Determinants of nutrition knowledge among student migrants in West Midlands, United Kingdom

Introduction

Dietary habits play significant roles in health and are largely influenced by an individual’s nutrition knowledge.¹ These are also related to food choices and eating patterns.¹ Moreover, the influence of factors such as demographic characteristics, culture, and socioeconomic inclinations on food choices and eating patterns have been recognized.^2,3 Mora and Golden⁴ reported that cultural values and practices are significant determinants of food choices and eating patterns. In addition, the influence of culture on food preparation processes and health consequences has been reported.^5,6 Nutritional requirements and food choices also change with age, level of education, type of job, living environment, and family income.^7–10

Migration affects these factors and has been recognized as a key determinant of dietary habits.^11–13 Often, people are exposed to new environments, cultures, and lifestyles, which warrant them to adjust their dietary choices when they migrate. Challenges such as such as lack of access to familiar food items in the new country may also necessitate the need to change dietary habits.^14–16 In this regard, commonly reported challenges for student migrants relate to acculturation, climate shock and language barriers.^3,17 These factors have also been shown to significantly influence dietary choices and habits of student migrants.¹⁷ According to Yahia et al.,¹ some student migrants are leaving home for the first time. Therefore, they may face additional problems, including lack of cooking skills, peer influence, and significantly increased academic rigour, which could have an impact on their dietary choices and habits.

The United Kingdom has experienced a significant increase in the number of student migrants in the last 10 years, and available data indicate that the majority of these students are from low- and medium-income countries (LMICs).¹⁸ In 2021, it was reported that the UK had about 700,000 student migrants with about 8 out of 10 students from LMICs.¹⁹ Due of differences in economic, geographical, and climatic factors. It is expected that students migrating to the UK will face diet adjustment/acculturation challenges.

Although there are several coping mechanisms that student migrants could adopt in coping with diet acculturation challenges, a role has been prescribed for good knowledge of nutrition as a coping strategy.²⁰ Belogianni et al.²⁰ reported a positive correlation between nutrition knowledge and healthy food choices among university students in the UK. The study particularly reported that students with good knowledge consumed more fruits, dairy foods, proteins, and white grains. among students have been reported. However, it is not yet fully understood whether this correlation is also true for student migrants, particularly in the West Midlands region of the United Kingdom. In addition, the extent to which good nutrition knowledge has helped student migrants cope with food acculturation challenges in the UK needs to be researched. This study is part of a program that investigates the role of migration in diet and diet-related diseases (such as obesity and diabetes). Specifically, this study investigates the level of nutrition knowledge among student migrants in the West Midland region of the UK and assesses how factors such as gender, length of stay in the country, marital status, level of academic program, enrolment in health-related courses, and history of diet-induced disease influence nutrition knowledge in student migrants.

Methods

Results

The data presented in Table 1 indicate the demographic profiles of the student migrants recruited for this study. The participants were mostly male (58.1%), enrolled in a postgraduate program (80.6%), married (77.4), and studying non-health-related courses (87.1%). Moreover, 38.7% of participants had a normal body mass index, 6.5% were underweight, 41.9% were overweight (41.9%), and the remaining 12.9% were obese. Moreover, 35.5% of the recruited student migrants lived in the UK for 12 months or less, and 38.7% had a UK residency period between one and three years. For longer residency periods, 6.5% of participants who had lived in the UK for 3 – 5 years and 9.7%) have lived in the UK for 5 to 10 years or more than 10 years in the UK (Table 1). Finally, 93.5% of the participants did not live with any diet-induced disease or had a history of these diseases.

Data on the scores obtained for the different categories of knowledge and overall knowledge are presented in Table 2 and Figure 1. The data indicate a median score of 54 out of 87 (62.1%) and a mean score of 52.3 ± 2.4 for the overall nutrition knowledge score. The median scores obtained for dietary recommendations (12 of 18, 66.7%), food classification (22 of 36, 61.1%), and diet-related diseases (14 of 20, 70.0%) were similar. Mean scores (expressed as percentages of the total score for each category) across these categories were also similar (dietary recommendations, 66.1%; food classification, 59.2%; and diet-related diseases, 66.0%). Compared to other categories, lower mean and median scores were observed for the food choices category (%; mean = 5.9±0.4, 41.5%; median score = 6 out of 13, 46.2) (Figure 1).

Figure 1. Overall and mean scores for each category of the General Nutrition Knowledge Questionnaire.

Values are mean ± SEM with n = 372.

The responses of student migrants to individual items in the four categories were analyzed to better understand the participants’ level of knowledge. The analysis of responses to items related to knowledge of dietary recommendations indicated good knowledge of the need for increased consumption of fruits (96.8%), vegetables (100%), water (93.5%), wholegrain (64.5%), and milk with reduced fat (83.9%). In addition, student migrants demonstrated good knowledge of the need to consume less food with salt (93.5%), high-fat content (90.3%), food and drinks with high sugar content (87.1%), and ultra-processed meat (87.1%). Conversely, the data obtained indicated poor knowledge of recommended daily portions of fruits and vegetables (66.7%) and fat types that are good for consumption (54.8%). With respect to fat, 41.9% of participants demonstrated poor knowledge of trans fat and 22.6% of participants expressed that the consumption of trans fat was good. In addition, the knowledge of the recommended consumption of oily fist was poor among participants (54.8%), while the majority of participants (83.9%) did not know the recommended limit of alcohol consumption or food composition listed in the Eatwell Guide (67.7%).

With respect to knowledge of food classification, the majority of student migrants demonstrated the ability to recognize food items with high added sugar content. Specifically, 87.1% of respondents recognized that ice cream had a high sugar content. However, knowledge of the high salt content of food items such as breakfast cereals (83.9%) and bread (51,6%) was poor. Moreover, the majority of student migrants showed good knowledge of the high fiber content of food items, such as oats (93.5%) and potatoes with skin (83.9%), while 96.8% of participants correctly indicated that poultry products are rich in protein. Similarly, 51.6% of the participants correctly identified that the fiber content of pasta was low.

Generally, knowledge of the fat composition of many food items is poor. The majority of student migrants were unable to identify healthy food combinations, low-fat strategies for cooking foods such as potato chips (74.2%), or cooking methods that do not require the addition of fat (80.6%). However, the knowledge of diseases associated with low fiber intake (71%), as well as high sugar (63.3%) and salt consumption (67.7%), was good among participants. In addition, student migrants correctly identified food-based measures for preventing cancer (58.1%), heart disease (61.3%), and diabetes (77.4%). Moreover, the majority of participants were able to identify food items that could lead to elevated blood cholesterol levels (58.1%), as well as food items with a high glycemic index (63.3%). Similarly, the majority of participants also identified reading food labels (80.6%), taking nutritional supplements (64.5%), and constantly monitoring eating habits (96.8%) as effective strategies for healthy weight maintenance. The overall scores shown in Table 2 indicate that 77.4% of participants had overall good nutrition knowledge. For the different categories, good knowledge of dietary recommendations, food classification, and diet-related diseases was observed in 93.5%, 71.0%, and 87.1% of participants, respectively. However, 61.3% of student migrants had poor knowledge of food choices.

The effects of demographic characteristics on the overall nutrition knowledge and knowledge of the different categories of nutrition knowledge are presented in Figure 2 and Table 3. The data presented in Figure 2A indicate that the overall nutrition knowledge of female students was significantly higher than that of male students (17.9%, P<0.001), and that more female students (92.3%) demonstrated good nutrition knowledge than male students (66.7%). Moreover, the mean overall score observed for postgraduate students was 8.0% (P<0.001, Figure 2B), which was higher than the scores obtained by undergraduate students. Despite this higher mean score, the proportion of postgraduate students with good knowledge (76.0%) was lower than that of the undergraduate students (83.3%). The mean score for married respondents was 9.6% (P<0.001, Figure 2C) higher than that for single respondents, and the proportion of married respondents (79.2%) with good knowledge was higher than the proportion of single participants (71.4%). A similar trend was observed for the effects of enrolment on health-related degrees (mean score higher by 17.9%, P<0.001, Figure 2D) and living in the UK for more than 3 years (mean score higher by 17.7%, P<0.001, Figure 2F). However, unlike other demographic parameters, more students enrolled in non-health-related degrees (77.8%) and those with 3 years or less of UK residency (78.3%) demonstrated good nutrition knowledge. BMI status did not have any significant effect on overall mean scores (Figure 2E), but more people with normal BMI (83.3%) values demonstrated good nutrition knowledge compared to those who were underweight, overweight, or obese. In addition, student migrants with or without a history of diet-related diseases had similar mean scores (Figure 2G), and all students with a history of diet-related diseases demonstrated good nutrition knowledge.

Figure 2. Distribution of overall mean scores of student migrants based on demographic parameters.

Values are mean ± SEM with n = the frequency for each demographic group. ***P<0.001 compared to the respective demographic group. A = Gender, B = Level of study, C = Marital status, D = Enrolment on health-related degree, E = Body Mass Index, F = UK residency, G = Living with a diet-related disease.

In this study, no association was found between overall nutrition knowledge and sex (P = 0.0920), level of study (P = 0.8509), marital status (0.6667), enrolment in health-related degree (P = 0.9013), BMI (P = 0.5314), length of UK residency (P = 0.8493), and history of diet-related disease (P = 0.4297). Odds ratios computed for these demographic characteristics revealed that the odds of having good nutrition knowledge was low among male students, unmarried students, and those enrolled in a non-health related degree (Table 4). However, there were increased odds of good nutrition knowledge among undergraduate students and students with normal BMI, 3 years or less UK residency, and those with a history of diet-related diseases (Table 4).

Discussion

This study investigated nutrition knowledge and the impact of demographic characteristics on nutrition knowledge among student migrants. It is evident from the data collected and analyzed in this study that respondents were mostly male, married, and enrolled in postgraduate programs. These demographic characteristics are different from other recent studies that investigated knowledge of nutrition among university students in the UK.^20,23,24 In the study by Belogianni et al.,²⁰ the majority of respondents were from a white ethnic background, female, aged 25 years or less, and studying at the undergraduate level. Similarly, the study by Cooke and Papadaki²⁴ had respondents with similar demographic characteristics. However, the difference in the demographic characteristics of the respondents in the present study is expected because the focus of the study is on student migrants. Although data on the ethnicity of respondents in the present study were not reported, respondents were more ethnically homogenous, as they were all of African origin. Moreover, the majority of respondents were in the age range of 35 to 45 years, and this was expected, as the majority were enrolled in postgraduate studies. Moreover, most international students come to the UK to study at the postgraduate level. The fact that these students would have completed undergraduate studies in the countries of origin and may have also worked for some time before returning to education is consistent with the observed age range of the respondents. This age and ethnic homogeneity explain why no analysis of the influence of age and ethnicity on nutrition knowledge was conducted in this study. The observation that more respondents study at the postgraduate level is also consistent with the recent surge in the number of migrant students studying at universities across the UK.²⁵ Also, available evidence indicates that most postgraduate students are usually accompanied by their family members to the UK,²⁶ hence a higher proportion of married respondents in this study.

Unlike other recent studies, most respondents in this study were either underweight, overweight, or obese.^20,23 The proportion of students with abnormal BMIs in previous similar studies conducted in the UK and the USA was reported to be approximately 33%.^20,23 The difference observed in this study could reflect the reported growing incidence of obesity globally.²⁷ Also, as the data used in the computation of BMI in this study were self-reported, it is possible that inaccuracies (as some respondents may not be sure of their heights or body weights) in self-reported data could have skewed the computation of BMI values conducted in this study. The majority of the respondents in this study were recorded as being apparently healthy. However, the fact that detailed health information of participants was not collected means that it is possible that respondents could be living with conditions that are not diet-related but could have significant implications on their dietary habits and choices. This, in turn, influences their nutritional knowledge. In addition, the role of diet in disease development may be subtle, and it is possible that respondents may not be aware of how dietary choices and habits contribute to the condition they live with.²⁸

This study reported an overall median nutrition knowledge score of 54 (62.1%). This is lower than the median scores reported by similar previous UK studies and studies worldwide. The mean scores recorded in UK studies ranged from 65.5% to 72.7%).^20,23 The study by Kresic et al.²⁹ conducted in Croatia reported a mean score of 67.4%. The fact that these studies used the same questionnaire for data collection also points to the fact that differences in the reported mean scores could only be attributed to characteristics inherent in the population of students recruited for individual studies. All respondents in the present study were university students. Therefore, the influence of education on nutrition knowledge could be ruled out. This is particularly important, as a previous study suggested an association between the level of education and knowledge of nutrition.³⁰ Based on this observation, postgraduate students expect a higher mean score. However, the opposite was observed in this study, and a significantly higher number of postgraduate students recruited as participants may have contributed to the lower mean score observed. The expectation is that students enrolled in health-related courses will have better knowledge of nutrition. However, the opposite result was observed in the present study. It is also possible that the low number of students enrolled in health-related courses was responsible for this observation.

The analysis of responses to individual items in the research questionnaire revealed specific gaps in the knowledge of the student migrants recruited for this study. These gaps may have significant implications on the dietary habits of these students. While this study revealed that student migrants are aware of the need to consume fruits and vegetables, the majority of them are unaware of the recommended daily allowances for fruits and vegetables. Therefore, it is possible that they may not consume the right amount of these food items. To support this assertion, the majority of respondents indicated daily consumption of two portions as opposed to the recommended five portions of these items. In addition, poor knowledge of health and unhealthy fats, as well as strategies for reducing fat consumption, means that these students may be consuming more fatty food than necessary. This assertion is consistent with the fact that it has been previously reported that fat consumption is generally high among students.^1,31 In addition, the majority of migrant students recruited in this study had difficulties identifying high-fiber food items. Instead, many of these students simply indicated food items that they probably commonly eat because they are cheap and/or easy to prepare.³²

These gaps in knowledge may be responsible for the generally poor knowledge of food choices observed in this study. Although no association between nutrition knowledge and dietary behaviours has been previously reported,³³ the observations in this study are not entirely different from this previous report. This study revealed that, although there were obvious gaps, respondents demonstrated good general nutrition knowledge. Therefore, it can be concluded that this knowledge does not generally reflect their ability to make good dietary choices. Several factors might have played a role in this study. In the first instance, because respondents were mainly of African origin, they may not be familiar with many of the food items listed in the questionnaire, and food items listed in the tool may not reflect items that they consume regularly. This observation suggests that modification of the tool may be necessary if it is to be used by non-Europeans. On the other hand, it is possible that respondents truly lack the ability to select healthy food choices because of factors such as the inability to properly read or understand food labels. Adequate food labelling is supported by policies and legislation in the UK and across Europe.^34,35 However, this may not be the case in LMICs. This study also revealed gaps in the knowledge of student migrants about how to maintain healthy weight, even though they demonstrated good knowledge of the relationship between diet and diseases. In fact, respondents were almost equally divided on whether excessive fat consumption was good for healthy weight maintenance.

No association between good nutrition knowledge and all demographic characteristics assessed in this study was observed; even disparities in the scores obtained by women and the proportion of females with good nutrition knowledge were observed. In addition, the odds of having good nutrition knowledge among male respondents were reduced. These observations are consistent with a previous report by Svendsen et al.³⁶ which highlighted a better functional knowledge of nutrition in women. In Africa (from which the majority of respondents originate), women are more involved in cooking than men.³⁷ However, it is not yet certain whether this plays a significant role in what is observed in this study. Similarly, better nutrition knowledge was observed in married respondents, which may also be associated with cooking duties for their family members, although further studies are needed to investigate this assertion.

Previously, the association between enrolment in a health-related degree and nutrition knowledge has been reported.³⁷ However, the opposite was observed in this study, even though students enrolled in health-related courses had higher mean scores. This is supported by the observation that a higher proportion of students enrolled in non-health-related programs demonstrated good nutrition knowledge and that the odds of good knowledge of nutrition is reduced in students enrolled in health-related programs. These results are consistent with a previous report by Belogiani et al.²¹ which recommended that interventions to improve dietary and nutrition knowledge should focus on all types of students, irrespective of the course they are enrolled in. The data collected in this study also indicated that residency in the UK for more than 3 years may be associated with good nutrition knowledge. However, this is negated by the fact that a higher proportion of students in the UK with less time demonstrated good nutrition knowledge. Previous studies investigating the effect of the length of UK residency on nutrition knowledge are lacking. This is because most respondents in previous UK studies were either born or grew up in the UK. Moreover, this observation also provides a role for early nutrition as a strategy for preventing diet-related diseases in people migrating to the United Kingdom.

All respondents in this study were of African origin, which is a limitation of this study to some extent. It is possible that data from students from non-European and non-African settings may provide new perspectives that will improve the understanding of the role of the migration of nutrition knowledge. Moreover, the influence of age, environmental factors, and social determinants of health (such as social support, family background, academic rigor, and cultural factors) on nutritional knowledge was not investigated in this study. It is also known that the use of a research questionnaire alone to collect data may have limitations. Future studies that adopt a qualitative approach may provide additional insights into the observations reported in this study.

Conclusion

In conclusion, good overall knowledge of nutrition among student migrants was reported in this study. In addition, good knowledge of dietary recommendations, food classification, and the relationship between diet and diseases, as well as poor knowledge of food choices and weight management, was observed. Gaps in the knowledge of recommended daily allowance, fat types, sources of fiber, food labelling, and weight management strategies were observed. The revision of the research questionnaire by incorporating food items that make the questionnaire more culturally sensitive is recommended. In addition, the inclusion of open-ended options that provide opportunities for respondents to freely express themselves may improve the effectiveness of the research questionnaire. Moreover, the expansion of respondent recruitment to include participants from diverse ethnicities and the investigation of the effect of wider determinants of health on diet knowledge are recommended.

Ethical standard disclosure

This study was conducted in accordance with the guidelines laid down in the Declaration of Helsinki. Ethical approval for the study was obtained from the Faculty of Education, Health, and Wellbeing Ethics Committee at the University of Wolverhampton, UK prior to the conduct of the research 16/08/2023). Approval Number. LSEC/2022-23/OO/005 Participants were provided with the Participants’ Information Sheet which clearly explained the aim of the research and processes involved prior to participation in this study. Written informed consent was obtained from all the subjects.

Authorship

OOO, YAA, PC contributed to the study conception and design, data analysis, and manuscript preparation. SO, OA, MO, AAF, ABF and CCO contributed to data collection and analysis. All authors reviewed the final manuscript.