COVID-19 and diet: efforts towards a balanced diet and sustainable nutrition among university students in Pakistan

Study design and setting

The study adopted a cross-sectional descriptive survey design and was carried out in four different universities from two developed and two non-developed cities of Pakistan. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Barani Institute of Sciences Sahiwal, Pakistan (IRB#2001).

Participants

Study participants were selected from a population of 10,000 students across four different universities (main campuses and sub campuses) in Pakistan from October 2021 to January 2022. Initially, the study participants were 1,000 selected medical and engineering students. Out of the 1,000 participants, 839 students completed the study. The inclusion criteria for the study subjects included written consent, availability to complete and return the questionnaire to the researcher on the spot, and status as a regular university student. People who were not currently enrolled as university students, had a history of serious eating disorders, or who refused to answer the survey truthfully and consistently were all excluded.

Assessment tools

The study questionnaire consisted of basic and widely-used tools validated in English in order to assess the important pillars of lifestyle medicine: medical history, physical activity, COVID-19 information, food and nutrition history, eating pattern (including risky substances such as smoking), and future nutrition goals. In addition, it asked about the participants’ self-reported height, weight, and smoking status as well as their sociodemographic factors.

Data collection

Data were collected over four months (October 2021 to January 2022) using a direct delivery and retrieval strategy implemented by the researchers. Researchers met the enrolled students individually and gave them the questionnaire to fill out and return directly. Incomplete forms were removed from the study. In order to reach as many students from the different universities as possible, instructors from all colleges were asked for permission to invite students from their classes to take the survey titled “Nutrition and Health Behaviour.” The last part of the survey consisted of an approved consent form; in other words, consent was obtained. Students were able to change their minds and withdraw from the study at any time, for any reason, without imposing any penalties or losing their eligibility to receive any future services from the institution.

The survey consisted of seven groups of questions around health and wellness, and requested information including the participants’ gender, age, ethnicity/race, year at college, medical history, COVID-19 information, eating habits, frequency of eating, types of daily beverages, appetite behavior, weight history, satisfaction about appearance, and nutritional goals.

Power estimation

To estimate the sample size, the power analysis method was conducted using SPSS software version 20. The results showed that the power of the current survey study was 0.90.

Data analysis

Descriptive analysis (mean and SD) was used to analyze the data. Item scores were designated as dependent variables and the medical and non-medical factors were set as independent variables. Using purposively set benchmark mean values, the item scores of the first cluster of questionnaire section A (medical history of participants) were interpreted on a scale of Yes or No. The item scores of the second cluster of questionnaire section B (information regarding COVID-19) were interpreted as Not Aware (NA), Slightly Aware (SA), Moderately Aware (MA), and Extremely Aware (EA). The item scores for the third cluster of questionnaire section C (food and nutrition information) were interpreted as Fully Aware (FA), Moderately Aware (MA), and Not Aware (NA). The item scores for the fourth cluster of questionnaire section D (eating practices of university students) were interpreted as Fully Adopted (FA), Moderately Adopted (MA), and Not Adopted (NAd); 2 T = two times, DS = Drink + Soda. The scores of the fifth cluster of questionnaire section E (weight history) were interpreted as Scale: Yes or No, Gained Weight (GW), Weight Loss (WL), Satisfied (S), Very Satisfied (VS), Dissatisfied (DS), and Very Dissatisfied (VDS). The scores for the sixth cluster of questionnaire section F (physical activity history) were interpreted as Physically activity Scale (Yes or No), Rate of workout intensity Light (L), Moderate (M), and Vigorous (V). The scores for the seventh cluster of questionnaire section G (nutritional goals) were interpreted as Important or Unimportant and in this section, participants were also asked about data publication on a Yes or No scale. The Student t test was employed to investigate the differences between the medical and nonmedical students. The Shapiro–Wilks normality test was used to determine the distribution of the data’s normality before the t tests were run. There was a normal distribution of the data (p −0.70). Item scores were utilized as test variables for the t tests, with medical and non-medical being the grouping variable. When coding, the label for medical students was assigned the numerical value 1, while the label for non-medical students was assigned the numerical value 2.

Participant characteristics

A total of 839 participants completed questionnaires and were included in the final analysis. The remaining 161 forms were excluded from the study because of incomplete data. Table 1 shows the demographic characteristics of all participants (gender, age, university name, and education level). Of the total number of participants (839), 49.9% were medical and 50.1% were non-medical students, and came from the following universities: GCUF Medical (11.9%), Barani Medical (11.9%), Montgomery Medical (13.0%), UCP Medical (13.1%), GCUF Engineering (11.9%), Barani Engineering (14.3%), Montgomery Engineering (11.9%), and UCP Engineering (11.9%).

Medical history of participants

Table 2 shows the average value of questionnaire results asked about the medical history of the participants. The average answers from medical and non-medical students of all universities about having any food allergy or intolerance, taking any type of supplement, and smoking were No. The average answer of all participants about having any past or current medical conditions was Yes. Overall, 55.6% of medical students were shown to have a history of past illness, while 47.85% of non-medical students showed a past history of illness. Medical students showed more cases of food intolerance as compared to non-medical students, i.e., 39.14% and 15.95%, respectively. Non-medical students showed a higher percentage of smoking compared to medical students, i.e., 52.61% and 45.82%, respectively.

COVID-19 information among participants

In addition to the medical history of participants, we analyzed data about information regarding COVID-19. Results in Table 3 show the participants’ awareness levels of COVID-19 information. Items about COVID-19 were answered on a three-point scale (Fully Aware, Moderately Aware, and Not Aware). On average, compared to non-medical students, medical students were more aware of immunity, immunity playing a vital role in COVID-19 infection, the first initial symptoms of COVID-19, that eating or having contact with wild animals would result in infection by the COVID-19 virus, that general medical masks prevent infection of the COVID-19 virus, and the use of hand sanitizer to wash hands after touching foreign surfaces outside the house and shaking hands.

Food and nutrition information among participants

Table 4 shows that students, after answering on a three-point scale, were fully aware that vitamin C helps to boost immunity, water helps to maintain homeostasis in the body, and carbohydrates elevate blood sugar levels. Additionally, students had a fair understanding of the importance of protein for the maintenance and repair of body tissues, the energy-giving properties of carbohydrates, the stimulation of insulin production by glucose, the protective properties of foods high in vitamins and minerals, the role of calcium in the maintenance and development of strong bones and teeth, and the necessity of milk and other dairy products for bone health. Although all students were aware of food and nutrient information, medical students showed more understanding when compared to non-medical students (Table 4).

Eating practices of participants

The results from participants’ responses to survey questions about eating habits, frequency of eating, and types of daily beverages are shown in Table 5. On average, eating habits like eating breakfast at home before leaving for work, skipping breakfast and only eating lunch and dinner, eating breakfast at work, preparing breakfast at home and bringing it to work, purchasing lunch from a university cafe, purchasing lunch from restaurants, eating at snack time, consuming soft drinks daily, having dinner at six o’clock each day, and purchasing breakfast or lunch from a restaurant are all unhealthy habits of university students from the cities Sahiwal and Lahore. On average, students typically eat two times a day and consume beverages like soda on a daily basis. Both types of students (medical and non-medical) did not show good eating practices or behavior.

Weight history of participants

Table 6 shows the results of the participants’ appetite behaviors, weight history, and satisfaction about appearance. Results show that the majority of the participants said Yes to questions about recent changes in appetite and concern about weight loss, but No to questions about trying to lose or gain weight. In addition, most participants wanted to lose weight and were dissatisfied with their appearance. Appetite changes and weight gain or loss practices were seen more in non-medical students. Medical students were more worried about their weight compared to non-medical students. Overall, medical students were not satisfied with their current body looks or appearance. Table 6 shows the physical activity history reported by the participants. The majority of students were physically active and the average intensity of the students’ workout was light.

Nutritional goals of participants

Table 7 shows the participant’s nutritional goals. Participants answered that it was important to make changes in their nutritional habits and it is also important that they are confident in their ability to improve their habits. In addition, participants allowed this research to be published. Medical students showed a positive response in changing eating behavior compared to non-medical students. After comparing the results from the medical and non-medical students, there was no significant difference between medical and non-medical students as the p value for all t tests ranged from 0.47–0.50.

National food safety emergency response plans

Pakistan faces food safety and security challenges, including foodborne illness, contamination, adulteration, and scarcity of food. The Pakistan Food Authority (PFA), established in 2017, plays a central role in regulating and enforcing food safety standards. The National Food Safety Contingency Plans are essential to protect public health and ensure food safety and security in Pakistan. These plans address a range of issues, including foodborne disease outbreaks and contamination incidents, in a coordinated effort between the PFA, the Ministry of Health, and provincial food authorities. They outline procedures for rapid detection, reporting, and response to food safety problems, and include surveillance, laboratory testing, recalls, public awareness campaigns, and communication strategies. Given Pakistan’s diverse food landscape, these plans are critical to maintaining a safe and trustworthy food market.

Study limitations

Our study has a number of limitations that deserve consideration. We did not stratify the population based on BMI, and the questionnaire we utilized was not intended to take energy consumption into account. The physical state of our subjects may have had an impact on food, taste, and eating habits. Finally, since each item was self-reported, reporting bias may have been introduced. Despite these drawbacks, we think that our findings are significant and highlight key changes in a particularly unique population. Our results may assist other researchers in studying the effects of lockdowns and aid in future pandemic preparedness.

Future research directions

The incorporation of wearable technology and mobile applications for nutritional tracking could improve data accuracy and track participants’ eating patterns in real time. Additionally, longitudinal studies that track dietary patterns and their consequences over time can provide important new information about the long-term effects of nutrition on health. A comprehensive understanding of food behavior and its psychological foundations can be fostered by cross-disciplinary studies that integrate dietitians, psychologists, and data scientists.