Relationship between Student Diet and Academic Performance

Relationship between Student Diet and Academic Performance 1.0  Ã‚   Introduction For many young adults joining university, it is a time of substantial change in social, economic and environmental surroundings.1 Currently, there is increasing advocacy for an emphasis on healthy lifestyle behaviours for student populations.2 Researchers have established that academic attainment plays a key role in an individual’s future health, wealth and social outcomes.3, 4 Providing this, academic achievement must be considered by public health decision makers aiming to improve health across the lifespan.5 A balanced and nutritious diet means it is adapted to special individual needs to reach optimal health, that is it supplies optimal levels of nutrients to maintain healthy function.6 Diet quality is a composite measure of scoring food patterns, with a focus on whole food intake.7 The objective is to maintain a high diet quality, through consuming the correct amounts of the food groups from relevant dietary guidelines. Assessment of dietary patterns can allow unfavourable intakes to be identified.8 Poor diet quality introduces nutritional inadequacies and is a significant predictor of poorer health status.9 While the connections between health and education are widely accepted, the mechanisms that contribute to this relationship remain poorly understood. Scholars propose that health behaviours contribute towards cognitive function and maintaining a productive work day.10, 11 The main goal for university students is academic attainment, yet despite this, a high proportion of students report engaging in poor health behaviours during the study period.12 Australian university students are consuming less than the recommended intake of fruit and vegetables, and have a high intake of convenience foods.12, 13 To ensure students are provided best opportunity for success, it is important to understand the determinants of academic performance. It is suggested that the type and variety of foods an individual consumes has an important influence on academic outcomes.14 Diet quality has an association with academic performance, though the isolated effects are yet to be fully explored.15 The scores gen erated may be able to determine areas that can be improved to increase academic performance. There are several variables which affect diet quality and this review will focus on four major themes which emerge repeatedly throughout the literature. These themes are: overall diet quality, eating patterns and behaviours, fruit and vegetable intake and convenience food intake. In order to understand how diet quality is linked to academic performance, the literature was searched for relevant articles released in the last ten years. An analysis of terms identified the key words of: â€Å"student†, â€Å"university student†, â€Å"diet quality†, â€Å"health behaviour†, â€Å"eating pattern†, â€Å"academic performance† and â€Å"academic achievement†. These were used across the electronic data bases of Cochrane library, Web of science, Pubmed, CINAHL and Scopus. Although preference was given to recent articles involving university students, the final search was expanded to incorporate sources of all years, as well as children and adolescent population groups. The aim of this review is to critique current literature between diet quality and university student academic performance. Furthermore, it will assess current measures of diet quality, and the significance of other factors that contribute towards overall diet quality. 2.0  Ã‚   Diet quality Diet is a key behavioral risk factor that can be modified to have an impact on health.16 Free living people consume whole foods, which contain both nutrient and non-nutrient substances.17 Dietary patterns have synergistic effects, which provide insights beyond the role of nutrients and single foods.18 For researchers, it can be difficult to quantify the diet, and any established values should only be used as an approximation. Diet quality is a composite measure of diet in its entirety, and involves the relationships between food groups.7, 8 This qualitative perspective is an alternative approach to provide more detailed dietary information. It can give an indication to the types of food people consume, and therefore where the nutrients are derived from. Diet quality encompasses the central areas of dietary variety, balance, adequacy, and moderation.19 These have been found to contribute to a nutritious diet and can give a greater understanding of dietary habits. Variety and balance involve the consumption of a range of options from the food groups, according to proportionality. Adequacy is attaining the recommended energy intakes to meet nutrient requirements, whilst moderation is regulating the intake of certain foods to prevent harmful effects on health (including convenience foods that are high in sugar and fat).20 It is widely recognised that a high quality diet should be safe, able to promote optimal development and reduce the risk of nutritional inadequacies.6, 21 Diet quality describes how well an individual’s diet conforms to dietary recommendations, and this differs according to country. Australia employs the ‘Eat for Health’ guidelines,6 which were developed through extensive research to provide information on the types and amounts of foods needed to promote health and wellbeing as well as reduce the risk of diet-related conditions. The food groups in the ‘Eat for health’ guidelines consist of: Vegetables and legumesFruitLean meats and poultry, fish, eggs, tofu, nuts and seeds, legumes/beansGrain (cereal) foods, mostly wholegrain and/or high cereal fibre varietiesLow fat milk, yoghurt, cheese and/or alternatives, mostly reduced fat. 2.1 Measuring diet quality The main tools used to measure diet quality are surveys and questionnaires.19 These are useful for time management, easily sorting data, are relatively simple to design and can be used on a large sample. The questions developed should be well thought out, and it is also necessary to define serving sizes and how often foods are consumed (such as once weekly). The chosen tool needs to consider recall bias, and the respondent’s level of literacy skills. A number of dietary indices have been developed, tested and validated to reflect various aspects of diet quality.7, 17 They are based on existing knowledge of optimal dietary patterns and provide a clear nutritional benchmark. The indices vary in design from simple tools measuring adherence to dietary recommendations, to intricate analyses of macronutrient and micronutrient intakes. The main diet quality indices have scored food patterns in terms of alignment with key dietary recommendations and diversity of healthy choices within core food groups.7 Food-based indices of diet quality are important, as they retain the complexity of foods and permit assessments of single, as well as grouped nutrient components. The dietary indices which are best translated to the Australian guidelines are the Diet Quality Index International (DGI-I), Healthy Eating Index (HEI) and the Dietary Guideline Index (DGI). These are all validated tools and are useful in various population groups.17 The indices have separate nutritional components which are combined into a single ‘overall diet quality’ score. This incorporates cut-off values or ranges for the food groups and selected dietary variables (considered to be representative of healthy eating). The DQI-I was derived from the original Diet Quality Index, and provides an effective means of cross-national comparative work for global understanding of diet quality.22 The DQI-I provides a ‘priori’ analysis (predetermined what is ‘healthy’ and ‘unhealthy’), as it incorporates both nutrient and food perspectives of the diet. The index is validated in both China and the United States, and so reflects a cross-section of cultural attributes.22 It is an in-depth measure which investigates multiple variables and gives a broad picture of diet quality. The DQI uses ranges to find more associations which broadens the information gathered and strengthens the validity of the results.23 The four aspects of a healthy diet comprise the four main categories of the DQI-I. Firstly, there are two variety components, which include the servings across food groups and the diversity within them. The adequacy components use eight food types, and indicates areas in the diet which may need to be improved, and moderation highlights areas that should be decreased (total fat, saturated fat, cholesterol, sodium, food types with empty calories). The balance component involves calculating the macronutrient ratio and fatty acid ratio. The scores for all four categories are summed, resulting in the total DQI-I score, ranging from 0 to 100 (the higher the score, the higher the diet quality).22 The HEI has been used in several studies that evaluate food consumption. It was originally based on the Dietary Guidelines for Americans, but has been adapted to other areas.24 It is similar to the DQI, with the addition of total fruit and whole fruit, plant proteins and seafood, and the moderation component includes refined grains.   Food group servings are evaluated on a per-thousand-calorie basis. The scores are calculated proportionally between 0 and 10, according to how well a food group recommendation is achieved.25 The main strength of the HEI is that it assesses diets on a given energy intake level, to characterise diet quality while controlling for diet quantity. The DGI was developed and predefined to the Australian Dietary Guidelines with an adherence to specific aspects of a healthful diet.26 However, it does not account for all aspects of diet quality, and could be beneficial if combined with other measures. The DGI consists of fifteen food components using standard adult portion sizes and the score calculation is based on regular consumption of food frequency questionnaire items. Each component contributed 0 to 10 points, where 10 indicated an optimal diet intake (meeting the recommended serves per week). The total DGI score is the sum of the thirteen items, indicating a maximum possible score of 130.27 Selecting a dietary index remains a complex matter with a large degree of subjectivity. It is important to consider whether the index is adaptable to the chosen dietary guidelines and that it fits within the constraints of the study. The specific context in which they are used should be noted when interpreting results and making comparisons. The main limitation of dietary indices is that there is no universal dietary guidelines representative of a healthful diet.7 The tools used need to consistently be revised if they are to truly reflect the latest nutrition science and policy. 3.0  Ã‚   University Students University academic performance is measured through grade point average, which incorporates the scores from all subjects during a study period.10 Identifying the factors that contribute towards academic performance has clear implications for university students. Diet quality is a health behaviour that may improve a student’s chances of furthering their academic career.15 The rate of enrolment for Australian universities is continuing to grow, with a large percentage being young adults (18 – 34 years old).28 A high proportion of students have an increase in independency, an altered support system and are perceived to be time poor.29 University can be a highly stressful environment, where health behaviours change (health may not be a high priority).1, 30 Amongst this group, there is an increased level of socio-economic disadvantage associated with the prevailing issues of food insecurity.28 This may be related to limited resources to source and prepare healthy foods, wher e individual diets decline in quality due to food insecurity.31 Food choice for university students can be influenced by their environment and can include the primary factors of: affordability, accessibility, peer influence and nutrition knowledge.32 Very few young Australians are following the dietary guidelines of consuming from the five food groups and are generally below recommended levels for fruit and vegetable serves.13 Approximately one-tenth are meeting the daily recommended serves of vegetables, and one-third are meeting recommended daily fruit serves.12 These health determinants mean that the diets of university students are quite poor and may be at risk of nutritional inadequacies. This is an issue, as it has been shown that being undernourished negatively effects academic outcomes.31 As the quality of food and drinks consumed have a significant impact on the health and wellbeing of individuals, better nutrition has a potential to improve public health outcomes. Performance management is always a concern for university administration bodies as they aim to provide the best environment for student growth and wellbeing. The food environment of a university campus should encourage students to adopt a 30healthful eating pattern.15 An institution is an effective setting for intervention, as it has the structure to bring together multiple strategies to a large group of people. A higher level of education can positively affect future health and employment opportunities.3 The development of healthy behaviors that can be continued during a student’s professional life should be strongly supported during tertiary education. 4.0  Ã‚   Diet quality and academic performance There is increasing evidence that nutrition behaviours have an influence on academic performance, which in turn influences future successes.33, 34 The aim of this review is to evaluate the association between dietary quality and academic performance in university students. However, there is a limited amount of literature related to the population group of university students, which is why much of the following research relates to children and adolescents (school-aged students). Current research has established a relationship between overall diet quality and student academic achievement.14, 35-39 Nutrition and health status have a complex and multifaceted effect on cognitive function.40 It has been identified that moderate associations exist between several aspects of diet quality and student performance.14, 34, 36, 38, 39, 41-43 There are a number of factors which have a direct effect on diet quality, and therefore have been included in this review. They include a person’s habitual eating patterns, fruit and vegetable intake, and convenience food (as well as take-away food) intake. The reviewed studies compared a variety of health behaviours to determine which are most significant to student outcomes. The majority reported statistically significant outcomes between diet and academic performance, which is likely a result of the relatively large numbers of participants. The results concerning dietary components strengthened the concept that diet quality has an influence on academic performance. All included research was adjusted for the modifiable and non-modifiable factors which affect student academic performance. The studies acknowledge that the health behaviours relating to academic work are multifactorial, and involve several influencing variables.    It should be noted there were some common limitations amongst the reviewed studies. The majority of the studies were cross-sectional in design, and were not able to determine an independent association between diet quality and academic achievement. This impedes any inferences that can be made about causality. It was important that authors controlled for significant confounding factors, including attendance, economic status, social support and family background. The nature of these studies left open the possibility that other intervening variables may have been related to the observed pattern of results. 4.1 Overall diet quality Overall diet quality was found to be associated with student academic performance. Across all studies, dietary habits that were in accordance with guidelines were related to better student outcomes.14, 33, 35, 37, 39, 44-46 Furthermore, an improvement in overall diet quality score increased likelihood of an improved academic performance. Students with a high intake of ‘high quality’ nutrient-dense foods, and a low intake of ‘low quality’ nutrient poor foods, had increased odds of a favorable school performance.44 The strongest outcome would be achieved through the combined effects of meeting multiple dietary recommendations. When controlling for the key health behaviors of physical activity and weight status, diet quality was a leading contributor to academic performance.45, 47, 48 Emerging evidence indicates that diet quality may have the strongest correlation to high academic achievement, though this warrants further research. The study by Florence et al.14 on school aged Canadian children found an independent association between diet quality attributes and academic achievement. Furthermore, dietary adequacy and variety were identified as specific components of diet quality which influence academic performance. These outcomes reflect the value of consuming a diverse range of foods from the core food groups. The studies with the best depth in information conducted a full assessment of diet quality, and used a validated tool. It is difficult to make sound comparisons when studies do not use similar diet quality parameters and scoring systems. Different cultures have a diverse range of cuisines which means they differ in how diet quality scores were measured. There were also vast variations in the reporting time period for the outcome measures for frequency of food consumption and academic achievement. Poor nutritional intakes do not meet macronutrient and micronutrient requirements, and this can impede on a person’s health status. Diet quality has been shown to be important for health and wellbeing, and may be beneficial to concentration and productivity levels.37 The consistency of this association across various indicators of diet quality gives emphasis to the importance of nutrition. An improvement in diet quality may be linked to enhanced learning and outcomes beneficial to students and institutions. 4.2 Eating patterns and behaviours Specific eating patterns have an influence on academic performance, as they contribute to the overall balance of a diet. It was found that adhering to a ‘healthy’ Mediterranean style diet pattern (high in fruit, vegetables, whole grains, legumes, fish and olive oil), as well as regularly consuming three meals per day, were positively associated with academic outcomes.37, 49-52 There is evidence that suggests habitual breakfast intake, compared to a period of fasting, is moderately related with an improved school performance.50, 53-59 Through a regular eating pattern, a person is more likely to consume the recommended serves from the core food groups, which contributes to an enhanced nutritional status. Eating behaviours influence the quality of a person’s diet, and generally account for whether a person is consciously controlling what they eat. In the studies regarding university students, eating patterns described uncontrolled eating (food consumption is attached to emotions) or cognitive restriction (highly controlling food intake). Overall, the results indicate that lower levels of uncontrolled or emotional eating is associated with a higher grade point average.34 Students reporting to be strict dieters, with a high amount of restrictive practices, were found to have a lower grade point average.15 On the other hand, the use of more ‘flexible’ cognitive restriction, which still involves self-regulation of food intake, but has allowances for all types of foods, may have the best indication to improving academic achievement.34 Additionally, frequency of alcohol consumption is found to be negatively associated with self-reported attendance, motivation and academic performance.15 If students were found to be in the alcohol dependent criteria, they had an excess risk of failing during the study period.60 High alcohol intakes are correlated with other adverse health behaviours, such as sleep deprivation and an increase in discretionary food consumption.11 4.3 Fruit and vegetable intake A higher fruit and vegetable intake is another aspect of diet quality which has a positive relationship with academic performance. When the self-reported daily intake of fruit and vegetables increased, there was a relatable increase in student grade point averages.10, 33, 36, 37, 39, 41, 52, 61-64 The main message is that an adequate fruit and vegetable intake is beneficial to health, and a vital component to good diet quality. Although, results in this area are inconsistent, with a small number of studies reporting no association between consumption of fruit and vegetables and academic performance.65-67 This may be attributed to their study design, as these may have lacked sufficient power to detect certain effects. It was difficult to detect differences between students when a large proportion did not meet the initial recommendations for fruit and vegetable consumption. 4.4 Convenience foods An increased consumption of convenience or ‘take-away’ foods and beverages has a strong link to poorer academic performance. There were consistent results amongst all studies which measured these associations, as well as across all age groups. 33, 37, 39, 41, 47, 52, 65, 68-73   Convenience foods are highly refined, and generally rich in salt, simple sugars or saturated fats, and included: sugar sweetened beverages, confectionary items and fried foods37.Serve sizes and options for convenience and take-away foods differed between studies, and thus interpretations may be difficult to generalise. Students who frequently consumed convenience snacks were less likely to pass standardised tests, in comparison with those who consumed healthier options.69 Poor dietary habits are shown to be a significant predictor of health and weight status, which contribute towards school performance.52 Even a moderate reduction in convenience food intake may lessen the negative influence it has on academic performance.   Current recommendations advise that discretionary foods should only be included in a diet once the other food group recommendations are met, to ensure that a high proportion of a person’s energy intake is comprised of nutritious sources.6 They should only be considered in the diet in moderation, with the consumption of foods from the core food groups being the priority.   5.0  Ã‚   Conclusion The findings from this review indicate that there is a positive association between diet quality and student academic performance. Furthermore, some evidence suggests that this is a dose-response relationship, as the higher the diet quality score, the higher the effect on academic outcomes. Diet quality and variety involve food groups and how a dietary pattern aligns with national recommendations. Several variables which impact on diet quality were investigated and shown to also be associated with academic performance. A number of gaps in the literature have been identified throughout this review. Research in this area is still developing, and there are limitations of the published research investigating the relationship between diet and academic outcomes. It is yet to be determined what specific aspects of diet quality have the greatest effect on student performance. Further investigation is needed to establish if the components of overall diet quality, variety, adequacy, balance and moderation have an independent relationship with academic performance. Longitudinal research is necessary to compare these associations over time. Public health investigations should consider whether interventions aiming at promoting healthy dietary behaviours could have a positive impact on academic performance. To date, there have been no studies regarding diet quality and academic performance at Australian universities. It is unknown how dietary intake influences a university student population group, as their stage in life and lifestyle differs from other student populations. Implications from this research support the broader implementation of effective university nutrition programs that aim to improve student’s diet quality, academic performance, and, in the long term, their health. They highlight the importance of promoting good dietary patterns, especially increasing fruit and vegetable consumption, whilst decreasing convenience food intake. The cumulative effect of dietary behaviours on academic performance emphasise the importance of an improved university environment. 6.0  Ã‚   References 1  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Ruthig JC, Marrone S, Hladkyj S, Robinson-Epp N. Changes in college student health: Implications for academic performance. J Coll Stud Dev. 2011; 52: 307-20. 2  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Basch CE. Healthier Students Are Better Learners: A Missing Link in School Reforms to Close the Achievement Gap. J Sch Health. 2011; 81: 593-98. 3  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Brunello G, Fort M, Schneeweis N, Winter-Ebmer R. The Causal Effect of Education on Health: What is the Role of Health Behaviors? Health Econ. 2016; 25: 314-36. 4  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Ross CE, Chia-Ling W. The links between education and health. American Sociological Review. 1995; 60: 719-45. 5  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Li J, Powdthavee N. Does more education lead to better health habits? Evidence from the school reforms in Australia. Soc Sci Med. 2015; 127: 83-91. 6  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Australian Dietary Guidelines. Canberra: National Health and Medical Research Council, 2013. 7  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Alkerwi A. Diet quality concept. Nutrition. 2014; 30: 613-18. 8  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Wirt A, Collins CE. Diet quality What is it and does it matter? Public Health Nutr. 2009; 12: 2473-92. 9  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Pengpid S, Peltzer K. Dietary health behaviour and beliefs among university students from 26 low, middle and high income countries. Asia Pac J Clin Nutr. 2015; 24: 744-52. 10  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Wald A, Muennig PA, OConnell KA, Garber CE. Associations between healthy lifestyle behaviors and academic performance in U.S. undergraduates: A secondary analysis of the american college health associations national college health assessment ii. Am J Health Promot. 2014; 28: 298-305. 11  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Trockel MT, Barnes MD, Egget DL. Health-related variables and academic performance among first-year college students: Implications for sleep and other behaviors. J Am Coll Health. 2000; 49: 125-31. 12  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Young Australians: their health and wellbeing. Canberra: Australian Institute of Health and Welfare, 2011. 13  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Australian Health Survey: Consumption of Food Groups from the Australian Dietary Guidelines, 2011-12. Canberra: Australian Bureau of Statistics, 2013. 14  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Florence MD, Asbridge M, Veugelers PJ. Diet quality and academic performance. J Sch Health. 2008; 78: 209-15; 39-41. 15  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Deliens T, Clarys P, De Bourdeaudhuij I, Deforche B. Weight, socio-demographics, and health behaviour related correlates of academic performance in first year university students. Nutr J. 2013; 12. 16  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Kourlaba G, Panagiotakos DB. Dietary quality indices and human health: A review. Maturitas. 2009; 62: 1-8. 17  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Kant AK. Indexes of overall diet quality: A review. J Am Diet Assoc. 1996; 96: 785-91. 18  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Tangney CC, Staffileno BA, Rasmussen HE. Healthy Eating: How Do We Define It and Measure It? J Nurse Pract. 2017; 13: e7-e15. 19  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Waijers PMCM, Feskens EJM, Ockà © MC. A critical review of predefined diet quality scores. Br J Nutr. 2007; 97: 219-31. 20  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Thiele S, Mensink GBM, Beitz R. Determinants of diet quality. Public Health Nutr. 2004; 7: 29-37. 21  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Jomaa LH, Hwalla NC, Zidek JM. Development of a standardized measure to assess food quality: a proof of concept. Nutr J. 2016; 15: 1-11. 22  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Kim S, Haines PS, Siega-Riz AM, Popkin BM. The Diet Quality Index-International (DQI-I) Provides an Effective Tool for Cross-National Comparison of Diet Quality as Illustrated by China and the United States. J Nutr. 2003; 133: 3476-84. 23  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Newby PK, Hu FB, Rimm EB, et al. Reproducibility and validity of the Diet Quality Index as assessed by use of a food-frequency questionnaire. Am J Clin Nutr. 2003; 78: 941-49. 24  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Guenther PM, Casavale KO, Reedy J, et al. Update of the Healthy Eating Index: HEI-2010. J Acad Nutri Diet. 2013; 113: 569-80. 25  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index. Design and Applications. J Am Diet Assoc. 1995; 95: 1103-08. 26  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Thorpe MG, Milte CM, Crawford D, McNaughton SA. A revised Australian dietary guideline index and its association with key sociodemographic factors, health behaviors and body mass index in peri-retirement aged adults. Nutrients. 2016; 8. 27  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   McNaughton SA, Ball K, Crawford D, Mishra GD. An index of diet and eating patterns is a valid measure of diet quality in an Australian population. J Nutr. 2008; 138: 86-93. 28  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Summary of the 2014 full year higher education student statistics. Canberra: Australian Department of Education and Training, 2014. 29  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Ganasegeran K, Al-Dubai SAR, Qureshi AM, Al-Abed AAAA, Am R, Aljunid SM. Social and psychological factors affecting eating habits among university students in a Malaysian medical school: A cross-sectional study. Nutr J. 2012; 11. 30  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Wengreen HJ, Moncur C. Change in diet, physical activity, and body weight among young-adults during the transition from high school to college. Nutr J. 2009; 8. 31  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Abebe F, Geleto A, Sena L, Hailu C. Predictors of academic performance with due focus on undernutrition among students attending primary schools of Hawa Gelan district, Southwest Ethiopia: a school based cross sectional study. BMC Nutrition. 2017; 3. 32  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Hebden L, Chan HN, Louie JC, Rangan A, Allman-Farinelli M. You are what you choose to eat: Factors influencing young adults food selection behaviour. J Hum Nutr Diet. 2015; 28: 401-08. 33  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Burrows T, Goldman S, Pursey K, Lim R. Is there an association between dietary intake and academic achievement: a systematic review. J Hum Nutr Diet. 2017; 30: 117-40. 34  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Valladares M, Duran E, Matheus A, Duran-Aguero S, Obregon AM, Ramirez-Tagle R. Association between Eating Behavior and Academic Performance in University Students. J Am Coll Nutr. 2016; 35: 699-703. 35  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Faught EL, Ekwaru JP, Gleddie D, Storey KE, Asbridge M, Veugelers PJ. The combined impact of diet, physical activity, sleep and screen time on academic achievement: A prospective study of elementary school students in Nova Scotia, Canada. Int J Behav Nutr Phys Act. 2017; 14. 36  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Abudayya A, Shi Z, Abed Y, Holmboe-Ottesen G. Diet, nutritional status and school performance among adolescents in Gaza Strip. East Mediterr Health J. 2011; 17: 218-25. 37  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Kim SY, Sim S, Park B, Kong IG, Kim JH, Choi HG. Dietary habits are associated with school performance in adolescents. Medicine. 2016; 95. 38  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   So ES, Park BM. Health Behaviors and Academic Performance Among Korean Adolescents. Asian Nurs Res. 2016; 10: 123-27. 39  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Sigfà ºsdà ³ttir ID, Kristjà ¡nsson AL, Allegrante JP. Health behaviour and academic achievement in Icelandic school children. Health Educ Res. 2007; 22: 70-80. 40  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Ells LJ, Hillier FC, Shucksmith J, et al. A systematic review of the effect of dietary exposure that could be achieved through normal dietary intake on learning and performance of school-aged children of relevance to UK schools. Br J Nutr. 2008; 100: 927-36. 41  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Kristjà ¡nsson AL, Sigfà ºsdà ³ttir ID, Allegrante JP. Health behavior and academic achievement among adolescents: The relative contribution of dietary habits, physical activity, body mass index, and self-esteem. Health Educ Behav. 2010; 37: 51-64. 42  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   McIsaac JL, Kirk SF, Kuhle S. The Association between Health Behaviours and Academic Performance in Canadian Elementary School Students: A Cross-Sectional Study. Int J Environ Res Public Health. 2015; 12: 14857-71. 43  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Taras H. Nutrition and student performance at school. J Sch Health. 2005; 75: 199-213. 44  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Fu ML, Cheng L, Tu SH, Pan WH. Association between Unhealthful Eating Patterns and Unfavorable Overall School Performance in Children. J Am Diet Assoc. 2007; 107: 1935-43. 45  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   McIsaac JLD, Kirk SFL, Kuhle S. The association between health behaviours and academic performance in Canadian elementary school students: A cross-sectional study. Int J Environ Res Public Health. 2015; 12: 14857-71. 46  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Correa-Burrows P, Burrows R, Blanco E, Reyes M, Gahagan S. Nutritional quality of diet and academic performance in Chilean students. Bull World Health Organ. 2016; 94: 185-92. 47  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Snelling A, Belson SI, Beard J, Young K. Associations between grades and physical activity and food choices: Results from YRBS from a large urban school district. Health Educ. 2015; 115: 141-51. 48  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Edwards JU, Mauch L, Winkelman MR. Relationship of Nutrition and Physical Activity Behaviors and Fitness Measures to Academic Performance for Sixth Graders in a Midwest City School District. J Sch Health. 2011; 81: 65-73. 49  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Esteban-Cornejo I, Izquierdo-Gomez R, Gomez-Martinez S, et al. Adherence to the Mediterranean diet and academic performance in youth: the UP&DOWN study. Eur J Nutr. 2016; 55: 1133-40. 50  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Acham H, Kikafunda JK, Malde MK, Oldewage-Theron WH, Egal AA. Breakfast, midday meals and academic achievement in rural primary schools in Uganda: Implications for education and school health policy. Food Nutri Res. 2012; 56. 51  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Kim HYP, Frongillo EA, Han SS, et al. Academic performance of Korean children is associated with dietary behaviours and physical status. Asia Pac J Clin Nutr. 2003; 12: 186-92. 52  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Stea TH, Torstveit MK. Association of lifestyle habits and academic achievement in Norwegian adolescents: A cross-sectional study. BMC Public Health. 2014; 14. 53  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Adolphus K, Lawton CL, Dye L. The effects of breakfast on behavior and academic performance in children and adolescents. Front Hum Neurosci. 2013; 7: 425. 54  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Boschloo A, Ouwehand C, Dekker S, et al. The Relation Between Breakfast Skipping and School Performance in Adolescents. Mind Brain EDucation. 2012; 6: 81-88. 55  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Fernà ¡ndez Morales I, Aguilar Vilas MV, Mateos Vega CJ, Martà ­nez Para MC. Relation between the breakfast quality and the academic performance in adolescents of Guadalajara (Castilla-La Mancha). Nutr Hosp. 2008; 23: 383-87. 56  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Gajre NS, Fernandez S, Balakrishna N, Vazir S. Breakfast eating habit and its influence on attention-concentration, immediate memory and school achievement. Indian Pediatr. 2008; 45: 824-28. 57  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Lien L. Is breakfast consumption related to mental distress and academic performance in adolescents? Public Health Nutr. 2007; 10: 422-28. 58  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc. 2005; 105: 743-60; quiz 61-2. 59  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   So WY. Association between frequency of breakfast consumption and academic performance in healthy Korean adolescents. Iran J Public Health. 2013; 42: 25-32. 60  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Aertgeerts B, Buntinx F. The relation between alcohol abuse or dependence and academic performance in first-year college students. J Adolesc Health. 2002; 31: 223-25. 61  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Alhazmi A, Stojanovski E, McEvoy M, Brown W, Garg ML. Diet quality score is a predictor of type 2 diabetes risk in women: The Australian Longitudinal Study on Womens Health. Br J Nutr. 2014; 112: 945-51. 62  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Harrington J, Fitzgerald AP, Layte R, Lutomski J, Molcho M, Perry IJ. Sociodemographic, health and lifestyle predictors of poor diets. Public Health Nutr. 2011; 14: 2166-75. 63  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   MacLellan D, Taylor J, Wood K. Food intake and academic performance among adolescents. Can J Diet Pract Res. 2008; 69: 141-44. 64  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Nyaradi A, Foster JK, Hickling S, et al. Prospective associations between dietary patterns and cognitive performance during adolescence. J Child Psychol Psychiatry Allied Discip. 2014; 55: 1017-24. 65  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Ickovics JR, Carroll-Scott A, Peters SM, Schwartz M, Gilstad-Hayden K, McCaslin C. Health and academic achievement: Cumulative effects of health assets on standardized test scores among urban youth in the United States. J Sch Health. 2014; 84: 40-48. 66  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Martà ­nez-Gà ³mez D, Veiga OL, Gà ³mez-Martà ­nez S, et al. Gender-specific influence of health behaviors on academic performance in Spanish adolescents; The afinos study. Nutr Hosp. 2012; 27: 724-30. 67  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Nigg CR, Amato K. The Influence of Health Behaviors During Childhood on Adolescent Health Behaviors, Health Indicators, and Academic Outcomes Among Participants from Hawaii. Int J Behav Med. 2015; 22: 452-60. 68  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Deliens T, Clarys P, De Bourdeaudhuij I, Deforche B. Determinants of eating behaviour in university students: A qualitative study using focus group discussions. BMC Public Health. 2014; 14. 69  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Correa-Burrows P, Burrows R, Orellana Y, Ivanovic D. The relationship between unhealthy snacking at school and academic outcomes: a population study in Chilean schoolchildren. Public Health Nutr. 2015; 18: 2022-30. 70  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Li J, Oconnell AA. Obesity, high-calorie food intake, and academic achievement trends among U.S. school children. J Educ Res. 2012; 105: 391-403. 71  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Nyaradi A, Li J, Hickling S, et al. A western dietary pattern is associated with poor academic performance in Australian adolescents. Nutrients. 2015; 7: 2961-82. 72  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Park S, Sherry B, Foti K, Blanck HM. Self-reported academic grades and other correlates of sugar-sweetened soda intake among US adolescents. J Acad Nutri Diet. 2012; 112: 125-31. 73  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Tobin KJ. Fast-food consumption and educational test scores in the USA. Child Care Health Dev. 2013; 39: 118-24.