Department of Public Health and Caring Sciences

Nutritional habits and physical activity among university students in Thailand

Authors: Supervisor: Emelie Persson Mariann Hedström Sara Flodmark

Examiner: Barbro Wadensten

Thesis of Caring Science, 15 HP Nursing Programme, 180 HP Spring term 2017

SAMMANFATTNING

Bakgrund: En ohälsosam diet och brist på fysisk aktivitet är ledande risker för den globala

folkhälsan och är orsaker till många icke smittsamma sjukdomar.

Syfte: Syftet med denna studie var att undersöka nutritions- och fysisk aktivitetsvanor bland

universitetsstudenter i Bangkok, Thailand.

Metod: Detta är en tvärsnittsstudie med en kvantitativ metod i form av en strukturerad enkät

som 121 andraårsstudenter från folkhälsoprogrammet besvarade.

Resultat: Den här studien visade att majoriteten av studiedeltagarna uppnådde de nationella

rekommendationerna i Thailand angående nutrition och fysisk aktivitet. Många studenter

uppgav att de ville öka sitt intag av frukt och grönsaker. Studenterna visade ett litet intresse

för fysisk aktivitet men uppnådde de rekommenderade nivåerna av motion. Männen ville öka

sin dagliga konsumtion av frukt och utövade fysisk aktivitet i högre grad än kvinnorna och

kvinnorna vägde sig oftare än männen.

Slutsats: Resultaten från den här studien visade att thailändska folkhälsostudenter

huvudsakligen följer de nationella rekommendationerna angående nutrition och fysisk

aktivitet. Från vad studenterna har svarat på enkäterna så kan det utläsas att de inte behövs

några specifika hälsointerventioner i denna grupp.

Nyckelord: Nutritionsvanor, fysisk aktivitet, unga vuxna, universitetsstudenter, Thailand

ABSTRACT

Background: An unhealthy diet and lack of physical activity are leading global risks to public

health and causes of many non-communicable diseases.

Purpose: The aim of the study was to investigate nutritional habits and physical activity

among university students in Bangkok, Thailand.

Method: This is a cross-sectional study with a quantitative method using a structured

questionnaire where 121 second level students from the public health program answered.

Result: This study showed that the majority of the participants more or less followed the

national recommendations in Thailand regarding nutrition and physical activity. A lot of the

students wanted to increase their daily intake of fruit and vegetables. The students showed

less interest in physical activity but still met the recommended levels of activity. The males

wanted to increase their daily intake of fruit and exercised in a greater extent than the females

and the females weighed themselves more often.

Conclusion: The results from this study showed that the Thai public health students followed

the national recommendations regarding nutrition and physical activity. From what the

students have stated in the questionnaire, there is no need for further interventions among this

particular population.

Keywords: Nutritional habits, physical activity, young adults, university students, Thailand

TABLE OF CONTENTS

BACKGROUND…………………………………………………….....…..1

Facts and history…………………………………………………....…….....1

International guidelines………………………………………………….......1

National guidelines of Thailand…………………………………………......2

Weight problem in youth……………………………………………….........2

University students………………………………………………………......3

Caring science and theoretical framework……………………………..........4

Rational of research…………………………………………………….........5

Purpose……………………………………………………………......……..5

Research questions…………………………………………………….....….5

METHOD……………………………………………………………….......6

Design………………………………………………………………......…....6

Sample…………………………………...…...…...…...…...….........…...…...6

Context…………………………………………………………......………...6

Data Collection………………………………………………......…………...7

Procedure…………………………………………………......………………7

Ethical considerations…………………………………....…….…………….8

Data processing and analysis……………………….....……………………..8

RESULT…………………………………………......………………………9

University students’ nutritional habits…………….....………………………9

University students’ physical activity habits……....………………………..11

Differences between genders……………………...………………………..13

DISCUSSION……………………………………...………………………16

Discussion…...…...…...…...…...…...…...…...….......…...…...…...…...…...16

Discussion of result………………………………....………………………17

Nutritional habits…………………………………....………………………17

Physical activity…………………………………...………………………..18

Self-care according to the theoretical framework of Orem…....……………19

Discussion of method…………....…………………………………………20

Setting…………………………………...…………………………....….....20

Sample…………………………………...………………………………....20

Data Collection…………………………...………………………………...20

Language………………………………...…………………………………21

Conclusion……………………………...…………………………………..21

Acknowledgement……………………...………………………………..…22

REFERENCES………....………………………………………………….23

Appendix 1 Questionnaire………...………………………………………26

Appendix 2 Letter of information……...…………………………………29

1

BACKGROUND Facts and history

According to the World Health Organization, WHO, (2015) an unhealthy diet and lack of

physical activity are leading global risks to public health. A healthy diet throughout the

lifespan prevents malnutrition and a vast number of diseases and conditions. In present time

people are consuming increasing amounts of processed foods and the changing lifestyles in

correlation with rapid urbanization are making the people overweight at the same time as

malnourished.

The diversity of the diet will vary owing to significant factors that influence the diet, e.g.

cultural context, locally available foods and dietary customs, but also individual factors such

as age, gender and state of physical activity will determine a person's health conditions.

World wide underweight and obesity is a public health problem that is constantly growing

(WHO, 2015). With lack of physical activity and healthy nutrition people around the world

have increased risk to develop chronic health conditions (WHO, 2007).

It was estimated in 2014 that 600 million adults worldwide were obese and 41 million

children under five years old were classified as overweight or obese. The worldwide

prevalence of the issue has doubled from 1980 to 2014. This is not only a problem in

industrialized developed countries as it is on the rise in low- and middle-income countries as

well. In 2014, nearly half of the children in Asia under five years old were overweight or

obese. In Africa the prevalence of childhood obesity and overweight has doubled from 1990

(WHO, 2016). As for gender differences, men are prone to be more overweight than women,

although women have a higher rate of being obese. Either way excessive weight poses a risk

for non-communicable diseases such as diabetes mellitus, cardiovascular disease,

hypertension, stroke and some forms of cancer (WHO, 2003).

International guidelines

The Food and Agriculture Organization of the United Nations, FAO, is responsible to

continually review and look for new research and information on human nutrients, both

requirements and recommendations regarding nutrition intake. These nutrients include

protein, fat and lipids, energy, carbohydrates, vitamins, minerals and trace elements. Many

countries around the world rely on these international guidelines from WHO and FAO when

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they adopt their own national dietary allowances and some countries use it as a base for their

standards (WHO, 1999).

National guidelines in Thailand

The Department of Nutrition for Health and Development together with FAO (2008) has set

up some national guidelines for Thailand in collaboration with the Thai ministry of health.

The guidelines have nine different goals that the population in Thailand should strive to

comply in order to maintain a good health. The guidelines point out the importance of eating

food from each of the five food groups regularly and that variety also is an important factor to

maintain a proper body weight. Eating an adequate amount of carbohydrate sources and fat is

recommended. Vegetables, fruit, fish, lean meat, eggs, legumes and pulses should be eaten

regularly. Drinking milk of appropriate quality and in a quantity for one’s age is

recommended. Sweet and salty food should be avoided and the consumption of alcoholic

beverages should be avoided or reduced. The Thai ministry of health believes it is of

importance to eat clean and safe foods because of the challenges developing countries face

and these are factors that Thailand has worked hard with (FAO, 2008).

In order to maintain a proper body weight the national recommendations state that for at least

three to five times per week one should exercise for 20-30 minutes so that the body and heart

muscles strengthen as well as it improves the blood circulation. They do also point out that

the exercise is important to alleviate stress and tension. Each person is suggested to check

their body weight once a month, depending on the results of the weighting there is

recommendations for underweight people as well as for overweight people (FAO, 2008).

Weight problem in youth

Childhood obesity and overweight amongst children have emerged in the last decade

(Chavasit, Kasemsup & Tontisirin, 2013). It has a higher prevalence in developed countries

than in developing countries worldwide. An increased chance of obesity and overweight can

be seen in developing countries and industrialized countries due to the easier access of

energy-rich diets (Wang & Lim, 2012). These are current rising problems in Thailand and it is

especially present in urban areas. The prevalence of childhood obesity among both urban and

rural children is increasing, although it is more common among urban children. The rural

children are more overweight rather than obese, but the prevalence of stunting as well as

underweight is higher in rural children as that in urban children. This indicates the double

burden of malnutrition that the public health in Thailand faces (Rojroongwasinkul et al.,

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2013). Thai children between the ages 7-12 with obesity are significantly less active during

school breaks, watches more TV and sleep less than non-obese children. Children in families

with a better socio-economic status are also more likely to be obese (Thasanasuwan et al.,

2016). Several studies have shown that children that are obese or overweight in their youth

has an increased risk of becoming obese or overweight in their adulthood. Persistence of

overweight during youth showed that the person is more likely to increase their overweight

later on in life (Singh, Mulder, Twisk, Van Mechelen & Chinapaw, 2008).

University students

More than half of university students are aware of the connection between bad dietary habits

and non-communicable diseases such as high blood pressure and heart disease. The study was

implemented worldwide in universities in low-, middle- and high-income countries and

showed that the lowest awareness of health risks was found in sub-Saharan Africa region. The

highest awareness was found in the Caribbean and South America and Southeast Asia (Peltzer

& Pengpid, 2015)

Poor eating habits have previously been shown among Italian students, e.g., including

omitting breakfast, not eating enough fruit and vegetables and eating too much sweets,

although females were shown to eat more fruit and vegetables than males (Teleman, De

Waure, Soffiani, Poscia & Di Pietro, 2015). Only six percent of college students in the United

States of America eat five or more daily servings of fruits and vegetables. The students also

has a small variety in their intake of food, several students say that they eat the same foods

day after day. When the students start their freshman year the quality of food intake

decreases, but studies has shown that the food intake gets better later on during the college

years. Although the habits gets better the students state that they often eat fast food or at “all

you can eat”-dining halls. Data indicate that 37 % of the students consume five or more

alcoholic beverages in a two-week period (Nelson, Story, Larson, Neumark Sztainer & Lytle,

2008). In a study on Swedish university students of differences between genders regarding

lifestyles, it was shown that female students had healthier habits, mainly because of less

alcohol consumption and better nutrition habits. Although the female students had healthier

habits the study showed that they were more stressed than male students. Male students had a

higher prevalence of overweight and obesity, and less interest in the nutritional guidelines and

guidelines on physical activity. The male students tended to drink more alcohol, had

unhealthy nutrition habits and were physically inactive (von Bothmer & Fridlund, 2005).

4

Greek students still living at home during their studies had not changed their eating habits

comparing to students living away from home. The students not living in their family home

had developed more unfavorable nutritional habits with a higher consumption of sugar,

alcohol and fast food. This suggests a negative effect on nutritional habits regarding food

purchases and preparation when students move out for the first time (Hondros, Kapsokefalou,

Papadaki & A Scott 2007).

Data from the USA indicate that only 42 % of the college students exerted exercise

vigorously for twenty minutes or moderate exercise for thirty minutes three times per week.

Students estimate that they are sitting still for more than thirty hours per week, eleven hours

of watching TV or videos, thirteen hours studying and six hours using the computer (Nelson

et al., 2008). Grygiel-Go´rniak and co-workers (2016) concluded that although university

students tend to do more exercise than the average adult, the level of physical activity

decreases with age. They therefore argue that students should have compulsory physical

activity in their schedule, be encouraged to physical activity and to promote good health

status (Grygiel-Go´rniak et. al., 2016). This was also shown in an interview study done in

southern Thailand. To involve university policies for better health promotion and develop

peer support systems for initiating and maintaining health-related behaviors were some of the

cornerstones found to improve health among university students. Another suggestion was to

focus on the family’s role in promoting physical activity at home. Some barriers that were

found for lack of physical activity among the majority of students were study-related

activities and overtime shift work. For female students, there was a significant barrier

regarding exposure of sunlight when doing physical activity during the day due to cultural

belief of the importance of fair skin (Wattanapisit, Fungthongcharoen, Saengow &

Vijitpongjinda, 2016).

Caring Sciences and theoretical framework

Dorothea Orem’s self-care theory is used in this study to identify risk behavior among

university students in nutritional and physical habits according to the four concepts; person,

nursing, environment and health. Orem identifies a person as someone that has the ability to

take initiative for its own actions that empowers the individual to maintain health or

counteract poor health. Orem thinks that a person learns through cultural and social context

and uses its knowledge in a suitable way. This study focuses on people’s decisions that can

affect their health both now and later on in life, which could lead to compromising their

5

overall health and self-care at any time, which is the main purpose of Dorothea Orem´s

theoretical framework. People could also be affected by environmental factors such as

different living forms. The focus of the nursing aspect is that when the patient is not in

position to pursue self-care, society can provide support for them i.e. programs to educate

about nutritional values and physical health (Kirkevold, 2000).

Rational of research

The health among adults is decreasing due to changed habits of nutrition and physical

activity. By mapping out what habits there are among university students and if there is a

difference between genders on nutritional habits and physical activity, appropriate

interventions can take place in an earlier stage. The national food committee in Thailand has

implemented several programs and strategies to educate the population more about nutrition

and the importance of physical activity. The committee focuses on the connection between

agriculture, food, nutrition and health. By learning from other countries and evaluate these

programs and strategies, the committee hope for a healthier population (Chavasit et al., 2013).

Therefore, it is also important for nurses and other healthcare providers to be aware so that

they can increase understanding and knowledge about health status among university

students. Further studies need to be done on university students in Thailand, due to minimal

research in the field at the moment, to be able to map out current dilemmas and help to set a

foundation for future health interventions in Thailand.

Purpose

The aim of the study is to investigate nutritional habits and physical activity among university

students in Bangkok, Thailand.

Research questions

1. What are the nutritional habits and physical activity among university students in

Thailand?

2. Is there a difference between men and women regarding nutritional habits and

physical activity?

6

METHOD

Design

This was a cross-sectional study with a quantitative method using a structured questionnaire.

The quantitative method was chosen in order to study larger groups with limited resources. To

review several aspects in the selected group this method answered to the purpose of the study

and the possibility to measure the results in numbers. With this method, the data analysis was

less time consuming which was relevant seen to the short timeframe for the study (Eliasson,

2013).

Sample

The data was collected in April, 2017 at Rangsit Campus, Thammasat University in Bangkok,

Thailand. The campus is located in the Khlong Luang district of Pathum Thani approximately

50 kilometers north of Bangkok city center.

A nonprobability sampling method was used to select university students. In collaboration

with the dean and Professor Sirima Mongkolsomlit at the Faculty of Public Health, 136

students from the 2nd level class were asked to partake in the study. Inclusion criteria for the

study were university students of both genders at Thammasat University.

Out of 136 university students that were asked to partake in the study, 121 students chose to

participate (response rate = 89 %). The students were between 19 and 23 years old, M=20.

Missing values n = 2. Of the students, 23 were men (19%) and 81 were women (81%).

Regarding accommodation 10 % (n=12) were living in an apartment, 12 % (n=14) were living

in a house, 74 % (n=90) were living in a dorm and 2 % (n=2) stated “other” as their

accommodation. The number of participants that chose not to answer was 3 % (n=3). Students

that were living alone were 13 % (n=16), with parents were 12 % (n=14), with partner 3 %

(n=4), with roommates 71 % (n=86) and other household arrangements were 1 % (n=1). The

level of education among the university students was second level, 99 % (n=120) although

one participant, 1 % (n=1), reported “first level”.

Context

The river Chao Phraya flows through the Pathum Thani province and leaves many canals that

are used for rice paddies. The province has a great deal of higher education institutions,

industrial parks and research facilities (Tourismthailand, 2017). Rangsit Campus is one of

7

four campuses of Thammasat University in the Bangkok area. The Thammasat University

Hospital is set together with the Faculty of Public Health were this study took place.

Data collection

The authors developed a questionnaire partly based on the national recommendations in

Thailand, which was used for data collection. The questionnaire consists of 5 demographic

background questions, 12 claims and 14 questions (Appendix 1). The claims and questions

are divided into two groups; nutritional habits and physical activity. The claims 1-8 are about

nutritional habits and claims 9-12 are about physical activity. Each claim has 4 response

categories: strongly agree, agree somewhat, disagree somewhat and strongly disagree. The

questions 13-20 are about nutritional habits and questions 21-26 are about physical activity.

Each question was answered with a number that represent quantity or minutes. Professor

Sirima Mongkolsomlit translated the questionnaire into Thai language orally to the students

via a projector in the front of the classroom and each student was presented an own copy of

the questionnaire in English.

Procedure

This study was a collaboration between the Faculty of Public Health, Rangsit Campus,

Thammasat University, Pathum Thani Province, Bangkok, Thailand, and the Department of

Public Health and Caring Sciences, Uppsala University, Sweden. The international

coordinator Dr. Helena Volgsten contacted Thammasat University to ask for permission to

carry out the study. The approval of the data collection was given by the dean of the Faculty

of Public Health, Thammasat University, as well as a written consent from the Institutional

Review Board, Department of Public Health and Caring Sciences, Uppsala University.

Professor Sirima Mongkolsomlit helped the authors to find a suitable time for collecting data

from the 2nd level students and recommended oral translation due to the students’ good

knowledge in English. The students were seated in one classroom and were given the

questionnaires by hand. A letter of information (Appendix 2) was with help from Professor

Sirima Mongkolsomlit translated into Thai language orally at the time of the data collection.

The authors informed the students about the study and their rights if they chose to participate.

The questionnaire was then answered. The respondents thereafter put the questionnaires into a

box after completion. The authors were present in the classroom during the time when the

respondents answered the questionnaire. This also made it possible for the respondents to ask

questions.

8

At the completion of data collection, the authors checked that the questionnaires were

answered properly and excluded the ones that were not filled in.

Ethical considerations

The authors of this study chose to adapt the Belmont Report to protect the participants. The

Belmont Report have articulated three primary ethical principles; beneficence, respect for

human dignity and justice. Beneficence is the duty to minimize harm and maximize benefits.

Respect for human dignity includes the right to self-determination and the right to full

disclosure. Justice, which included participants right to fair treatment and their right to

privacy (Polit & Beck, 2014).

Before the study could take place in Bangkok, Thailand, the authors submitted the project to

the dean of the Faculty of Public Health, Thammasat University for approval. The

Institutional Review Board at the Department of Public Health and Caring Sciences, Uppsala

University, reviewed and approved the project before it was carried out.

According to the Declaration of Helsinki the authors made sure that the participants were

informed in their own language about the study and their rights for participation via a letter of

information (Appendix 3). The participants were informed about the participant’s role and

rights, to clarify that their participation was voluntary, the information was treated

confidentially and they could withdraw from the study at any time. This made sure that no

misunderstanding existed before participation in the study (World Medical Association,

2017).

Data processing and analysis

The collected data was analyzed with the statistical program Statistical Package for the Social

Sciences version 23. Research question 1 was analyzed using descriptive statistics and

research question 2 was analyzed using the non-parametric Mann Whitney U-test. Differences

were considered significant if p≤0.05 (Polit & Beck, 2014).

9

RESULT

University students’ nutritional habits

The majority of the students agreed (strongly or somewhat) that they were satisfied with their

nutritional habits (68 %) but that they would like to increase their daily intake of vegetables

(72 %) and fruit (78 %). Most of the students agreed to that they wanted to decrease their

intake of sweets (61 %), alcohol (75 %) and fast food (69 %). The following claims showed

that majority of the students agreed that they eat enough food to meet body needs and to

maintain a healthy body weight (77 %) and eat clean and safe food (72 %), (see Table 1).

Table 1. Claims on nutritional habits, n= 121.

Claims Strongly agree % (n)

Agree Somewhat % (n)

Disagree somewhat % (n)

Strongly disagree % (n)

Missing % (n)

I am satisfied with my nutritional habits

8 % (n=10)

60 % (n=72)

31 % (n=38)

0 % (n=0)

1 % (n=1)

I would like to increase my daily intake of vegetables

18 % (n=22)

54 % (n=65)

26 % (n=31)

3 % (n=3)

0 % (n=0)

I would like to increase my daily intake of fruit

24 % (n=29)

54 % (n=66)

20 % (n=24)

0 % (n=0)

2 % (n=2)

I would like to decrease my intake of sweets/candy

17 % (n=21)

44 % (n=53)

36 % (n=43)

3 % (n=4)

0 % (n=0)

I would like to decrease my intake of alcohol

61 % (n=74)

14 % (n=17)

16 % (n=19)

9 % (n=11)

0 % (n=0)

I would like to decrease my intake of fast food per month

12 % (n=15)

57 % (n=69)

31 % (n=37)

0 % (n=0)

0 % (n=0)

I eat enough food to meet body needs and to maintain a healthy bodyweight

20 % (n=24)

57 % (n=69)

22 % (n=26)

2 % (n=2)

0 % (n=0)

I eat clean and safe food according to national recommendations

22 % (n=27)

50 % (n=60)

26 % (n=31)

3 % (n=3)

0 % (n=0)

10

The majority of the 121 students did not eat breakfast every day of the week (M=5.4), 41 %

(n=49) said to eat breakfast seven days a week. Although the second largest group of 24 %

(n=29) ate breakfast five days a week, (see Graph 1).

Graph 1. Breakfast habits, n= 121.

The students most typically ate three full meals a day, fruit and vegetables three times a day,

sweets four times a week and legumes, tubers, roots and whole grain cereals two times a

week, fast food five times a week, drink alcohol one time per month and checked their weight

three times per month (approximate mean values). The range for students checking their

weight varied between one and twenty times per month. For range, mean and mode values,

see Table 2.

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Table 2. Questions about nutritional habits, n=121.

Questions Range Mean Mode

How many days a week do you normally eat breakfast? 1-7 5.4 7

How many full meals a day do you eat? 1-7 3.1 3

How many times a day do you normally eat fruits/vegetables? 0-7 2.5 2

How many times a week do you normally eat sweets? 0-7 3.5 2a

How many days a week do you eat whole grain cereals or legumes or roots or tubers?

0-7 2.1 2

How many days per month do you eat fast food? 0-30 5.4 4

How many times per month do you drink alcohol? 0-8 0.8 0

How many times per month do you check your weight? 0-20 3.3 1a

a Multiple modes exists. The smallest value is shown.

University students’ physical activity habits

Most of the students responded that they disagreed (strongly or somewhat) to the claim

regarding liking to spend leisure time doing exercise (60 %). The majority of the students

agreed (strongly or somewhat) to the claim that they studied two or more hours a day (94 %).

Most students claimed that they did not exercise every day of the week, (53 % disagreed

strongly or somewhat). A majority of the students used the internet to visit social media more

than 3-4 hours a day (92 %), (see table 3).

12

Table 3. Claims on physical activity, n=121.

Claims Strongly agree % (n)

Agree somewhat % (n)

Disagree somewhat % (n)

Strongly disagree % (n)

Missing % (n)

I like spending my leisure time doing exercise

6 % (n=7)

33 % (n=40)

46 % (n=55)

14 % (n=17)

2 % (n=2)

I spend two hours or more for studying within a day

66 % (n=80)

28 % (n=34)

3 % (n=4)

3 % (n=3)

0 % (n=0)

Physical activity is something that I do every day of the week

8 % (n=10)

38 % (n=46)

42 % (n=51)

11 % (n=13)

1 % (n=1)

I usually use 3-4 hours/day on the internet to visit social media

51 % (n=62)

41 % (n=50)

6 % (n=7)

2 % (n=2)

0 % (n=0)

Regarding the questions about physical activity the students visited the gym between zero and

seven times per week and exercised with increased pulse rate zero to twenty times per week.

In comparison, the students spent zero to ten hours a day in front of the TV or computer and

were sedentary between zero and 710 minutes per day. The students spent zero to 600 minutes

a week doing exercise that increased their pulse rate and the same time per day doing

moderate exercise such as walking. For range, mean and mode see Table 4.

13

Table 4. Questions about physical activity, n=121.

Questions Range Mean Mode

How many times a week do you visit the gym? 0-7 1.4 0

How many times a week do you normally exercise (with increased pulse rate and breathing)?

0-20 2.5 3

How many hours a day do you spend in front of the TV or computer?

0-10 3.2 2

How many minutes per day do you spend sitting still? 0-710 140.8 60

How many minutes a week do you normally exercise (with increased pulse rate and breathing)?

0-600 81.1 30

How many minutes a day do you normally exercise with normal pulse rate and breathing, e.g. walking?

0-600 63.8 30

Differences between genders

For most claims, there were no differences between genders, there was a significant

difference on three out of twelve claims. The male students wanted to increase their daily

intake of fruit in greater extent than the females. However, the females did not like spending

their leisure time doing exercise as much as the male students and engaged in physical

activity to a smaller extent than male students (see Table 5).

14

Table 5. Gap analysis on claims, n=121, male n=23, female n=98, response alternatives: strongly agree (1)-

strongly disagree (4).

Claims Male Md, IQR

Female Md, IQR

z-value

p-value

I am satisfied with my nutritional habits 2.0 1.0

2.0 1.0

-0.78 0.48

I would like to increase my daily intake of vegetables

2.0 1.0

2.0 1.0

1.32 0.19

I would like to increase my daily intake of fruit 2.0 1.0

2.0 1.0

-2.38 0.02

I would like to decrease my intake of sweets/candy 2.0 1.0

2.0 1.0

-0.18 0.99

I would like to decrease my intake of alcohol 1.0 2.0

1.0 1.0

-1.26 0.21

I would like to decrease my intake of fast food per month

2.0 0.0

2.0 1.0

-1.48 0.14

I eat enough food to meet body needs and to maintain a healthy bodyweight

2.0 1.0

2.0 0.0

-0.65 0.52

I eat clean and safe food according to national recommendations

2.0 1.0

2.0 1.0

-0.44 0.64

I like spending my leisure time doing exercise 2.0 1.0

3.0 1.0

-1.96 0.05

I spend two hours or more for studying within a day 1.0 1.0

1.0 1.0

-0.03 0.98

Physical activity is something that I do every day of the week

2.0 1.0

3.0 1.0

-3.02 0.03

I usually use 3-4 hours/day on the internet to visit social media

1.0 1.0

1.5 1.0

-0.46 0.65

15

Four out of fourteen questions showed a significant difference according to the p-value (see

Table 6). The females checked their weight more often than the males. The males visited the

gym more often than the females did and they worked out with an increased pulse rate and

breathing in a greater extent. The males exercised for a longer period of time during the week,

about double the amount compared to the females. For mean, standard deviation and range

see Table 6.

Table 6. Gap analysis on questions, n=121, male n=23, females n=98.

Questions Male M, Sd, range

Female M, Sd, range

z-value

p-value

How many days a week do you normally eat breakfast?

5.17 2.08 1-7

5.40 1.67 1-7

-0.18 0.86

How many full meals a day do you eat? 2.67 1.14 1-5

3.16 1.12 1-7

-1.49 0.14

How many times a day do you normally eat fruits/vegetables?

2.41 1.57 1-6

2.58 1.60 0-7

-0.65 0.52

How many times a week do you normally eat sweets?

3.24 1.66 1-7

3.59 1.72 0-7

-0.81 0.42

How many days a week do you eat whole grain cereals or legumes or roots or tubers?

1.93 1.43 0-5

2.20 1.64 0-7

-0.44 0.66

How many days per month do you eat fast food?

4.52 3.31 1-15

5.60 5.13 0-30

-0.45 0.66

How many times per month do you drink alcohol?

0.59 1.11 0-4

0.80 1.46 0-8

-0.48 0.63

How many times per month do you check your weight?

2.04 1.49 0-5

3.62 3.94 0-20

-1.94 0.05

16

How many times a week do you visit the gym? 2.09 1.80 0-5.5

1.19 1.41 0-7

-2.31 0.02

How many times a week do you normally exercise (with increased pulse rate and breathing)?

3.02 1.62 0-6

2.38 2.48 0-20

-2.31 0.02

How many hours a day do you spend in front of the TV or computer?

3.00 2.20 0-8

3.26 1.87 0-10

-1.02 0.31

How many minutes per day do you spend sitting still?

213.09 152.44 2-600

147.35 175.94 0-710

-0.46 0.65

How many minutes per week do you normally exercise (with increased pulse rate and breathing)?

146.96 147.87 0-600

65.64 70.00 0-420

-2.52 0.01

How many minutes a day do you normally exercise with normal pulse rate and breathing, e.g. walking?

80.43 118.96 5-600

59.88 65,88 0-400

-1.78 0.08

DISCUSSION The purpose of this study was to investigate nutritional habits and physical activity among

university students in Bangkok, Thailand. This study showed that the Thai university students

more or less followed the national recommendations in Thailand regarding physical activity

and nutrition. However, there were a lot of students that wanted to increase their daily intake

of fruit and vegetables and to decrease their intake of sweets. The students showed less

interest in physical activity; the majority stated that they did not like to do exercise during

their leisure time. The students agreed on spending two hours or more studying every day and

visiting social media for at least three to four hours a day. When comparing males and

females there was a difference regarding both nutritional habits and physical activity.

Regarding nutritional habits, males in greater occurrence wanted to increase their daily intake

of fruit. The male students stated that they exercised more than females. Female students

weighed themselves in greater extent than the male students.

17

Discussion of result

Nutritional habits

The majority of the Thai students were satisfied with their nutritional habits. According to this

study most of the students consumed vegetables and fruit that match with the national

recommendation of Thailand where the people are recommended to eat vegetables and fruit

regularly (FAO, 2008). The female Thai students were shown to consume more fruit and

vegetables than the males and this corresponds with previous data from Italy (Teleman, et al.,

2015). Although, in this study the male students wanted to increase their daily intake of fruit

in greater extent than the female students. Some students ate sweets several times a week

although the consumption should be avoided. It is of great concern because sugar promotes

non-communicable diseases such as diabetes mellitus and cardiovascular disease (WHO,

2003). Earlier research show that university students are aware of the connection between

nutritional habits and non-communicable diseases, South East Asia is among those areas with

most awareness (Peltzer & Pengpid, 2015). With this in mind, the public health students that

constituted this study population may be more aware than the average university student.

Even though the sample group were second level students and not fully educated, they are

probably more prone to be more aware of health promoting life style than the average adult in

Thailand. The national food committee in Thailand is on their way to create increased public

health with intervention programs in form of education about nutrition and physical activity

(Chavasit et al., 2013).

It is shown in student life style studies that not living in one’s family home correlates with

poor nutritional habits such as consumption of sugar, alcohol and fast food (Hondros, et al.,

2007). In this study, students that were living out of their family home were a majority, either

in a dormitory, with roommates or alone. This factor could be of interest in further studies.

Consumption of fast food is a growing problem among people; it is cheap and very available

in correlation to the rapid urbanization (WHO, 2015). According to this study the students

spend several hours a day on studying, which could affect their choice of food and as fast

food is easily accessible, it was consumed more than once a week by some students in this

study.

According to the national recommendations in Thailand (FAO, 2008) adults should weigh

themselves one time per month. However, in the result from this study it was shown that both

genders exceed the recommendations. It was also shown that females checked their weight in

greater extent than the males.

18

Physical activity

The study results showed that the surveyed public health students are rather in line with the

national health recommendations regarding physical activity. From what the students have

stated in the questionnaire, there is no need for further interventions among this particular

population. However, continuous work in schools and in the younger ages to promote good

health early on in life could be a good intervention. A study suggests scheduled, compulsory

physical activity to promote good health status and to encourage exercise (Grygiel-Go´rniak

et. al., 2016). This could be a future option in higher levels of education in Thailand to

improve public health.

According to this study the Thai students were more active and less sedentary than American

college students. Although the American students are double as much sedentary as the Thai

students (Nelson et al., 2008), this study showed that they on the other hand spent more time

in front of the TV and computer. The data results demonstrates that male students visited the

gym more often and rated a greater activity level than female students, e.g., exercising with

increased pulse rate and breathing for the double amount of time than the females. The males

also stated, in greater occurrence, that they liked to spend their leisure time doing physical

activity. This might be an effect of the barrier Wattanapisit, et al. (2016) found regarding

exposure of sunlight when doing physical activity during the day due to cultural belief of the

importance of fair skin.

Regarding spending leisure time doing exercise shows that most of the Thai students did not

agree with the claim. The students did not exercise every day of the week, although most of

them reached the national recommendations that recommends 20-30 minutes of exercise that

increases pulse rate three to five times a week (FAO, 2008). This correlates with Swedish

guidelines for public health. The healthcare system has a responsibility to reach the whole

population and the more vulnerable groups that are most sedentary. In Sweden the healthcare

system has invented a method for promoting and encouraging physical activity for those who

are having problems with for example obesity. The healthcare personnel can prescribe

physical activity as a prescription. This starts in the public health center by nurses screening

patients for their habits regarding nutrition, alcohol and physical activity. The simple method

is used with a purpose to prevent and treat diseases. The high credibility of the healthcare

personnel in society makes the method a successful intervention (Folkhälsomyndigheten,

2013).

19

Self-care according to the theoretical framework of Orem

In this study Dorothea Orem’s self-care theory was used to identify risk behavior among Thai

university students. Nutritional habits and physical activity can be seen from different

perspectives, such as; person, nursing, environment and health (Kirkevold, 2000). The

research questions regard the fact that nutrition and physical activity are matters that only the

person him or herself can affect. The environment and metabolic causes can of course

influence a choice or an action but in most cases the human behavior is the biggest cause for

our unhealthy habits. To maintain a good health a person needs to be aware of his or her own

situation. For this, education and knowledge is needed and national interventions could pave

the way for public and personal health. Without knowledge in younger school years, it could

have continuous health consequences later on in life. There is no difference between genders

in accordance to pursuing self-care according to Orem, every human being can affect their

own life choices (Kirkevold, 2000).

In this study most of the students were living away from their family homes and

environmental factors can have an effect on a person’s nutritional and physical activity habits

as it is more common to eat fast food when a person have moved out (Hondros,

Kapsokefalou, Papadaki & A Scott 2007). The focus of the ethical principles as a nurse are

that when the patient is not in position to pursue self-care the nurse can, with respect for the

patient, give them the tools for recovery by themselves. Another aspect is that society can

provide both economical and social support for them in order for the patient to get better. In

this case in form of school interventions and programs, to educate about nutritional values and

physical health. With individualized care, nurses can detect health problems and give

motivation and suggestions to the patient, who in turn can take the tools provided by the nurse

to pursue better self-care.

Our results indicate that the public health students enrolled in this study are pursuing good

health. In this case, their education could provide them with greater knowledge than a non-

health educated person. According to Orem’s theory, these students have a greater advantage

to maintain self-care because of their knowledge about health. Although there is still always a

personal choice and there are more influential factors affecting a person than just knowledge

as Orem explains (Kirkevold, 2000). As a public health worker, Orem’s theory can be used to

empower the individuals’ self-realization to obtain a good health when constructing

intervention programs.

20

Discussion of method

Setting

In our study the interpreter to the students was one of their teachers. The authors ensured that

the students understood that their participation was voluntary and that they could discontinue

participation at any time. Their answers would also not be able to trace further as long as

destroyed after finishing this study and it was in our greatest interest to mediate this to the

students repeatedly, regardless if they chose to participate or not. When the study took place

the students were placed in their classroom, next to each other, this enabled them to talk to

one another, which could be a threat to the validity of the study, but might also have helped

them translate the questions correctly. Social desirability was considered a factor during the

study, as people tend to answer questionnaires favorably in order to appear better in front of

others in contrast to how they really live and behave (Psykologguiden, 2017). Still, the

participants were familiar to the setting and it could also have made them feel more

comfortable to sit next to their classmates while answering. The setting could have had one or

more positive influential effects on the students’ choice to participate, because of the high

number of participants in this study. However, there was an attrition rate, which strengthens

the assumption that the voluntary factor worked (Polit & Beck, 2010).

Sample

In this study there was a convenience sample including public health students from Rangsit

Campus, Thammasat University, Thailand, and because of this the generalizability to Thai

student in general was limited. To increase the generalizability of the findings, it would have

been preferable with a randomized sample of university students (Polit & Beck, 2010).

Data Collection

Regarding claim 5 and question 19 about alcohol consumption, the results did not correspond

because of the answers of the question showed that the students did not consume alcohol even

though they claimed they wanted to decrease their intake of alcohol. This is interpreted as a

misreading and a faulty result regarding the claim. There was also a questionable result

regarding question 22, about how many times a week the students normally exercise with

increased pulse rate and breathing. It showed a range of 20 for the females and six for the

males. The authors believe it is possible that the question is misread in some cases but the

reason for this is unclear. Regarding question 24, how many minutes the students sit still a

day, the results showed a range of 590 in males and 710 in females. This is interpreted by the

21

authors as faulty data as it was highly possible that it was misinterpreted by some of the

students and can therefore not be considered as a final result. The misinterpreted data is most

likely an error made by mistaking minutes for hours. The questionnaire could have been

formulated differently as the authors have detected flaws in the layout of the questions. In

hindsight, it would have been preferable to test the instrument on a small test group of

students before the study was carried out, this to discuss how they interpreted the claims and

questions in the questionnaire. Although, because of the short timeframe this was not possible

and therefore the reliability of the questionnaire was compromised (Polit & Beck, 2010).

Internal validity could have been challenged because of the students’ educational knowledge

about nutritional habits and physical activity that might have had an effect on their answers

due to the aforementioned reasoning about social desirability.

For data on interval scale in this study, the authors could have used a non-dependent t-test.

However, Mann Whitney u-test was chosen over a non-dependent t-test as this study required

a test that supported a non normal distribution sample between genders (Polit &, Beck, 2010).

Language

The data collection of the study was carried out in a foreign language, which the authors had

no knowledge in. Therefore the authors needed help from an interpreter with translation,

regarding both the information letter and the questionnaire. The questionnaire could therefore

have been translated wrongfully and cause information to be lost or misinterpreted and not

answered to the purpose. However, the interpreter, Professor Sirima Mongkolsomlit, were

excellent in understanding and communicating in English, she made sure that the purpose of

the questionnaire matched the authors intentions, before she translated it orally. Also the letter

of information was translated orally to the students. Even though there was a structured

translation process there might have been some misunderstandings regarding some of the

claims and question in this study.

Conclusion

As indicated in the beginning of this study, the health among adults is decreasing due to

changed habits of nutrition and physical activity. Although, from the results of this study,

Thai public health students followed the national recommendations regarding nutrition and

physical activity more or less. The results showed that they did not drink much alcohol and

they ate the recommended amount of vegetables and fruit. However there were a lot of

22

students that wanted to increase their daily intake of fruit and vegetables and to decrease their

intake of sweets, males wanted in greater occurrence to increase their daily intake of fruit.

The students showed less interest in physical activity; the majority stated that they did not like

to do exercise during their leisure time although the male students stated that they exercised

more than females. Female students weighed themselves in greater extent than the male

students. From what the students have stated in the questionnaire, there is no need for further

interventions among this particular population.

Acknowledgement

We want to give our greatest gratitude to the organization SIDA, via Universitets- &

högskolerådets (UHR) for making this thesis possible through the scholarship Minor Field

Study (MFS). Without the scholarship and the experiences we got from SIDA and UHR none

of this would have been doable.

Continuing, we are very thankful for our international coordinator Dr. Helena Volgsten for all

her help organizing this exchange with Rangsit Campus, Thammasat University.

Our greatest and sincerest thanks to our supervisor Mariann Hedström that have been an

excellent supervisor and an asset in our work with this thesis. Without her, this thesis would

not have been able to accomplish.

Our sincerest gratitude to the Public Health Faculty at Rangsit Campus, Thammasat

University, the dean and all their staff members that welcomed us to their university. With

help from Professor Sirima Mongkolsomlit it was possible for us to conduct the data and the

thesis became possible because of the help we got and we are deeply thankful. Without her

and the Public Health Faculty at Thammasat University we could not have had this

opportunity and experience to write our bachelor thesis abroad.

Last but not least we would like to thank all of the second level public health students, who

participated at Thammasat University, for their time and effort. Without them - no data, which

means that no thesis would have been made.

23

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26

Appendix 1 Questionnaire

“Nutritional habits and physical activity among university students in Thailand”

Please answer every question in the questionnaire by marking ”X” the answer you have

selected.

Demographic background

1. Gender: □ Male □ Female

2. Age: ………………………………………. years old

3. Where do you live?

□ 1. Apartment □ 2. House □ 3. Dorm

□ 4. Other:…………………................

4. How do you live?

□ 1. Alone □ 2. With your parents □ 3. Partner

□ 4. Roommates □ 5. Other:............................................

5. Education: What year do you study?

□ 1. First year □ 2. Second year □ 3. Third year

□ 4. Fourth year □ 5. Fifth year

27

Direction; Mark “X” in the box that is the most appropriate to your decision.

Claims

Strongly agree

Agree

somew

hat

Disagree

somew

hat

Strongly D

isagree

1. I am satisfied with my nutritional habits

2. I would like to increase my daily intake of vegetables

3. I would like to increase my daily intake of fruit

4. I would like to decrease my intake of sweets

5. I would like to decrease my intake of alcohol

6. I would like to decrease my intake of fast food per month

7. I eat enough food to meet body needs and to maintain a healthy bodyweight

8. I eat clean and safe food according to national recommendations

9. I like spending my leisure time doing exercise

10. I spend 2 hours or more for studying within a day

11. Physical activity is something that I do every day of the week

12. I usually use 3-4 hours/day on the internet to visit social media

28

Direction; Mark the box to the right with a number that you find most accurate to your habits, e.g. 1 or 2, or 3 etc.

Questions

Quantity/minutes

13. How many days a week do you normally eat breakfast?

14. How many full meals a day do you eat?

15. How many times a day do you normally eat fruits/vegetables?

16. How many times a week do you normally eat sweets?

17. How many days a week do you eat whole grain cereals or legumes or roots or tubers?

18. How many days per month do you eat fast food?

19. How many times per month do you drink alcohol?

20. How many times per month do you check your weight?

21. How many times a week do you visit the gym?

22. How many times a week do you normally exercise (with increased pulse rate and breathing)?

23. How many hours a day do you spend in front of the TV or computer?

24. How many minutes per day do you spend sitting still?

25. How many minutes a week do you normally exercise (with increased pulse rate and breathing)?

26. How many minutes a day do you normally exercise with normal pulse rate and breathing, e.g. walking?

Thank you for your answer!

29

Appendix 2

Department of Public Health and Caring Sciences

Letter of information

Our names are Emelie Persson and Sara Flodmark. We are students at the Nursing

Programme at Uppsala University, Sweden. We are working with our Bachelor Degree thesis

with the aim to study nutritional habits and physical activity in university students in

Thailand. Would you like to participate in our study?

It is voluntary to participate in the study and you can choose to discontinue participation at

any time. You will be anonymous and it will not be able to trace your answers to you

personally. All the questionnaires will we destroyed after finishing our thesis. It will take

around 10 minutes to answer the questionnaire. If you have any questions, please contact us

via our e-mail address. We thank you for your time!

Sincerely,

Student: Emelie Persson, persson_emelie1@hotmail.com

Student: Sara Flodmark, saraflodmark@hotmail.com

Main Supervisor: Associate Professor, Mariann Hedström, Uppsala University, Sweden