ORIGINAL COMMUNICATION The impact on eating habits of temporary translocation from a Mediterranean to a Northern European environment

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1 ORIGINAL COMMUNICATION The impact on eating habits of temporary translocation from a Mediterranean to a Northern European environment A Papadaki 1 and JA Scott 1 * (2002) 56, ß 2002 Nature Publishing Group All rights reserved /02 $ Department of Human Nutrition, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK Objective: To assess the effect of temporary translocation from a Mediterranean to a Northern European environment on the eating habits of a group of foreign students. Design: Cross-sectional survey of eating habits before and after moving from Greece to Glasgow, Scotland. Setting: University of Glasgow. Subjects: Eighty post-graduate Greek students. Interventions: A self-administered questionnaire comprising of three major sections: (1) general eating habits; (2) frequency of eating selected food items; (3) opinion of food availability in Glasgow. Results: After moving to Glasgow, significant decreases were reported in the frequency of consuming fresh fruit, raw vegetables, fish, legumes, meat, poultry and fresh fruit juice. The frequency of eating biscuits, savoury snacks, soft=fizzy drinks, alcoholic drinks and mayonnaise, dips and sauces increased. The estimated median daily consumption of fruit and vegetables decreased from 363 g in Greece to just 124 g in Glasgow, well below the Scottish and WHO dietary target of 400 g=day. The main perceived barriers to maintaining customary eating habits were the price of food, the lack of familiar tastes, the greater availability of convenience food and the limited variety of food available in Glasgow, when compared to Greece. Conclusions: These findings highlight the difficulties that migrant populations face in retaining traditional, often healthier, eating habits when migrating to a foreign country. Barriers of high cost, limited availability and poor quality of familiar foods, need to be addressed in order for migrants to maintain their customary eating patterns. Furthermore, these barriers need to be addressed before nutritionists can expect to see the widespread adoption of the Mediterranean diet by Western populations less familiar with this eating pattern. (2002) 56, DOI: =sj=ejcn= Keywords: students; migrants; food frequency questionnaire; dietary habits; Mediterranean diet Introduction Food habits, while shaped by culture, are dynamic and susceptible to changes, through a process of acculturation, brought about by migration to a new country (Wenkam & Wolff 1970; Lee et al, 1999). It is well documented that migrants, on immigrating to a new country, often find it *Correspondence: JA Scott, Department of Human Nutrition, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER, UK. j.a.scott@clinmed.gla.ac.uk Guarantor: Dr JA Scott. Contributors: AP designed and conducted the study, analysed the data and co-authored the paper. JS assisted with data analysis and coauthored the paper. Received 1 March 2001; revised 10 August 2001; accepted 6 September 2001 difficult to maintain their traditional eating habits, with traditional foods often being difficult to find (Pan et al, 1999) and more expensive than Western equivalents (Sharma et al, 1999). Dietary changes are related to length of exposure to the new environment, ability of immigrants to speak or read the new language and extent of social contact with people of the new culture (Lee et al, 1999; Pan et al, 1999). It has also been observed that younger immigrants tend to change their food habits more readily than older immigrants (Lee et al, 1999; Pan et al, 1999; Sharma et al, 1999). In some cases, a move from a traditional eating pattern to a more Westernised diet has had some undesirable effects on health status (Wenkam & Wolff, 1970; Wahlqvist et al, 1999). Studies highlighting the differing disease rates between

2 456 migrant, original and local populations have supplied vital clues to aetiology of chronic diet-related diseases (Wenkam & Wolff 1970; Kouris-Blazos et al, 1996; Sharma et al, 1999). Most studies have looked at the effect of long-term migration (Wahlqvist et al, 1999) or have compared the dietary patterns and nutritional status of different generations of migrant families (Wenkam & Wolff 1970; Sharma et al, 1999). Few studies have investigated the effect of shortterm migration, or temporary translocation, on eating habits. Studies of international students suggest that even a short-term stay in a foreign country can result in significant and often undesirable changes in eating patterns (Pan et al, 1999). The Mediterranean diet is a dietary pattern that is promoted for both its palatability and health benefits (Willett et al, 1995). Its health-promoting benefits are demonstrated by the lower rates of circulatory disease and diet-related cancers in Greece when compared with other European countries (Kafatos et al, 1991; Trichopoulou et al, 1995). In contrast, the Scottish diet is characterised by low average intake of fruit and vegetables and a high percentage of energy from fat, particularly the saturated kind, and is associated with some of the highest rates of circulatory disease and diet-related cancers in Western Europe (The Scottish Office, 1993). The aim of this study was to determine whether the temporary translocation of a group of Greek students to Glasgow has caused undesirable changes to their dietary habits in line with the Scottish pattern of eating. Materials and methods Subjects All Greek postgraduate students (n ¼ 84) enrolled at the University of Glasgow for the academic session were invited to participate in the study. Apart from Greek nationality, subjects were required to have lived in Glasgow for less than 1 y and to be consuming their usual mixed diets. Subjects were initially approached by mail, through the University s Hellenic Society. Those who met the study criteria were invited to complete a self-administered eating habits questionnaire. Once their willingness to participate was verified, subjects were contacted in person by the researcher (AP) to discuss the study and resolve questions or concerns. The survey was conducted in the summer of Participation was voluntary and anonymity was ensured. The study was approved by the Ethics Committee of the University of Glasgow. Questionnaire development A self-administered questionnaire was used to obtain data about sociodemographic characteristics, general food habits and consumption frequency of selected food items. Demographic information was limited to the age and sex of the student, as well as field of study. The section on general food habits included questions about types of food eaten in both Greece and Glasgow; frequency of eating home cooked meals, convenience meals (eg microwave or frozen) and take-away meals since moving to Glasgow; and living and food purchasing and preparation arrangements prior to moving to Glasgow. Subjects were also asked their opinion about the availability of food in Glasgow, compared to Greece, and whether they perceived that their eating habits and weight had changed since arriving in Glasgow. The questionnaire incorporated a short food frequency list (the Eating Habits Questionnaire) which had previously been validated and used locally to assess the habitual consumption of foods by Scottish adults with respect to the national dietary targets (Lean et al, 1998). Minor additions and substitutions were made to the food frequency list so that it better reflected Greek, as well as Scottish, eating patterns. Subjects were asked the number of times each day, week or month specific food items were consumed. Each food item was rated twice; the first rating reflected frequency of consumption while living in Greece and the second rating reflected consumption after arrival in Glasgow. The modified food frequency list contained eight questions relating to frequency of consumption of fruit and vegetables, beans and pulses, starchy foods and fish. In this context, fruit and vegetables included fresh fruit, cooked vegetables (fresh or frozen), raw vegetables or salad and fresh fruit juice. Starchy foods were defined as breakfast cereals, bread and potatoes, rice and pasta. In this study no distinction was made between white fish and other fish. The food frequency list also included dietary questions about the consumption frequencies of chips, meat, meat products, poultry, cheese, yoghurt, sweets or chocolate, crisps or savoury snacks, mayonnaise, dips and sauces, soft=fizzy drinks, alcoholic drinks, cakes, scones or pastries and biscuits. Statistical analysis The Statistical Package for the Social Sciences (SPSS for Windows, release 9.0, 1998, SPSS, Chicago, IL, USA) was used for data analysis. In order to examine the effect of temporary translocation on consumption frequencies of selected food items, the data were collapsed into dichotomous variables and comparisons before and after coming to Glasgow were made using the McNemar test. A P-value of 0.05 was considered statistically significant. Other data are reported descriptively. Total daily fruit and vegetable consumption was estimated using the method employed by Cox et al (1997). It was assumed that times could be equated to portions and the fruit and vegetables frequency of consumption was multiplied by the nominal portion of 80 g to generate a grams=day figure (Williams, 1995; Cox et al, 1997). Only one intake of fresh fruit juice counted as part of the estimated daily intake of fruit and vegetables. A problem with most food frequency

3 questionnaires is that, while they have ordinal scales, they have their own distinct categories on each measure rather than an interval scale providing a true measure. For instance, consumption frequency for each specific food item was measured by the response 6 þ times per day, 4 5 times per day, 2 3 times per day, once per day, 5 6 times per week, 2 4 times per week, once a week, 1 3 times per month and less than once a month. To estimate total fruit and vegetable consumption it was therefore necessary to group values from each relevant food item response. For this purpose, 6 þ per day became 6 times per day, 4 5 times per day became 4.5 times per day and 2 3 times per day became 2.5 times per day and so on. For this reason, parametric tests between the two measures were not appropriate statistics for describing the central tendency of the responses. Results Eighty of the 84 postgraduate students invited to participate in the study returned useable questionnaires. Of the four subjects who failed to enter the study, two had been living in Glasgow for more than 1 y and two subjects were unavailable due to vacation commitments. The subjects were equally divided by gender and ranged in age from 22 to 35 y (mean age y). The majority were studying science or finance (31 and 28%, respectively) and a smaller proportion medicine or related fields (17%). The rest of the sample was fairly evenly distributed across other faculties of the University. Students lived in university-owned student housing (n ¼ 75), with shared self-catering facilities, or in rented offcampus accommodation shared with other students (n ¼ 5). Comparison of food habits in Greece and in Glasgow The results of this survey indicate that students had changed their dietary habits in a number of ways since moving to Glasgow. A few of the observed changes can be considered positive or healthy changes. For instance, 7% of student had replaced white bread with wholemeal, brown or wheatmeal bread. A slight increase (4%) in consumption of skimmed=semi-skimmed milk was observed when subjects lived in Glasgow (48% Greece vs 52% Glasgow). In addition, since moving to Glasgow a greater number of students were eating cereal at breakfast (49% Greece vs 69% Glasgow), although refined cereals predominated rather than high fibre varieties (50 and 19%, respectively). There was, however, a noticeable trend for subjects to have adopted a number of less desirable eating habits. For instance, consumption of biscuits was significantly increased after moving to Glasgow; 52% of subjects in Glasgow, compared to 15% in Greece, ate one or more biscuits per day. While living in Glasgow, subjects also tended to increase their use of butter and margarine spreads. It was observed that 11% of the subjects started using spread on bread after coming to Glasgow, instead of eating bread plain (65% used no spread in Greece vs 56% in Glasgow). A relatively large number of subjects (17%) replaced olive oil with other fats in cooking (mainly sunflower oil and margarine), although the majority of students continued to use olive oil in cooking (95% in Greece vs 78% in Glasgow). Changes in eating habits were not associated with gender. Comparison of frequencies of eating selected foods in Greece and in Glasgow There were a number of changes in the frequencies of consumption of specific foods before and since coming to Glasgow (Table 1). There were statistically significant decreases in the frequencies of consuming fresh fruit, raw vegetables, meat, poultry, fish, yoghurt, beans=pulses and fresh fruit juice since moving to Glasgow. In addition to a decline in intake of healthy food items, there was an increase in frequency of consumption of a number of less desirable food items. Significant increases were observed in the frequency of consuming crisps and savoury snacks, soft=fizzy drinks, alcoholic drinks, mayonnaise, dips and other sauces, as well as biscuits. Attitudes towards food availability in Glasgow Figure 1 illustrates the differing attitudes towards food availability in Glasgow. Most of the subjects (64%) faced problems finding familiar Greek food, although finding fresh fruit and vegetables did not seem difficult for 41% of the subjects. The majority thought that food in Glasgow was less tasty (89%) and more expensive (94%) when compared to food in Greece. Almost half of the subjects (49%) reported that they found the variety of foods in Glasgow to be limited. For example, the variety of milk products was reported to be less than in Greece by almost half of the subjects (51%), while the quality of meat was judged not to be as good as in Greece (54%). The majority (61%) disagreed with the statement that fish was easy to find in Glasgow. The majority of subjects (61%) agreed that there was greater availability of convenience food in Glasgow. This greater availability of convenience food is reflected in the frequency of consumption of various meal types while living in Glasgow (Figure 2). More than one-third (35%) prepared convenience meals (microwave or frozen meals) at least 3 4 days a week while 20% ate take-away or fast food at least 3 4 days per week. Less than a quarter (22%) of students prepared home-cooked food on a daily basis. Living and food purchasing and preparation arrangements prior to moving to Glasgow Prior to moving to Glasgow to study, the majority of subjects (60%) lived with their parents or relatives and just under one-third (30%) lived alone or shared a flat with other students=friends. For the majority (70%), food shopping 457

4 458 Table 1 Comparison of frequencies of eating selected foods in Greece and in Glasgow (n ¼ 80) Greece Glasgow P-value Fresh fruit 1 time=day 62 (78%) 30 (38%) < 1 time=day 18 (22%) 50 (62%) Cooked vegetables 1 time=day 17 (21%) 10 (13%) < 1 time=day 63 (79%) 70 (87%) Raw vegetables 1 time=day 54 (68%) 13 (16%) < 1 time=day 26 (32%) 67 (84%) Fresh fruit juice 5 times=week 42 (53%) 26 (33%) < 5 times=week 38 (47%) 54 (67%) Cereals 5 times=week 27 (34%) 35 (44%) < 5 times=week 53 (66%) 45 (56%) Bread 1 time=day 67 (84%) 72 (90%) < 1 time=day 13 (16%) 8 (10%) Potatoes, rice, pasta 1 time=day 14 (18%) 21 (26%) < 1 time=day 66 (82%) 59 (74%) Chips 1 time=week 52 (65%) 55 (69%) < 1 time=week 28 (35%) 25 (31%) Beans or pulses 1 time=week 58 (73%) 16 (20%) < 1 time=week 22 (27%) 64 (80%) Meat > 1 time=week 62 (78%) 38 (48%) time=week 18 (22%) 42 (52%) Meat products > 1 time=week 45 (56%) 45 (56%) time=week 35 (44%) 35 (44%) Poultry 1 time=week 67 (84%) 58 (73%) < 1 time=week 13 (16%) 22 (27%) Fish 1 time=week 66 (83%) 24 (30%) < 1 time=week 14 (17%) 56 (70%) Milk 1 time=week 57 (71%) 56 (70%) < 1 time=week 23 (29%) 24 (30%) Cheese 1 time=week 39 (49%) 34 (43%) < 1 time=week 41 (51%) 46 (57%) Yoghurt > 1 time=week 44 (55%) 27 (34%) time=week 36 (45%) 53 (66%) Sweets, sugar, chocolate 1 time=day 17 (21%) 23 (29%) < 1 time=day 63 (79%) 57 (71%) Crisps, savoury snacks, 1 time=week 40 (50%) 56 (70%) < 1 time=week 40 (50%) 24 (30%) Soft=fizzy drinks 1 time=day 11 (14%) 20 (25%) < 1 time=day 69 (86%) 60 (75%) Alcoholic drinks 5 times=week 15 (19%) 28 (35%) < 5 times=week 65 (81%) 52 (65%) Mayonnaise, dips, sauces 1 time=week 41 (51%) 51 (64%) < 1 time=week 39 (49%) 29 (36%) Table 1 cont. Table 1 continued Greece Glasgow P-value Biscuits 5 times=week 11 (14%) 23 (29%) < 5 times=week 69 (86%) 57 (71%) Cakes, scones, pastries 5 times=week 8 (10%) 13 (16%) < 5 times=week 72 (90%) 67 (84%) and cooking had been performed mostly by family members. No significant association between living arrangements before translocation and gender was found. Perceived changes to eating habits The majority of subjects (85%) perceived that their eating habits had changed for the worse since coming to Glasgow (Table 2). Almost one-third of the subjects (35%) reported that they had gained weight since living in Glasgow, however no attempt was made to quantify the extent of weight gain. Discussion The health-promoting properties of the traditional Mediterranean diet have been recognised from as early as the 1960s (Keys, 1995). The Greek dietary pattern, however, has been changing rapidly and generally in an undesirable direction. Kafatos et al (1991) reported an increase in intakes of meat, fish and cheese and a decrease in bread, fruit, potatoes and olive oil consumption. This has resulted in a higher contribution of saturated fat to energy intake, especially in the younger age groups (Moschandreas & Kafatos, 1999). Despite having undergone these changes, the Greek diet is still recognised as being one of the healthiest in Europe and continues to be associated with some of the lowest rates of coronary heart disease and some cancers (Kafatos et al, 1991; Trichopoulou et al, 1995). This study examined only qualitative changes in dietary patterns. Additional measures such as portion sizes would have allowed a more quantitative examination of dietary changes and food-related patterns. Lack of information about portion size meant we were unable to compare the nutrient content of students diets in Greece with the nutrient characteristics of the current (Moschandreas & Kafatos, 1999) or traditional Greek diet (Kromhout et al, 1989; Keys, 1995). Nevertheless, the overall picture of eating habits of subjects in Greece, appears to reflect the current Greek dietary pattern. In this study, the comparison of students eating habits in Greece and Glasgow revealed a shift away from the current Mediterranean way of eating towards the typical Scottish eating pattern in a number of areas. A key feature of the Mediterranean diet is the relatively high intake of fruit and vegetables. Fruit and vegetable consumption, despite having

5 459 Figure 1 Attitudes of Greek students regarding food availability in Glasgow (n ¼ 80). Figure 2 Frequencies of type of meal eaten by Greek students in Glasgow (n ¼ 80). declined since the 1960s (Kromhout et al, 1989), remains relatively high when compared with Northern European countries. For instance, the average diet of older Greeks (Kromhout et al, 1989) contains more than 500 g of fruit and vegetables daily while the average Scottish diet contains just 181 g (The Scottish Office, 1993).

6 460 Table 2 Perception of body weight and eating habit changes of Greek male and female students since living in Glasgow Males Females Total (n ¼ 40) (n ¼ 40) (n ¼ 80) Eating habits changed: for the better 1 1 (1%) for the worse (85%) no changes (8%) do not know (6%) Body weight changed: weight gain (35%) weight loss (29%) weight has been stable (31%) do not know (5%) Although portion sizes were not measured, an estimate of daily intake of fruit and vegetables as g=day was generated. The median estimated daily intake of fruit and vegetables decreased from 363 g in Greece to just 124 g in Glasgow. In Greece, the median estimated daily intake of fruit and vegetables of students approached the recommended dietary target of 400 g=day (World Health Organization, 1990; The Scottish Office, 1993); indeed 45% ate this amount or more. However, since moving to Glasgow their intake had dropped dramatically to such an extent that only 5% of subjects were meeting this target. It is unlikely that this marked decline in fruit intake can be attributed to seasonal differences in intake as subjects completed the survey during the summer when the variety of available fruit and vegetables was at its peak. It is possible, however, that the computed daily intake of fruit and vegetables may be underestimated. The food frequency list which recorded number of servings per day or week may not have accounted for hidden fruit and vegetables within composite meals (for example vegetables added to meat dishes; Cox et al, 1997). Similarly, subjects may have eaten more than one portion each time that they consumed fruit or vegetables. Nevertheless, this error is likely to have been consistent across both recordings of frequency of consumption of fruit and vegetables and is unlikely to affect the relative difference that reflects a significant decline in intake since living in Glasgow. Undesirable changes in the diets of foreign students have been reported previously by Pan et al (1999) in a study of Asian students living in the United States. Compared with their dietary habits in their native countries, there was an increased tendency for Asian students, when living in the United States, to skip meals, usually breakfast, and to increase their consumption of salty and sweet snack items and American-style fast foods. The dietary changes of Asian students were influenced by a lack of availability of ethnic foods, poor quality of ethnic foods and ethnic foods being more expensive. Barriers to maintaining customary dietary habits similar to those encountered by subjects in this study. The dietary habits of university students are generally characterised by frequent snacking and meal skipping, particularly breakfast (Bull, 1988; Huang et al, 1994; Pan et al, 1999). Bull (1988) reviewed a number of studies that suggest students living in self-catering accommodation have poorer diets when compared with students living in traditional student halls of residence. She proposed that for young adults, who have left home and are catering for themselves for the first time, an inadequate diet may result from lack of experience in planing meals, or a general lack of interest in food. It is possible that changes in eating habits reported in this study were in part the result of students having left the family home and taking on responsibility for food purchasing and preparation for the first time. The majority of students (70%), prior to moving to Glasgow, had lived at home, where the food preparation and purchasing was the responsibility of someone else, usually their mother. Not knowing how to cook and a lack of time to prepare traditional foods were some of the reasons given for the dietary changes observed in a group of Asian students studying in the United States (Pan et al, 1999). Similarly, a lack of time, not knowing how to cook, limited catering facilities and the ready availability of take-away foods in Glasgow could account for the frequent consumption of take-away and convenience foods and the limited consumption of homeprepared foods by students in this study. We contend, however, that the dietary changes reported by subjects were, to a greater extent, related to their temporary translocation from Greece to Scotland. The students in this study came from a country with a strong cultural identity, in which food plays an important role. Food is more than nutrition; Greeks are taught that food enriches life, and individuals participate in cultural activities surrounding specific religious festivals where food plays symbolic roles (Freedman & Grivetti, 1984). Given that subjects were well-educated post-graduate students with an average age of 25.5 y, it might be expected that they would have wellestablished food preferences and eating habits that were less susceptible to changes than those of younger undergraduate students. Cultural differences in the dietary habits of students have been reported in a study of University students from 21 European countries (Bellisle et al, 1995). The meal and snack patterns of Greek students studied by Bellisle et al, were close to the traditional Greek dietary model (Wahlqvist et al, 1999). Furthermore, the mean number of snacks consumed per day by Greek students was 1.2 for males and 1.1 for females, compared with 2.3 and 2.0 for Scottish male and female students, respectively. Similarly, in another study adolescents from Southern European countries, including Greece, were reported to eat out in fast food restaurants less frequently than their counterparts in the USA (Amorim Cruz, 2000). These findings support our argument that the dietary changes observed among the Greek students living in Glasgow were the result, at least in part, of rapid dietary acculturation related to their temporary translocation.

7 While there is evidence that the diets of Greek students differ from those of their UK counterparts, it cannot be ruled out that the changes in diet quality reported in this study are related to the fact that the majority of Greek students were living on their own, away from the family home, for the first time. To the best of our knowledge there are no published studies that have measured the change in diet quality of Greek students leaving family life for student life in Greece, against which we could compare our findings. However, the difficulties reported by Greek students in this study related to the preparation and purchasing of familiar foods are similar to those difficulties encountered by immigrants on migrating to a new country (Pan et al, 1999; Sharma et al, 1999). This suggests that the changes in diet quality reported here are due, at least in part, to the temporary translocation of students from a Mediterranean to a Northern European environment. The Mediterranean diet is recommended to the Western world as a dietary pattern that is both palatable and healthy. Willett et al (1995) purport that for Mediterranean people it is a traditional diet that can be readily preserved and revitalised within a modern lifestyle. While this may be the case when living in Mediterranean countries, in this study Greek postgraduate students studying in Scotland had difficulty maintaining their customary eating patterns when faced with the high cost and limited availability, quality and palatability of familiar foods. The reasons given by Greek students for failing to maintain a relatively high intake of fruit and vegetables, in particular, are similar to those given by Scottish adults as barriers to eating a healthier diet (The Scottish Office, 1993). 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