begin with is already so caloric, and then
you just add on top of it, let’s get appetizers and desserts” (FG4_F19).
High school had also a strong determinant on eating habits; most of the time, eating in secondary
school was related with a negative experience: “a lot of times in high school I just ate chips, because I just
hated my school lunch, it was pretty bad. But I think if the school lunch is the only thing that’s available to you,
it’s definitely going to affect what you’re eating and how you’re eating” (FG4_F21). Several students reported
that they did not feel that the school meal was healthy, due to limited choices. One remembered: “we
always used to joke about saying that pizza counted as a vegetable, we had to get a vegetable but pizza counted,
so we’d always get pizza” (FG4_M19). However, almost all of the participants agreed that nowadays,
schools are getting more involved in providing healthy options than in the past: “I think our school
definitely they had healthier options” (FG5_F19).

Friends and Media Pressure

Young adults are often influenced by their peers for many habits, and also when eating behaviors
are involved [29]; as one male participant, who had a high frequency in activity level and played in
a team, said: “there is just so much social pressure to eat healthy around other people” (FG3_M23). As one
female student reported: “I think every girl has this kind of thing and you have some pressure from your
friends and if you will see them wearing beautiful dresses you want to lose weight or something” (FG5_F24).
Another explained: “I think general rule of thumb, if you see people [friends] that look healthy, that we tend to
ask someone, what do you eat? How do you do that?” (FG5_M21). Usually, meals with friends tended to be
not healthy: “when I’m with my friends in the evening we do tend to eat heavier meals, which make me feel
pretty sick the next morning”. However, for someone else, the experience was the opposite: “I think the
big thing that changed for me was when I came here at Cornell, I saw other people and their eating habits, and
some of them were eating lean or eating healthier, and I tried to pick up on some of those too” (FG4_M21).
Many participants raised concerns about the role of television and other mass media on how an
adolescent or young adult should look: “I just feel like in the media, you see all these images of celebrities and
their body type is glorified, so you just want to eat healthier to look like that” (FG4_F19). In addition, they also
considered advertisement on TVs for candies and other sweet foods to be negative communication on
what to eat, as one participant said: “ . . . there’s all these ads on TVs for candies and stuff like that . . . kids
would rather have the bright colors, the fun candies and stuff that aren’t necessarily healthy” (FG1_F21).
Nutrients 2018, 10, 1823 11 of 16

3.2.3. University Environment and Student Life

Besides human physiology, the physical environment is also another element that can strongly
shape our food choices [36]. In general the surroundings where you are living can strongly determine
your diet: “I also think like your environment that you’re in and that like you’re constantly in really affects how
you eat” (FG3_M19).
The university environment could have both a positive and negative influence on eating habits, as
one participant explained: “I think if the community is driven to be healthier, then I think once you’re in that
environment, it tries to influence you to be healthier. And seeing other people around you eat healthy and want
to be healthier is a big influencer on changing your habits. And vice versa” (FG2_F20). For example, most
of the students thought that the dining halls strongly influenced their eating habits. Some students
started to eat irregularly when starting college: “I eat irregularly, like sometimes for dinner I just don’t want
anything in the dining halls and I’ll just eat cookies or the ice cream” (FG5_F19); “I probably eat more meat at
college, I don’t know, just a lot of food” (FG5_F19). When asked what events could make a person gain or
lose lots of weight, someone said that going to college made people gain weight: “having that sort of
unrestricted freedom of being able to choose whatever you want to eat, and also having a meal plan where it’s like
an “all-you-can eat” buffet” (FG1_F20). One participant shared a personal experience and said: “I need to
go eat every meal at the dining hall. And once you’re at the dining hall, you have unlimited food, so I feel like
I overate a lot in the dining halls. And now living off campus, I’m able to just buy what I want to cook, and
sometimes I cook all my food at once. So I can plan, this is for lunch, this is for dinner. So I can do better with
portion control” (FG1_F21).
For some other students, especially athletes, having the dining hall always available and close to
the dormitory or workplace was instead an advantage: “it was good to have the dining halls right there
so you could kind of eat whenever you wanted to. So it helped me stay healthy and had a good eating pattern
for that kind of lifestyle. And then, I think once when I got off campus, it’s like harder to keep up with good
eating patterns” (FG6_M21). Student life could be a critical period regarding unhealthy changes in
lifestyle behaviors: “I also sometimes skip lunch when I have class or studying to do, and a lot of times when
I’m studying I also eat junk food, try to keep myself awake” (FG4_M21).
Table 4 summarizes the main barriers and enablers that are associated with health decisions
during college life.

Table 4. Summary of the main barriers and enablers to a healthy diet among college students (n = 35).

BARRIERS ENABLERS
Individual-level
Individual-level
Not exercising
Maintenance of healthy lifestyle
Not eating healthful food
Healthy eating habits
Time constraints
Food knowledge and education
Unhealthy snacking
Meal planning
Convenience food
Involvement in food preparation
Bad mood & stress
Physical activity
High prices
Being portion-aware
Junk food home availability
Social-level
Social-level
Parental food behavior and influence
Friends pressure and influence
Friends pressure and influence
Parental food behavior and influence
Low food culture
University Environment
Environmental-level
College’s dining services
College’s dining services
Availability of high-calorie food and fast food
Source: own elaboration.
Nutrients 2018, 10, 1823 12 of 16

4. Discussion
Using an adapted version of an Ecological Model used by Deliens et al. [29], we developed a
framework that included individual (intrapersonal), social (interpersonal), university environment
(community settings), and students’ life factors as influences affecting eating habits. This model
integrated individual healthy and unhealthy eating patterns, in combination with the main barriers
and enablers that are associated with health decisions during college life. Many researchers [4,15,37–39]
identified a great number of factors that may contribute to the malnutrition epidemic, and related
health problems (e.g., weight gain and other dietary disorders) in emerging adulthood: unhealthy
eating habits increased when young adults leave their home circumstances, such as lower consumption
of healthy options (i.e., fruit and vegetables), irregular meals (e.g., breakfast skipping), and increasing
intakes of unhealthy snacks and other “junk food” (e.g., fried food). For college students, the transition
phase from living at home to living alone/with roommates during the period of postsecondary
education, is one of the most important life changes, and many food choices are deeply involved in
this change.
As indicated by other authors [2–4,35], the most common factors that are reported as barriers to a
healthy diet are time constraints, the high price of food items, and their availability, followed by the
lack of motivation in food preparation, which is strongly related to intention. Regarding the latter
barrier, as reported by Menozzi, Sogari & Mora [35], intention is the main factor in predicting behavior
regarding the consumption of healthy foods, such as fruits and vegetables. Therefore, we believe
that nutrition professionals within the university community should design programs and tools that
can help students to be more motivated in choosing healthy food. During the focus groups, students
realized the strong role of college facilities in influencing their eating habits. In fact, when students
start college, they will face a new (food) environment (e.g., all-you-can-eat formula dining), which can
have strong impact on their eating habits and intention to perform a healthy behavior. Interventions
across campus dining facilities should decrease the potential barriers to healthy food, and increase
self-efficacy and behavioral controls, to encourage students to embrace a better diet [40].
Among the social enablers, students found that having the support of friends to be active in
healthy eating was an important stimulus. We also observed that students who have a higher frequency
of physical activity believe that social pressure helps them to stay healthy. Parents also have a crucial
role, both positive and negative, in shaping the concept of healthy eating and in encouraging children
in healthy activities, both related to eating (e.g., food preparation) or more physical (e.g., sport,
outdoor activities). We noticed how perceived benefits of healthy eating also influence the intention to
consume healthier food [41], which seems to be more easily achieved if students start planning their
meals (self-control technique). Moreover, university characteristics, such as living arrangements (i.e.,
dormitory, off-campus, with parents) or academic schedules (e.g., classes, exams, etc.), also influence
the relationships between individuals and their eating behaviors [18,29,42], and they should be taken
into account when designing effective and tailored multilevel intervention programs.
Finally, it should be noted that some barriers for certain individuals, might be perceived
as potential drivers by others. For instance, and not surprisingly, some students stated that
“all-you-can-eat” formulas have a negative impact on the amount and quality of food consumed,
whereas others believed that these types of dining halls facilitated their ability to have a healthy diet.
The focus groups confirmed that both lifestyle and behavioral factors are strongly associated with
dietary patterns among college students: participants were aware that “being a healthy person” was
not just exercising and eating healthy foods, but also taking time for yourself and being an overall
happy individual.
One of the methodological limitations to the current study is that these results cannot be
automatically generalized to the whole population of university students, when considering the
specific and limited sample of participants (i.e., US college environment, healthy BMI status, other).
Another limitation is related to the presence of students who might have been more interested in this
topic, and decided to participate at the focus group, leading to “selection bias”.
Nutrients 2018, 10, 1823 13 of 16

5. Implications
More precision in the relationship between food and health is a topic of growing importance on
the public agenda [43]. Nevertheless, even with wide recognition that the food that we consume has a
strong impact on our health, consumers’ food preferences do not always lead to the best nutritional
choices. A better understanding of the link between diet and health among college students is
important for developing programs and behavioral change strategies to improve their lifestyle in
general, and to reduce diet-related diseases in particular [9].
This study highlights the importance of consulting college students when developing healthy
eating interventions across the campus for dining services or programs. As suggested by Stok et al., [10],
researchers in the food and nutrition field should not only focus on individual-level factors, but they
should also integrate socio-ecological aspects into the analysis. Dining halls and other University
facilities should ensure the availability of healthy food choices, as well as promoting physical activity
practices regularly. They should also provide food education and food preparation classes, to make
students more knowledgeable on how to cook and better plan meals.
Giving college students the necessary skills to be more aware of what a healthy diet style means
would empower them to make better food choices throughout their life. As suggested by many
authors [4,44], interventions should be specific for the targeted population (i.e., young adults) in order
to help individuals to behave accordingly with their healthy intentions. For instance, social media
facilitates the interaction between individuals and organizations (e.g., university administrators and
food researchers), in order to provide tailor-made information [29,45]. This aspect can be helpful in
promoting healthy diets without creating eating disorders. In addition, price reductions for high-cost
foods in campus facilities, such as dining halls and cafeterias, should also facilitate the purchase of
more healthy options (e.g., fruits and vegetables). Environmental modifications can include changing
and/or labeling healthy food options to make them more appealing, while creating a point of nutrition
information where students can see healthy food options.

6. Conclusions
The aim of this study was to identify factors driving healthy lifestyle behaviors among US college
students. Opinions and recommendations for effective and tailored-made intervention programs
or environmental modifications that support healthy eating were presented, using an ecological
framework that combined psychological, social, and environmental strategies.
Consumer behavior scientists typically do not contribute to the scientific debate about what is
best to eat from a nutritional point of view or give recommendations about dietary components for the
specific amounts and limits for food groups. In this study, we instead tried to understand the individual,
social, and environmental factors that influenced students’ healthy eating choices. Our results suggest
that participants were influenced by individual, social, and university environmental factors.
The Ecological Model can help university communities to gain more insights into how and why
students make certain food choices, and support them in staying healthy.
Colleges and dining halls on campuses should acknowledge their crucial role in guiding healthy
eating behaviors, and be the first subjects to be interested in creating a healthy environment for
the students. Unless they start understanding the reasons behind unhealthy eating behaviors of
young adults, effective policies and managerial strategies to fight malnutrition (obesity, anorexia,
micro-deficiency) cannot be developed.
The next step of this research will include the collection of a larger and more representative
sample size, especially when taking into consideration the socio-cultural differences of college
students between the US and other Western countries. Considering that the same negative trend of
overweightness and unhealthy eating behavior among children, adolescents, and young adults is
emerging in Europe, and also in Mediterranean countries [46], discussions on potential and future
studies addressing this problem in a national context are advised. In addition, further research should
Nutrients 2018, 10, 1823 14 of 16

evaluate whether specific tailor-made interventions are effective in changing behaviors towards a
healthy lifestyle.

Author Contributions: G.S. took lead in writing the manuscript and was overall responsible for the study design,
data collection and analysis. C.V.-A. has contributed in the study design and in the data collection (Focus Group
moderator). C.M. and M.I.G. contributed in the result interpretation and made suggestions and comments of the
final version of the manuscript. All authors read and approved the final manuscript.
Acknowledgments: This study, which is part of a wider project called “CONSUMEHealth. Using consumer
science to improve healthy eating habits”, has received funding from the European Union’s Horizon 2020 research
and Innovation programme under the Marie Sklodowska-Curie grant agreement No 749514. We appreciate the
assistance of Liam Wickes-Do and Zekun Ma, two research assistants, for the contribution in data collection,
cleaning and transcription of the focus groups. The authors also thank all students participating in this study
and the staff members of the Cornell Institute for Social and Economic Research (CISER). We also sincerely
appreciate the feedbacks and insightful comments of the anonymous reviewers who helped improve and clarify
this manuscript.
Conflicts of Interest: None of the authors or affiliated institutions associated with this manuscript submission
has any financial or personal relationship or affiliation that could influence the present work.

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