i Zamorano University Master of Science in Sustainable Tropical Agriculture Master´s Thesis Degree Eating behaviors, adherence, and acceptance of a healthy and sustainable diet in Zamorano Student Jean Pierre Enriquez Murcia Advisors Adriana Hernández, Dr.P.H. Sandra Espinoza, M.Sc. Honduras, June 2021 ii Authorities TANYA MÜLLER GARCÍA Rector ANA M. MAIER ACOSTA Vice-President and Academic Dean a.i. ARIE SANDERS Associate Dean of Graduate Studies HUGO ZAVALA MEMBREÑO General Secretary iii ZAMORANO MAESTRÍA EN CIENCIAS EN AGRICULTURA TROPICAL SOSTENIBLE Comportamientos alimenticios, adherencia, y aceptación de una dieta saludable y sostenible en Zamorano Tesis presentada como requisito parcial para obtener el título de Maestría en Ciencias en Agricultura Tropical Sostenible Presentada por: Jean Pierre Enriquez Murcia Zamorano, Honduras Junio, 2021 iv The oral defense and the thesis document of Jean Pierre Enriquez Murcia was reviewed and approved by the following faculty staff and authorities from Zamorano University 1: _________________________ Adriana Hernández, Dr.P.H. Principal Advisor _________________________ Sandra Karina Espinoza, MSc. Advisor _________________________ Arie Sanders, Ph.D. Associate Dean of Graduate Studies _________________________ Juan Carlos Rosas, PhD. Research Director, MATS _________________________ Ana Margarita Maier, PhD. Academic Dean a.i. 1 The approval sheet contains the signatures, and this document is in the custody of the Registry Office. v The research and development activities on which much of this thesis work is based were made possible thanks to the support from Nippon Foundation and the Institute for Technology in Health Care (ITHC). The content is the responsibility of the author and does not necessarily reflect the views of the Nippon Foundation nor ITHC. vi Eating behaviors, adherence, and acceptance of a healthy and sustainable diet in Zamorano Jean Pierre Enriquez Murcia Abstract. Sustainable diets arise as a challenge to the nutritional problems of public health, and the lack of sustainability of food systems, requiring the transformation and the eating behaviors of university youth towards sustainable consumption and production. The objectives of the research were to determine student´s adherence to a healthy and sustainable diet (HSD), to establish the influence of motivations on food choices and behaviors before and after educational interventions, and to sensorially evaluate the acceptance of dishes prepared with local products. A prospective longitudinal study was conducted with two groups, one of whom received eight educational interventions, four face-to-face and four online, seeking to make them aware of the benefits of DSS, and one group had no interventions. The target population was Zamorano University first-year undergraduate students from 16 countries. The group's eating habits were improved with interventions, going from unhealthy to moderately healthy habits. There were no improvements in relation to adherence to the DSS in any group. The students presented a good acceptance of the menus with little waste on the tray. Keywords: community nutrition, consumer perceptions, nutritional interventions, sustainability university students. Resumen. Las dietas sostenibles surgen como desafío ante la problemática nutricional de salud pública, y la falta de sostenibilidad de los sistemas alimentarios, requiriendo la transformación de las conductas alimenticias de la juventud universitaria hacia el consumo y producción sostenibles. Los objetivos de la investigación fueron determinar la adherencia a una dieta saludable y sostenible (DSS), establecer la influencia de motivaciones en elecciones y conductas alimenticias antes y después de intervenciones educativas, y evaluar sensorialmente la aceptación de platillos preparadas con productos locales. Se realizó un estudio longitudinal prospectivo con dos grupos, a uno se le aplicaron ocho intervenciones educativas, cuatro presenciales y cuatro en línea, buscando concientizarlos los beneficios de la DSS, y un grupo no tuvo intervenciones. La población meta fueron estudiantes de primer año de pregrado de la universidad Zamorano de 16 países. Se lograron mejorar los hábitos alimenticios del grupo con intervenciones, pasando de hábitos poco saludables a moderadamente saludables. No se registraron mejoras en relación con la adherencia a la DSS en ningún grupo. Los estudiantes presentaron una buena aceptación de los menús con pocos desperdicios en bandeja. Palabras clave: estudiantes universitarios, intervenciones nutricionales, nutrición comunitaria, percepciones del consumidor, sostenibilidad. vii TABLE OF CONTENTS Cover page ……………………………………………………………………………………………………………………………..i Signature page ………………………………………………………………………………………………………………………iv Acknowledgement …………………………..………………………………………………………………………………….…v Abstract ..……..……………………………………………………………………………………………………………………….vi Table of contents ..……………………………………………………………………………………………………………....vii List of Tables, and Figures ………………………..……………………………………………………………………………ix INTRODUCTION ...................................................................................................................... 1 CHAPTER 1: Social and cultural influences on food choices: A review ....................................... 4 1.1 Introduction ............................................................................................................................ 4 1.2 Materials and Methods: Research Strategy ........................................................................... 6 1.3 Food Choice Motivators ......................................................................................................... 6 1.4 Cultural Capital ....................................................................................................................... 7 1.5 Food Environment .................................................................................................................. 7 1.6 Food Choices ........................................................................................................................... 8 1.7 Moral Background and Orientations to Healthier Choices .................................................... 9 1.8 Barriers of Access to Food and Consumer Attitudes ............................................................ 10 1.9 Conclusions ........................................................................................................................... 10 1.10 References .......................................................................................................................... 11 CHAPTER 2: Confinement by COVID-19 in the transition to online modality of nutritional and sustainability educational interventions in Latin-American university students of agricultural majors .................................................................................................................................. 16 2.1 Introduction .......................................................................................................................... 16 2.2 Theoretical framework ......................................................................................................... 17 2.3 Purpose and objectives ........................................................................................................ 18 2.4 Methods ............................................................................................................................... 18 2.5 Results .................................................................................................................................. 19 2.6 Impact of educational interventions on improving eating habits ........................................ 19 2.7 Importance of the information received about consumption choices and trends post- intervention ................................................................................................................................ 20 2.8 Comfort and adaptability in the transition to online mode ................................................. 20 2.9 Conclusions, Implications, and Recommendations .............................................................. 21 2.10 References .......................................................................................................................... 21 CHAPTER 3: Unhealthy eating behaviors of first year Latin-American students: an opportunity for sustainable nutritional interventions ............................................................................... 24 3.1 Introduction .......................................................................................................................... 24 3.2 Materials and Methods ........................................................................................................ 26 3.3 Results .................................................................................................................................. 27 viii 3.4 Discussion ............................................................................................................................. 30 3.5 Conclusion ............................................................................................................................ 33 3.6 References ............................................................................................................................ 33 CHAPTER 4: Sustainable diets: a way to improve and maintain eating behaviors and health in times of COVID-19 in first-year university students ................................................................ 38 4.1 Introduction .......................................................................................................................... 38 4.2 Materials and Methods ........................................................................................................ 39 4.3 Results .................................................................................................................................. 41 4.4 Discussion ............................................................................................................................. 42 4.5 Conclusion ............................................................................................................................ 44 4.6 References ............................................................................................................................ 45 CHAPTER 5: Food choice motivators and relationship with the improvement of eating behaviors during COVID-19 in multinational university students ............................................ 50 5.1 Introduction .......................................................................................................................... 50 5.2 Materials and Methods ........................................................................................................ 51 5.3 Results .................................................................................................................................. 53 5.4 Discussion ............................................................................................................................. 57 5.5 Conclusion ............................................................................................................................ 61 5.6 References ............................................................................................................................ 61 CHAPTER 6: Changing consumption patterns through the implementation of a healthy and sustainable diet in a multicultural university cafeteria using plate waste estimation .............. 67 6.1 Introduction .......................................................................................................................... 67 6.2 Materials and Methods ........................................................................................................ 69 6.3 Results .................................................................................................................................. 71 6.4 Discussion ............................................................................................................................. 73 6.5 Conclusion ............................................................................................................................ 76 6.6 References ............................................................................................................................ 77 CONCLUSIONS AND CALL TO ACTION .................................................................................... 81 ix LIST OF TABLES AND FIGURES Tables Page CHAPTER 3 1. Linear regression on the dependent variables to the independent one: adherence. ............ 27 2. Adherence levels mean separation. ........................................................................................ 28 3. Distribution of adherence levels across countries and gender. .............................................. 29 4. Mean separation for eating behaviours. ................................................................................. 29 5. Distribution of eating behaviours levels across countries and gender. .................................. 30 CHAPTER 4 1. Distribution of means of adherence in the control group and with interventions. ................ 42 CHAPTER 5 1. Percentage distribution of eating behaviours and place of residence in the pandemic for both groups. ......................................................................................................................................... 54 2. Means of eating behaviors and motivations in food choice. .................................................. 57 3. Paired samples in the two data collections. ............................................................................ 58 4. Independent means in the two groups in both periods. ......................................................... 59 CHAPTER 6 1. Description of the menus according to each food group. ....................................................... 70 2. Frequency in which panelists repeat their food at lunch in the student cafeteria. ................ 71 3. Frequency of consumer behaviours in the student cafeteria. ................................................ 72 4. Beverage consumption frequency. .......................................................................................... 72 5. Food waste category using the plate-waste method. ............................................................. 73 Figures Page 1. Scale for panelists visual estimation........................................................................................ 71 1 INTRODUCTION Society faces an imbalance in the use of food resources generated by the lack of sustainability in the world food market, causing an epidemic of chronic diseases such as obesity, diabetes, and cardiovascular diseases (Dussaillant et al. 2016). This is how the population requires a healthy diet, adequate for the environment, and that comes from a sustainable production and use of resources (Corella et al. 2018). The university stage generally coincides with the time when people leave their family environment, to live independently. This gives them responsibility for their own diet, making them vulnerable to malnutrition, sedentary lifestyle and overweight (Blázquez Abellán et al. 2016; (Woodhall-Melnik and Matheson 2017). In these stages, unbalanced diets trigger consequences due to patterns of high consumption of fast food with high content of saturated fat, sugar, and salt, incorporating ultra-processed products in the daily diet. Sustainable development is a way to achieve a three-dimensional balance between society, the economy and the environment, the latter being the one that encompasses the conservation of natural resources and the reduction of environmental impacts (Rodríguez and Suazo 2017). (FAO 2016) has reaffirmed the concept of sustainable agriculture as a tool to strengthen food and nutritional security in Latin America and the Caribbean, promoting policies and practices for the benefit of the agricultural and productive sectors. Sustainable diets arise as a challenge to the nutritional problem of public health, and the lack of sustainability of food systems. These diets require the transformation of food systems towards more efficient consumption and production patterns, being possible by applying dietary practices that benefit environmental sustainability, such as the three “Rs”: reduce waste, reuse leftovers safely and properly recycle food. food (Aranceta-Bartrina 2016; Clark and Tilman 2017). The Mediterranean diet (DM) or healthy and sustainable diet (HSD) has undergone an evolution in the last 50 years, going from being a healthy dietary pattern to a sustainable life and diet model (Dernini et al. 2017). Vegetables, cereals and legumes are the food groups used in DM with the lowest greenhouse gas emissions, which also implies less demand for soil, water and energy resources in their production, even when they go through processing and transportation (Serra- Majem and Ortiz-Andrellucchi 2018). It has been argued that legitimate knowledge about what constitutes a healthy food influences people’s food choice towards greater compliance with nutritional recommendations (Oncini and Guetto 2017). However, one of the main characteristics that influences people's food choices is taste, having an impact on the demand for different types of food and consequently on how resources are used to produce and transport those foods (Donini et al. 2016). 2 It is important to work on taste perceptions to appreciate new flavors that lead to sustainable food choices, creating a relationship between eating habits and consumer memory (Carolan 2016). At the same time creating awareness in consumers and contributing to environmental sustainability. A healthier academic and institutional context may be associated with a general improvement in student eating habits (Raulio et al. 2010). In addition, an adequate combination in the preparation and presentation of the different DSS dishes will contribute to a better consumer acceptance (Corella et al. 2018), and with it, the benefits of this type of food. Already in university action, at the Zamorano University, the Zamorano Healthy statement, seeks to promote strategic actions and encourage students to assume responsibilities for their well- being and health, protecting it as a common good. The DSS contributes as a mechanism for the adoption of new behaviors and eating habits in the student population of Zamorano, thus achieving the potential of the university's productive chain seeking to increase the internal consumption of university agricultural production. The challenges of this research stand out in that despite the existence of the Healthy Zamorano declaration, which does not have a wide application, students continue to offer processed and ultra-processed foods in supermarkets and university cafeterias. The present degree thesis focused on the study of the influence of nutritional education interventions on adherence to the DSS, eating behaviors and motivations in the food choices of students of the first academic year of Zamorano University. In addition, a sensory analysis was carried out to know the acceptance from the point of view of the student as a panelist and consumer of menus made with DSS products. This document is presented as chapters for a clearer direction of the conductive line of research. Chapters 2 to 7 are about academic articles already published and in the process of peer review in scientific journals. Being the case of chapters 2, 4 and 5, articles accepted and published. On the other hand, chapters 3, 6 and 7 are in the peer review process, where all have already had at least one feedback from the reviewers. References Aranceta-Bartrina J. 2016. Guías alimentarias para la población española (SENC, 2016); la nueva pirámide de la alimentación saludable. Nutrición Hospitalaria. 33(8):1–48. doi:10.20960/nh.827. Blázquez Abellán G, López-Torres Hidalgo JD, Rabanales Sotos J, López-Torres López J, Val Jiménez CL. 2016. Alimentación saludable y autopercepción de salud [Healthy eating and self- perception of health]. Aten Primaria. 48(8):535–542. doi:10.1016/j.aprim.2015.12.001. Carolan MS. 2016. The sociology of food and agriculture. 2nd ed. London: Routledge. 348 p. (Earthscan food and agriculture). ISBN: 9781138946255. Clark M, Tilman D. 2017. Comparative analysis of environmental impacts of agricultural production systems, agricultural input efficiency, and food choice. Environmental Research Letters. 12(6):64016. doi:10.1088/1748-9326/aa6cd5. Corella D, Barragán R, Ordovás JM, Coltell Ó. 2018. Nutrigenética, nutrigenómica y dieta mediterránea: una nueva visión para la gastronomía [Nutrigenetics, nutrigenomics and 3 Mediterranean diet: a new vision for gastronomy]. Nutrición Hospitalaria. 35(Spec No4):19– 27. doi:10.20960/nh.2120. Dernini S, Berry EM, Serra-Majem L, La Vecchia C, Capone R, Medina FX, Aranceta-Bartrina J, Belahsen R, Burlingame B, Calabrese G, et al. 2017. Med Diet 4.0: the Mediterranean diet with four sustainable benefits. Public Health Nutr. 20(7):1322–1330. doi:10.1017/S1368980016003177. Donini LM, Dernini S, Lairon D, Serra-Majem L, Amiot M-J, Del Balzo V, Giusti A-M, Burlingame B, Belahsen R, Maiani G, et al. 2016. A Consensus Proposal for Nutritional Indicators to Assess the Sustainability of a Healthy Diet: The Mediterranean Diet as a Case Study. Front Nutr. 3:37. doi:10.3389/fnut.2016.00037. Dussaillant C, Echeverría G, Urquiaga I, Velasco N, Rigotti A. 2016. Evidencia actual sobre los beneficios de la dieta mediterránea en salud [Current evidence on health benefits of the mediterranean diet]. Rev Med Chil. 144(8):1044–1052. doi:10.4067/S0034- 98872016000800012. [FAO] Food and Agriculture Organization. 2016. Agricultura sostenible: Una herramienta para fortalecer la seguridad alimentaria y nutricional en América Latina y el Caribe. Chile: Food and Agriculture Organization. 48 p; [accessed 2020 Oct 27]. http://www.fao.org/3/i5754s/ i5754s.pdf. Oncini F, Guetto R. 2017. Determinants of dietary compliance among Italian children: disentangling the effect of social origins using Bourdieu's cultural capital theory. Sociol Health Illn. 39(1):47–62. doi:10.1111/1467-9566.12482. Raulio S, Roos E, Prättälä R. 2010. School and workplace meals promote healthy food habits. Public Health Nutr. 13(6A):987–992. doi:10.1017/S1368980010001199. Rodriguez E, Suazo L. 2017. Introducción al Cambio Climático. 1st ed. Honduras: Zamorano Academic Press. 174 p. ISBN: 978-99926-790-8-1; [accessed 2020 Feb 9]. https:// www.shareweb.ch/site/DRR/Documents/Related%20Sectors/Publication_Introduction_ Climate_Change_Zamorano_Spanish.pdf. Serra-Majem L, Ortiz-Andrellucchi A. 2018. La dieta mediterránea como ejemplo de una alimentación y nutrición sostenibles: enfoque multidisciplinar [The Mediterranean diet as an example of food and nutrition sustainability: a multidisciplinary approach]. Nutrición Hospitalaria. 35(Spec No4):96–101. doi:10.20960/nh.2133. Woodhall-Melnik J, Matheson FI. 2017. More than convenience: the role of habitus in understanding the food choices of fast food workers. Work, Employment and Society. 31(5):800–815. doi:10.1177/0950017016648255. 4 CHAPTER 1: Social and cultural influences on food choices: A review Review Paper: Published in Critical Reviews in Food Science and Nutrition (2021, pp. 1-7). Abstract Human food choices (FC) influence food production systems. Agriculture is responsible for feeding the entire population, and somehow generates different types of environmental degradation. Consumers play a decisive role in consumption trends because FC has shaped habits and behaviors. Food is an expression of people’s identity, values, and lifestyle. The objective of this article is to analyze the factors that influence FC and to consider intervention strategies used to work on improving behaviors and FC. The influence of socio-cultural aspects, such as cultural capital, social stratifications, and the inequalities could possibly trigger consumers’ FC. The effects of different factors such as foodscapes, social environments, tastes, and even nutritional information, have generated that, the consumer chooses a product under pressure or makes an uninformed choice that generally is unhealthy. Restricting food accessibility generates a reactive but non-aware action, so it is necessary to work creating a sustainable food culture, with the first step of consumers being self-aware of their current FC. Keywords: consumer attitudes, food barriers, food environments, food motivators. 1.1 Introduction Consumers play an essential role in setting consumption trends in the market, as many factors can influence the FC of people. Agriculture is responsible for feeding a global population of 7 billion, but at the same time, it is a significant cause of environmental degradation. The FC influences production systems and, therefore, causing environmental impacts (Clark and Tilman 2017). All around the world, some governments are increasingly implementing health-enhancing interventions to steer people towards healthier lifestyles (Matjasko et al. 2016). These nudges are approaches to policies that maintain freedom of choice but guide people in certain directions (Thaler and Sunstein 2009). The taste experiences of people since their childhood until adulthood can impact their health, as well as their FC. For example, early-life experiences with healthy tastes and flavors can promote healthy eating, giving a significant impact on the development of chronic diseases associated with poor food choices (Mennella 2014). Moreover, a constant exposure to the same food groups could lead complications in the acceptance and adoption of new food experiences. Therefore, it is essential to work on the perception of tastes to be able to appreciate new flavors that lead to a sustainable FC, creating a relationship between eating habits and consumer memory (Carolan 5 2016). The sensory properties and the knowledge that a consumer has previously acquired, play a fundamental role in FC (Brunstrom 2007). It has been developed associations closely related between sensory characteristics of food (named conditioned stimulus), and its effects after intake (also known as an unconditioned stimulus). Over time, this association leads to a flavor preference and can affect the amount of food consumed (Leng et al. 2017). There are also adaptive preferences, which occur when people in unfavorable circumstances develop preferences in response to their restricted options. This is the tendency that often occurs in people who live under severely restricted choices. These generate preferences according to the available set, with adaptive preferences, consumers tend to prefer what is within their reach and reject what is beyond their reach. Food habits and behaviors are preferences that have been shaped by past FC; these patterns help to understand how they arise. Information, in its many ways, influences consumers; even the name of the product, plays a vital role in it is perceived as healthy (Leng et al. 2017). Mead (1943) defined food habits as the set of culturally standardized behaviors regarding food, shown in individuals who raised within a given cultural tradition. Also, other standardized behaviors in the same culture systematically interrelate with these behaviors. The trends in FC direct the research toward the influence that cultural value has over this, as food is an expression of identity, values, and lifestyle of people. A study in France, which sought to explore the social value of organic foods, found that the behavior of people together with environmental attitudes are critical determinants for the choice of organic food (Costa et al. 2014). A study conducted in Norway which analyzed the cultures of different social class divisions mapping the differences in original taste in respondents' preferences found that the upper and middle classes exhibit various healthy tastes. Contrasting with the most restricted and commonly considered as less healthy tastes found in the working classes (Flemmen et al. 2018) because they generally face economic problems as well as limited time availability to prepare healthier foods, opting for ready-to-eat ones. There are two main factors influencing consumer behavior. First, there is the consumer's preference or taste for various combinations of goods. The second factor is the consumer's ability to purchase goods, depending on their income and the price of those goods. This is where a purchase decision reflects the diversity of preferences, income, and prices (Bridle-Fitzpatrick 2016). Low-income communities generally lack economic or physical access to healthy foods (Bridle-Fitzpatrick 2015). Modern societies are changing to diets high in fat, sugar, refined foods, animal, and low-fiber foods. This dietary pattern is often known as the western diet; however, it is a global trend (Bridle-Fitzpatrick 2016). One way to confront bad FC is through educational, nutritional interventions, which can also significantly reduce the environmental impacts of agriculture (Springmann et al. 2016). Work in redesigning menu engineering involves making changes to location, order, labeling, even item description, which could increase sales of healthier menu items by making them more cost- effective (Attwood et al. 2020). Therefore, this article aims to analyze the factors that influence FC and intervention strategies to work on behavioral improvements and FC. 6 1.2 Materials and Methods: Research strategy The search strategy for this review basis was on FC. Since this review focused on socio-cultural influences towards FC, the keywords used for the search were food choices, cultural capital, social food stratification, consumer attitudes, and food tastes. The review focused on an extensive and exhaustive search of literature through the databases: PubMed, Elsevier, Springer Lind, and Google Scholar in the period 2010-2020 however, ten written works (including books and articles) were exempt from this period due to their relevance for this review. The publications included were only in English. The selection criteria focused on the identification of the content that defines and explains the FC through different areas such as cultural capital, socio-economic, and psychology of consumer’s sense. The content of the documents was reviewed and selected based on their direct or indirect relevance to this review. The process also included additional relevant references found throughout the search from already selected publications. It is essential to establish the main parts that link the socio-cultural environment, through the motivators and tastes for certain types of food and the main causes for FC generated in consumers. 1.3 Food choice motivators The FC motivators are factors considered when selecting foods. These may be due to weight management, sensory attractiveness, price, health, and ethical issues about foods. The motivators in FC predict the differences between the choices managing to establish socio-economic differences in FC (Steptoe et al. 1995). Taste is generally the main determinant of FC; therefore, sensory evaluation is crucial in interventions designed to improve the quality of the diet through modification and use of new recipes (Moore et al. 2020). Food choice motivators related to FC decisions can be qualified as an absolute motivator, or as a relative motivator. In other words, an absolute motivator in terms of the measurement scale and then as a relative measurement in consideration of personal priorities in FC (Steptoe et al. 1995; Markovina et al. 2015). The motivator to use a specific diet pattern to improve health depends mostly on the benefit perceived by the consumer over that diet. Consumers need to perceive a beneficial effect for their health, being also necessary for them to perceive the importance and relevance of food health when choosing a food (Lähteenmäki 2013). The choice of foods that are part of a diet and its behavior can occur when absolute motivators align with the choice of diet and not with relative motivators that could cause conflict (Clarke and Best 2019). The higher and lower socio-economic groups have distinctions form each other, being the taste for a series of culinary, artistic, and cultural attributes of the lifestyle that creates this difference. Taste develops through cultural capital, a non-material resource accumulated throughout life (Bourdieu 2006). Although taste links to economic capital, it is common to relate it mainly with cultural capital, because taste remains stable even when people’s incomes increase over time, reflecting certain cultural norms and values (Blasius and Friedrichs 2008). 7 1.4 Cultural capital The concept of cultural capital indicates that the accumulation of culture is inherited or acquired through socialization; hence cultural values increase as the social class gets higher. It comes in three forms: institutionalized, embodied, and objectified. The first corresponds to the educational credential acquired during life; the second concerns the fulfillment of legitimate cultural knowledge and taste; the third concerns the possession of cultural goods of high symbolic significance, all of which function as cultural signs for offspring. The cultural and socio-economic environment takes center stage over trends in food behaviors, as well as in intake ideologies. Therefore, the educational level is significantly associated with the health and healthy habits of the consumer (Oncini and Guetto 2017). People with higher education have substantially more cultural capital, and they generally make healthier eating choices compared to those with low cultural capital. Thus, cultural capital can be a new explanation for inequalities in FC (Kamphuis et al. 2015). As incomes increase, not only do food spending quotas decrease, but consumer trends are on track to diversify their diets, generating greater demand for the variety of products consumed (Chai et al. 2015; Clements and Si 2018). The growing diversity of FC reflects a more remarkable ability for consumers to find foods that fit their preferences as their income increases. However, greater demand for higher-income food options could lead to further deviations from rationality, defined as consistently made choices according to fixed and stable preferences (Lusk 2019). However, some people do not have enough resources, so their choices are limited to their budget, with food insecurity therefore. In response, food banks emerge, which provide emergency food packages to those most in need, usually consist of non-perishable foods donated by the public. They often constitute a balanced and nutritious diet, thus fighting food inequalities. Food insecurity is a significant public health issue that emphasizes the need for personalized interventions and preventive approaches to facilitate healthy dietary behaviors in all social classes (Puddephatt et al. 2020). 1.5 Food environment The food environment can be an opportunity to obtain food, which includes physical, socio- cultural, economic, and political influences at the micro and macro level (Townshend and Lake 2009). As an overview, it also encompasses the domestic food environment, school food policies, and the food environment in the residence area (Buttriss et al. 2017). The environment that surrounds a person has an impact on the FC as well of the eating behavior, so approaches that change the environment should have the potential to help in this complex condition (Lake 2018). The type of social network they occupy can affect an individual's FC because these decisions are usually made as a group, not individually. A study conducted in South Korea showed that FC values are associated with a social network affecting the quality of the diet. The relation between the value of FC and the quality of the diet was prone to be modified by the type of social networks, such as independent and private local restricted networks (Kim 2016). 8 A university campus is an ideal place to promote the health and well-being of students, among them the international students, being possible to provide them opportunities to promote health effectiveness and influence their health results. International students have an essential role on the contribution to the development of different forms of learning as they improve intercultural understanding by bringing different ideas and experiences to the classroom, benefiting the entire university community (Corcoran 2017). Doherty et al. (2011), highlight the potential role that universities can play in promoting a healthier approach to food, referring to the food landscape of a university that facilitates or restricts healthy eating options. School meal programs are essential tools for achieving healthy and sustainable societies in the future (Oostindjer et al. 2017). Effort of health promotion for international students should focus on nutrition education that increases healthy FC (Corcoran 2017). Health inequalities can be addressed by the immediate provision of a nutritious diet, as well as by establishing healthy eating habits. One way to improve school feeding is by restricting food to healthy choices, making it easier to make healthy decisions, or introducing a pricing policy in favor of healthier options (Ensaff et al. 2013). Universities have the potential for nutritional interventions if they can provide equal access to food, resources, and nutritional information to all students (Merhout and Doyle 2019). 1.6 Food choices There is the so-called choice architecture, which refers to strategic changes made in the environment, to alter people's behavior predictably without banning any option, using nudging strategies to promote healthier food behavior (Bucher et al. 2016). These strategic changes can include how products are being displayed in a food setting and the proximity of certain food products to the consumers (Bucher et al. 2016). People in charge of the design of food establishments should be conscious of their responsibility to organize food architecture optimally to simulate the consumption of healthy foods (Filimonau and Krivcova 2017). Interventions in food taste regulations could alter the way people evaluate their food. This regulation could be generalizable and flexible even in tempting situations, being able to reduce the consumption of unhealthy foods (Boswell et al. 2018). A study on consent feeding found that people with high body fat percentage make more impulsive dietary choices compared to those with low body fat percentage, which could increase the risk of obesity over time (Hendrickson and Rasmussen 2017). Studies on sustainability concerns found that consumers of organic food paid close attention to the environment, health, and food safety aspects (Baudry et al. 2017). Pechey and Marteau (2018), suggest that altering the availability of less healthy foods could have a greater impact on healthier FC rather than altering the availability of healthy foods. People who have greater concerns about food sustainability motivations, such as ethics, environment, local production, tradition, and health, have a healthier diet regardless of the health problems that might be linked (Allès et al. 2017). A study about responsible consumer choice found that restaurants have an essential role as consumer choice architects because they can use menus to effectively intervene in the costumer's 9 decision-making on foods that are beneficial to society and the environment (Filimonau et al. 2017). Another study of consumer influences in urban adolescents in India reported that printed and electronic media had a great influence on adolescents eating habits, criticizing the mass marketing of energy-rich, low-nutrient foods because it promotes unhealthy eating in adolescents (Rathi et al. 2016). 1.7 Moral background and orientations to healthier choices To fully understand the processes of food consumption, it is necessary to understand how consumers evaluate goods, attributing a quality to consumer products. People often must justify and rate their actions concerning consumption because society always questions FC and how they consumed them. By making claims about what good food is and the right forms of consumption, people with more cultural capital are more likely to adhere to arguments about whether food can provide collective well-being (Stamer 2018). For example, Radnitz et al. (2015) showed two main reasons to choose and maintain a vegan diet: the concern for animals’ welfare (ethics) and their health. Ethical veganism is against killing animals for consumption when there are many available plant-based alternatives, categorizing animal consumption as immoral (Alvaro 2017). The same author, also commented that ethical veganism encompassed virtuous individuals and emphasized the temperance virtue regarding food, referring to a person who will consume not by pleasure, rather eat with moderation, be nourished, and choose healthy food. Healthy habits are socially determined; in most cases, influenced by socio-economic status, personal values, and parental behaviors. One research on workers of fast-food shows that a greater influence of the familiar culture of fast food tends to get complicated due to structural restrictions on their job, such as inflexible hours, or incentives to eat foods at their jobs like cheap food, contributing to the habit formed through familiar and cultural exposure (Woodhall-Melnik and Matheson 2017). Memory and past experiences are relevant in self-regulation of behavior, so the success of diets is related to a better visual-spatial working memory, which is associated with healthier FC (Whitelock et al. 2018). When health is incorporated into the food classification or recommendation process, it creates the potential to improve food habits; this is also common in people who use the internet as a source of food inspiration. People make bad choices because of stimuli when they are excited, stressed, or hungry, and are in an environment surrounded by smells of high-calorie foods (Macht 2008; Oliver et al. 2000). Third parties' incentives may increase the probability of choosing a healthy snack, especially in children. Angelucci et al. (2019), states that if an individual watches someone in their circle of friends choose healthy food, the person thinks that this snack is delicious and healthy. Moreover, food production systems food production systems also influence the healthiness of the foods that are consumed by the people. In this sense, there are food production systems designed to produce healthier foods than other food production systems such as mandala or regenerative agriculture, and consumers are not aware of this. If consumers would be aware of this, they might have different FC showing that consumers’ nutritional ignorance are also impacts patterns of FC for the society. 10 1.8 Barriers of access to food and consumer attitudes Front labeling attempts to mitigate barriers by simplifying nutritional information to reduce cognitive load and achieve a more enhancement in packages to increase the likelihood that nutritional value can be significant in FC. Studies have shown that nutritional information can lead to healthier food purchases on consumers that choose to use them (Ni Mhurchu et al. 2018) and that some front-of-pack nutrition labels have been more effective (Fialon et al. 2020; Zhang et al. 2020). However, consumers do not frequently use this component of the food industry, and therefore, there is a need for additional food labeling policies that require the constant provision of more affordable products with easy-to-use nutritional information (Talati et al. 2017). People who are highly motivated by a desire to improve and maintain health as a consequence of their FC, have positive attitudes and are more likely to adopt personalized nutrition, which recommends foods based on health benefits as well as functional foods. Those for whom healthy body weight and natural content of the products are essential motivators of FC, maintain favorable attitudes and intentions to adopt personalized nutrition (Rankin et al. 2018). Nutritional labeling approaches in foods and menus have the potential to help reduce the prevalence of unhealthy dietary behaviors by promoting healthier choices at the point-of- purchase by helping consumers to make an informed decision (Kerins et al. 2017). Menu labels may need to be combined with additional strategies such as product placement and price promotions to improve FC based on population. Privitera et al. (2019) suggest that eating in response to emotional cues is associated with unhealthy foods eating. There is not much information about the extent to which obesity and depression can differentially influence food intake in a buffet environment where people can choose from low-calorie and high-calorie foods. The combined effects of limited income and rising food costs have led people, especially older adults, to seek alternative sources of food and assistance programs. These options may help some older adults, while others choose not to use it due to suggested barriers, such as stigma, lack of money, limited transportation, and lack of knowledge about the program (Oemichen and Smith 2016). The use of visual manipulation of effects to increase attention capture and improve FC could be a viable tool for food policymakers and marketers to increase the efficiency of the message they wish to convey to the consumer (Peschel et al. 2019). Time resources and motivation in terms of general health interest are necessary for consumers to pay attention to health labels (Fenko et al. 2018). Labels that provide guidance to consumers and have additional product information have the potential to improve consumer decision-making. 1.9 Conclusions This article discussed the potential influences on consumer FC. The effects of different factors such as cultural capital, foodscapes, social environments, tastes, and even nutritional information, have generated that the consumer chooses a product under pressure or makes and uninformed choice that can be unhealthy. 11 To address the problem facing society and the world as a result of humanity's eating patterns, it must be in a comprehensive framework with proposals to bring into action policies that seek the health and well-being of the consumer. To achieve this, the consumer must take self-awareness to the outcome of their eating patterns. While it is true that at a more outstanding cultural capital and social status may lead to healthier food habits and food behaviors, it can change because often that more excellent status of people expands the portfolio of products that they have available for acquisition, with the temptation to choose according to the taste of food. Education is a strategy to promote and improve FC with the idea of making the proposed changes healthier and more sustainable. It is necessary to work through educational interventions, to make the consumer understand that they must improve their eating habits and behaviors, which translates into FC. By not limiting and restricting certain types of food and opting for education, it avoided that in the future, when the consumer has again access to unhealthy food, they fall back on them. 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Abstract Create positive visions and attitudes towards university students’ educational interventions is often challenging due to misuse and lack of sustainability in the global food market. However, gamification-based programs seek to create a more inclusive space where the student and trainer can strengthen the teaching-learning process more dynamically. The gamification aims to retain students to find a mechanism that facilitates learning, and useful comprehension of the academic content addressed in this methodological strategy. This research note reviews the results of the transition to online modality, due to COVID-19, of a nutritional education intervention in first-year university students (n=85) of agricultural sciences, from 16 countries of the Americas, which was developed at the peak of the pandemic: March to May 2020. The educational intervention results showed that most of the students perceived improvement in their eating habits during the confinement period due to the information provided in the different sessions. Moreover, most would have preferred that the talks had been in person; however, they did not feel a sudden change due to the transition period from face-to-face to online, demonstrating their resilience to the pandemic crisis. Keywords: community nutrition, educational intervention, pandemic crisis, sustainability. 2.1 Introduction Poor use of food resources due to lack of sustainability in the global food market leads to an epidemic of chronic diseases such as obesity, diabetes, and cardiovascular (Dussaillant et al. 2016). Moreover, a healthy diet does not mean that it is suitable for the environment or that it comes from sustainable production and use of resources (Corella et al. 2018). Thus, positioning agricultural sciences as the careers for the future, generating young people from urban and rural areas to choose them to face the challenges of food production in society. 17 The university years usually match with the time when a more independent life begins. This makes students responsible for their food consumption, becoming vulnerable to malnutrition, sedentary lifestyles, and overweight (Blázquez Abellán et al. 2016; Woodhall-Melnik and Matheson 2017), even when the agricultural sciences require practical classes in those fields. Sustainable development is a way to achieve a three-dimensional balance between society, the economy, and the environment, being the last responsible for natural resources conservation and reducing environmental impacts (Rodríguez and Suazo 2017) in food production. There´s been established sustainable agriculture as a tool to strengthen food and nutrition security in Latin America and the Caribbean by enhancing policies and practices to benefit the agricultural and productive sectors. In this context, sustainable diets arise as a challenge to the nutritional problem of public health and sustainable food systems. This concept involves transforming food systems into consumption patterns and sustainable production (Aranceta- Bartrina 2016; (Clark and Tilman 2017). But these patterns of food consumption and production must be strengthened through educational interventions that link agricultural sciences, nutrition, and health with efficient use of resources. Formal education techniques such as gamification can involve students more closely in the learning process (García-Lázaro 2019) and raise awareness. However, other factors influencing the choice, consumption, and sustainable food production are world crises such as the current COVID-19 pandemic. For example, in Spain, healthier habits have been evident in the population during its confinement (Rodríguez-Pérez et al. 2020), which can be reflected due to the informative campaigns carried out worldwide. Faced with this pandemic, it is necessary to migrate to sustainable and modern food systems using the three “R” (Galanakis 2020), with university students being a key piece to face this new reality, so it is essential to adapt to the new modality of online education. 2.2 Theoretical framework This study was guided by the gamification theory. It is defined as a learning technique that uses the dynamic of a game to the educational-professional field to achieve better results in educational interventions and share content between the research team and participants (Chau et al. 2018), which is increasingly practiced as a learning instrument, as well as a facilitator of collaborative behaviors since currently, students prefer an entertaining education instead of traditional teaching. This education is delivered with three main reasons: commitment, experimentation, and results. The COVID-19 pandemic has generated a migration towards online community nutrition programs, where the most widely disseminated channels are social media. Social media's three primary functions in online nutrition educational interventions are facilitating communications and peer relationships, supporting self-monitoring, and gamification. Currently, this pedagogical field has been extended in the educational system, with the teaching strategies of gamification being given in three main purposes: to motivate action, to arouse learning, and to solve problems. The evaluation and teaching resources become a system in which players engage in an abstract challenge determined by rules, interactivity, and feedback, generating a quantifiable result with an emotional reaction (Kapp 2012). According to Volkova (2013), the consolidation of the games’ dynamics with the media gave origin to gamification. Games’ unique characteristics lie on voluntary and free participation, an escape 18 from reality into an imaginary world with codes and norms, and seek to motivate the individual intrinsically. Therefore, educational gamification delivers attractive and novel learning proposals that enhance the resolution of challenges (Lee and Hammer 2011). Young university students are a priority population for educational interventions due to their high prevalence of unhealthy eating behaviors, high risk of weight gain, and the importance of this stage of life in the development of eating habits and behaviors (Blázquez Abellán et al. 2016; Woodhall-Melnik and Matheson 2017), which will delimit future trends in food production. Community nutrition pursues identifying and evaluating nutritional problems to design, organize, evaluate, and implement nutritional intervention programs (Aracenta et al. 2006). The interventions with a target group of people have the challenge of achieving a healthy nutritional profile progressively over time (Aranceta-Bartrina 2010), through activities planned to be carried out at a global level or with specific groups. 2.3 Purpose and objectives The purpose of this study was to determine the influence of the COVID-19 pandemic on the adaptability to the transition from face-to-face to online interventions from a program of nutritional and sustainability education through gamification concept theory with first-year university students from 16 countries across the American continent. The objectives that led this study were to gather information after a series of educational interventions on: (1) The impact of the information provided using gamification in the talks on improving food consumption habits. (2) The importance of information received in consumer choice and trends after completing the interventions. (3) Comfort and adaptability to interventions from face-to- face to online mode. 2.4 Methods With the application of educational interventions, it was sought to generate self-awareness in decisions when choosing food, so that the choices are made under the principles of sustainability, through the basis of the Mediterranean Diet (MD) as a sustainable diet and lifestyle (Dernini et al. 2017), which was named as a healthy and sustainable diet (HSD) for this study. There were 85 first-year students from the undergraduate agricultural sciences of Zamorano University, located in Honduras. All from General Curriculum Department, where they learn the basis for the university's four majors (Agricultural Sciences and production, Agribusiness Management, Food Science and Technology, and Environment and Development), which is selected in the third year. Eight learning sessions through gamification-based education supported this initiative, and were based on: (1) Introduction: healthy habits promotion with emphasis on sustainable food choices (2) What is a sustainable diet? (3) HDS: as a preventive lifestyle 19 (4) HDS: health and nutrition benefits (5) HDS: influence on food choice (6) HDS: wealth in biodiversity and decreased environmental impact (7) HDS: high sociocultural food value; and (8) HDS: positive local economic benefits. At the time of the study was planning, it was not considered the possibility of the pandemic crisis, so the first four sessions were delivered face-to-face. Once the COVID-19 crisis broke out in Honduras, a two-week transition period to online modality was carried out, providing additional information to strengthen the topics already addressed. The online platforms used to share content with students were social media (Facebook, WhatsApp, and Microsoft Teams) that included educational information, messages, reminders, surveys, and events information related to HSD. It emphasized how consumers' good food choices can bring benefits to the near future for their health and nutrigenetics and nutrigenomics descendants. 2.5 Results After completion, a survey was conducted in which the degree to which participants were able to engage to the online modality through the transition period was evaluated through gamification teaching using dynamic materials that allowed interaction with participants through informative notes, trivia, and exchange of ideas through conversations, giving feedback to each participant. The following sections provide a clear and concise picture of the impact of nutritional education interventions in students form agricultural sciences. 2.6 Impact of educational interventions on improving eating habits It was identified that 75.3% (n=64) students stated that at the time of confinement by COVID-19, they had a moderate impact on improving their eating habits due to the knowledge acquired in the intervention, while 12.9% (n=11) reported an extreme impact. On the other hand, 11.8% of participants (n=10) reported having had a mild impact, very mild impact, and even no impact on improving their eating habits due to educational interventions using gamification. The participants also emphasized points of view about the sessions received, one said “these talks are not only necessary for first-year, I think that talks about healthy nutrition are necessary for all the years because it is notorious how in all the years there is a disorder when choosing food”. Another participant mentioned: “The topics were of great importance to make a change decision when choosing my food, the truth is that it is valuable information that should be shared with all future classes.” In general, participants did not express opinions of rejection or demerit towards talks about education, but most (91.8%) agree that it is important that they be delivered at the university introduction, at the beginning of the first year. 20 2.7 Importance of the information received about consumption choices and trends post intervention After surveying students with the question: “After receiving information about HSD, how important is it now (in time of confinement by COVID-19) the information when choosing your food (portions, place of production, seasonality, production chain)?” Around 68.2% (n=58) mentioned that it was important to have received such information, while 25.9% (n=22) was extremely important. However, no participant considered it to be unimportant. This shows that even when little importance is perceived that small percentage denotes a positive effect on them. One participant stated, “The disinterest of some student was of little help,” perceiving that those who considered the minor interventions need to become more aware. Other participants shared: “The talks given formed a new facet of improvement in personal food consumption” and “I would like more awareness talks in general, as it is a matter of great importance”. In general, positive contributions were made by participants; some of the most positive statements linking the information received to the field of agriculture were, “It was very interesting and important to learn about how to take care of our health through nutrition and also help to take into account certain factors that are very important to know since we will be future farmers producers,” it was also mentioned that “I liked very much this type of project, because in one way or another it helped us to see clearly everything we can consume and the right way to do it, even helped to know the food production process,” relating the entire production chain. 2.8 Comfort and adaptability in the transition to online mode When questions about conformity on face-to-face or online modality were asked, 88.2% (n=75) mentioned that they felt more comfortable in-person intervention. Similarly, 87.1% (n=74) felt that when sharing the information, there was a greater dynamism and interaction with their peers and the researcher in the face-to-face modality; however, in the end, they managed to adapt to the online modality. It is important to mention that 61.2% (n=52) students stated that the modality change was slight after the online mode transition period. In comparison, 17.6% (n=18) mentioned that no change was perceived in the dynamism and exchange of information. One participant stated: “I liked it and learned a lot; I feel that it was better in the virtual mode because you can concentrate more, because in person you get distracted being with friends.” Other students mentioned: “Basically, I had never had training about the correct way to eat, the talks helped me to expand the way I see how the country or communities can be supported by consuming the right food and, more importantly to improve my health,” “I believe that it is an issue that falls to us not only as consumers but also as future producers because not only the impact of an HSD was showed in our feeding, but also the impact generated when producing and transporting the food in the environment, and how can we reduce the impact with small actions.” 21 Even with the online mode, students assimilated the current situation and could apply what they had learned and even visualize that practicality in the future. 2.9 Conclusions, implications, and recommendations Efforts to deliver educational interventions that strengthen knowledge, such as agricultural sciences students’ health, were not stopped due to the COVID-19 pandemic. Conversely, the interventions were transformed to be more accessible to participants without losing the principle of gamification to make the process of learning and interaction more beneficial. Although COVID- 19 brought a series of events and situations that limit peoples’ physical coexistence and has generated a new reality where most activities are being carried out by telework and even classes delivered online. It was possible to get a positive perspective from the students at the end of the educational intervention, even though most would have preferred to do it entirely in person. This showed a level of understanding and maturity in facing the pandemic and its resilience and willingness to receive information that could improve their eating habit through this crisis. In this frame, this study managed to overcome the usual barrier in education using gamification to motivate students to have a persistent commitment in the long term (Ibáñez 2016). It is recommended that educational programs be developed to integrate all the productive chain of agricultural products from the farm and beyond the table, with nutrition, where through gamification techniques and sustainability principles, students may be able to integrate broader knowledge that can be interrelated, and that can address the COVID-19 limitations. The educational models of gamification should be designed beforehand and subsequently set learning objectives to evaluate the educational intervention at the end of it, taking into account the student's profile to which it is addressed (García-Lázaro and Gallardo-López 2018). 2.10 References Aracenta B, Pérez R, Serra-Majem L. 2006. Nutrición Comunitaria: Artículos de Revisión. Revista de Medicina de la Universidad de Navarra; [accessed 2020 Jun 20]. 50(4):39–45. https:// revistas.unav.edu/index.php/revista-de-medicina/article/view/7617. Aranceta-Bartrina J. 2010. Nuevos retos de la nutrición comunitaria. 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Agricultura sostenible: Una herramienta para fortalecer la seguridad alimentaria y nutricional en América Latina y el Caribe. Chile: Food and Agriculture Organization. 48 p; [accessed 2020 Oct 27]. http://www.fao.org/3/i5754s/ i5754s.pdf. Galanakis CM. 2020. The Food Systems in the Era of the Coronavirus (COVID-19) Pandemic Crisis. Foods. 9(4). doi:10.3390/foods9040523. García-Lázaro I, Gallardo-López J. 2018. Escape room: actividades de escape para trabajar la educación vial en Educación Primaria. III Congreso Virtual Internacional de Educación, Innovación; [accessed 2020 Aug 14]. 115–119. https://dialnet.unirioja.es/servlet/ articulo?codigo=7359972. García-Lázaro I. 2019. Escape Room como propuesta de gamificación en educación. Hekademos Revista Educativa Digital; [accessed 2020 Aug 15]. 27:71–79. https://dialnet.unirioja.es/ servlet/articulo?codigo=7197820. Ibáñez MB. 2016. Gamificación en la educación [Actas de la VIII Jornada profesional de la red de bibliotecas del Instituto Cervantes]. España: Instituto Cervantes; [accessed 2020 May 22]. 6 p. https://www.cervantes.es/imagenes/File/biblioteca/jornadas/jornada_8/acta_ibanez_ maria_blanca_gamificacionEnLaEducacion.pdf. Kapp KM. 2012. The gamification of learning and instruction: Game-based methods and strategies for training and education. San Francisco, CA: Pfeiffer. 336 p. ISBN: 978-1118096345. Lee J, Hammer J. 2011. Gamification in education: What, how, why bother? Academic Exchange Quarterly; [accessed 2020 Aug 15]. 15(2):146. https://www.researchgate.net/publication/ 258697764_Gamification_in_Education_What_How_Why_Bother. Rodriguez E, Suazo L. 2017. Introducción al Cambio Climático. 1st ed. Honduras: Zamorano Academic Press. 174 p. ISBN: 978-99926-790-8-1; [accessed 2020 Feb 9]. https:// www.shareweb.ch/site/DRR/Documents/Related%20Sectors/Publication_Introduction_ Climate_Change_Zamorano_Spanish.pdf. Rodríguez-Pérez C, Molina-Montes E, Verardo V, Artacho R, García-Villanova B, Guerra-Hernández EJ, Ruíz-López MD. 2020. Changes in Dietary Behaviours during the COVID-19 Outbreak Confinement in the Spanish COVIDiet Study. Nutrients. 12(6). doi:10.3390/nu12061730. Volkova I. 2013. Four Pillars of Gamification. Middle East Journal of Scientific Research. 13:149– 152. doi:10.5829/idosi.mejsr.2013.13.sesh.1427. 23 Woodhall-Melnik J, Matheson FI. 2017. More than convenience: the role of habitus in understanding the food choices of fast food workers. Work, Employment and Society. 31(5):800–815. doi:10.1177/0950017016648255. 24 CHAPTER 3: Unhealthy eating behaviors of first year Latin-American students: an opportunity for sustainable nutritional interventions Research Article: Published in Biomedical Journal of Scientific & Technical Research (Volume 34, Issue 5, pp. 27062-27069, 2021). Abstract The poor eating habits in the first year of college could trigger health problems and academic performance in students. The change of environment when moving from their home or country to the university could contribute to the adoption of those inadequate habits, where nutritional educational interventions can improve the student’s habits. There was evaluate the association of eating behaviors with adherence to a healthy and sustainable diet in multinational university students, establishing a foundational framework to create interventions that promote healthy eating habits. A cross-sectional study was conducted using print questionnaires to adherence to the Mediterranean diet and eating behaviors. The participants consist of three hundred university students from sixteen countries who voluntarily completed the surveys. The only eligibility criterion was to be a first-year student. The analysis was made by a descriptive statistic, correlational, ANOVA, and regression. The mean adherence for 300 students was 7.68 (low adherence). A total of 172 first-year students showed unhealthy and very unhealthy eating behaviors (57.3%). High adherence was observed only in four countries: Ecuador (n=2; 3.1%), Guatemala (n=1; 2.7%), Honduras (n=3; 2.6%), and other countries (n=1; 9.1%). Eating behaviors were the only predictor variable. These variables accounted for 15.3% of the variance in adherence to Mediterranean diet scores. In conclusion, Interventions and regulatory standards are needed, including policies supporting the development of healthful dietary behaviors using sustainable principles. Keywords: Communitarian nutrition, coping strategies, international students, sustainable diets, eating habits. 3.1 Introduction The global food system, currently, fails to meet the need of the population, classifying it as being unsustainable (Abarca-Gómez L et al. 2017); Béné et al. 2019), generating challenges in public health, environment, food safety, nutrition, and health. On the other hand, mortality levels increase concerning all forms of malnutrition (Hruby and Hu 2015; Tobias and Hu 2018; Bhaskaran 25 et al. 2018). The most current statistics show that 2 billion adults are overweight or obese (Abarca- Gómez et al. 2017), while 820 million are undernourished or hungry. The It has been shown that the economy, culture, and social resources contribute to uneven development in health outcomes such as weight gain and the development of Non-Communicable Diseases (NCDs) (Rauber et al. 2018; Cuevas García-Dorado et al. 2019; Fox et al. 2019) with repercussions on the diet of the population. The mass commercialization of processed foods and the rapid distribution into low and middle-income markets (Popkin 2013; Ronto et al. 2018) has resulted in the abandonment of traditional diets and the adoption of highly processed diets, which lack in nutritional quality (Kopp 2019). In terms of a healthy and sustainable diet, the Mediterranean Diet (MD) meets all established standards. It is recognized as a healthy, affordable, and environmentally sustainable eating model (Dernini et al. 2017; Berry 2019) being a Healthy and Sustainable Diet (HSD). It is widely documented that its adherence is linked to multiple health benefits in humans (Serra-Majem and Ortiz-Andrellucchi 2018). Recent meta-analyses have associated high adherence to MD and a reduction in general mortality, cardiovascular diseases, the incidence of certain types of cancer, diabetes, and metabolic disorders, among others (Dinu et al. 2018; Grosso et al. 2017; Sánchez- Villegas et al. 2016). First-year students enter a new phase of life, which is marked with diet and lifestyle changes, including making independent decisions on their own nutrition, generating vulnerability to malnutrition, sedentary lifestyle, and being overweight (Blázquez-Abellán et al. 2016; Woodhall- Melnik and Matheson 2017). In this context, diet and nutrition are crucial components in the promotion and maintenance of a healthy condition (Dernini et al. 2017) Furthermore, diets must meet energy needs, provide a variety of foods with nutritional quality, and be accessible and culturally appropriate. Specifically, the transition to university life is characterized by major changes, increased responsibilities arising from the independence of their parents and the reduction of time as a result of studies. Due to the different interests and levels of importance, a healthy lifestyle falls behind when compared to other aspects of the student’s life (Chacón-Cuberos et al. 2018). From another perspective, young adults tend to present bad habits, among which the omission of meals or fewer mealtimes per day stands out, as well as infrequent snacking, affecting the quality of their diet (Saiz PG. et al. 2017). Also, there is a demonstrated tendency to a sedentary lifestyle, with the consumption of alcohol, cigarettes, among others, which leads to excess weight gain and deterioration of health (Chacón-Cuberos et al. 2018; Barrios-Vicedo et al. 2014; Springmann et al. 2016). Additionally, it has been shown that low adherence to MD can be associated with lower academic achievement (Esteban-Cornejo et al. 2016). Therefore, it is possible to combat poor food choices through nutritional education, while significantly reducing the environmental impacts of agriculture (Martínez-González et al. 2015). The current study aims to determine the association of eating behaviours with adherence to HSD in multinational university students, establishing the foundations to create interventions that improve their eating habits. 26 3.2 Materials and Methods Location. This study was conducted at Zamorano University, Honduras, whose undergraduate program has a student population from around 29 countries, especially from the American continent. The students reside on campus from January until December for four years. The university has food services in the principal dining room, and there are also cafeterias, supermarkets, and restaurants offering a variety of food to students. Participants and recruitment. This study complies with the ethics protocols, which was approved by the Zamorano University Graduate Research Directorate meeting the ethics. The 319 first-year undergraduate students, come from 16 countries: Belize, Bolivia, Colombia, Costa Rica, Ecuador, El Salvador, United States, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, and the Dominican Republic. All of them were summoned to receive a keynote talk on nutritional education, during the first period of the 2020 academic year. The study was socialized, indicating the objective, topic, and benefits for the participant and researchers. The recruitment was voluntary, and participants were asked to sign an informed consent form. The 300 students who decided to participate received an electronic copy of the consent form. Type of study. An observational descriptive study of cross-sectional cohort was conducted. The eating behavior surveys were conducted in two groups on February 22 and 29, 2020, respectively. A healthy and sustainable eating model based on HSD as a lifestyle was proposed, which aimed to improve the eating behavior of first-year students. Instruments. The data were collected through the adherence questionnaire to the Mediterranean Diet and a questionnaire of eating behaviors (both in printed form). To determine adherence to the MD, a 14-point questionnaire was applied using the PREDIMED study (Prevention with Mediterranean Diet) (Martínez-González et al. 2015). The questionnaire is composed of 14 direct questions about the consumption of the main foods of MD. The scores were grouped into four categories: high adherence (12-14 points), medium adherence (8-11 points), low adherence (5-7 points) and very low adherence (<5 points). Subsequently, the students completed an eating behavior questionnaire with 28 multiple-choice questions, with scores grouped into four categories: healthy (23-30 points), moderately healthy (16-22 points), unhealthy (8-15 points) and very unhealthy (<8 points) (Márquez-Sandoval et al. 2014). Statistical analysis. The proposed model consists of the dependent variable being adherence to the HSD, and the independent variables: country, gender, eating behaviors. The model seeks to determine the variability in adherence to the HSD. The results were summarized by descriptive statistics such as means, percentages, and standard deviation. A linear regression of the model and a Pearson correlation were carried out for the independent variables with respect to the dependent variable. The categorical variable “countries”, Honduras was excluded, as it is the host country. For adherence and eating behaviors, an ANOVA was performed with Duncan mean separation for each level. 27 3.3 Results Participating age were 61% men and 39% women. Most of them, 38.67%, came from Honduras (n=116), followed by Ecuador 21.67% (n = 65), Guatemala 12.33% (n=37), El Salvador 11.33% (n=34), Panama 4% (n=12), Nicaragua and Others (Belize, Costa Rica, USA, Haiti, Mexico, Paraguay, Peru, and Dominican Republic) with 3.67% (n=11) each one. Finally, Colombia and Bolivia had the lowest number of participants each with 2.33% (n=7). The model had statistical significance (P <0.001), according to the R2 obtained, the model explains approximately 15.3% the variability in adherence to the HSD where the only "eating behaviors" were significance. The variables of country and gender did not show predictive ability on adherence to the HSD (P > 0.05), however, the variable eating behaviors have the predictive ability on the adherence to HSD (P <0.05). A student from Ecuador and Bolivia has an average of 0.48 and 0.82 points more adherence to the HSD respectively than a student from Honduras. On the other hand, students from Guatemala, El Salvador, Panama, Nicaragua, Colombia, and members from other countries have, a lower adherence score than a Honduran student. The adherence average of a male was 0.31 points more than the adherence of a female (Table 1). Table 1. Linear regression on the dependent variables to the independent one: adherence. Predictor Estimate S.E. t P value Intercept ᵃ 4.11 0.60 6.84 <0 .001 Country: Ecuador 0.48 0.31 1.56 0.12 Guatemala -0.28 0.37 -0.74 0.46 El Salvador -0.35 0.38 -0.91 0.36 Panama -0.89 0.60 -1.48 0.14 Nicaragua -0.26 0.62 -0.43 0.67 Others -0.04 0.62 -0.06 0.95 Bolivia 0.82 0.77 1.07 0.29 Colombia -0.44 0.77 -0.58 0.57 Gender: 1 – 0* 0.31 0.24 1.33 0.19 Behaviors 0.23 0.04 6.23 <0 .001 ᵃ Represent the level of reference. S.E: Standard error. * 1 = Male, 0 = Female. When performing the correlations of the variables, there was an only significant correlation in eating behaviors (P <0.001; Pearson´s r: 0.344), with a low positive correlation indicating dependence between adherence to the HSD and eating behaviors. 28 Adherence to Mediterranean Diet. When performing the ANOVA for the adherence, a significant difference was found between each level of adherence (P <0.001). The mean adherence of the 300 participants was 7.68, ranking in low adherence (Table 2). Table 2. Adherence levels mean separation. Very low Low Medium High Total (n = 21) (n = 106) (n = 167) (n = 6) (n = 300) Mean S.D. Mean S.D. Mean S.D. Mean S.D. P value 3.19 d 0.87 6.21 c 0.79 8.99 b 0.95 12.14 a 0.37 <0.001 S.D: Standard deviation. Lowercase letters a-c shows mean separation. The percentage scale was made for each country and gender based on the four levels of adherence to the HSD. High adherence was observed only in four countries: Ecuador (3.1%), Guatemala (2.7%), Honduras (2.6%), and Others (9.1%) (Table 3). All countries had medium adherence, with Bolivia being the country with the highest percentage of participants (85.7%), followed by Ecuador (61.5%), and the countries with the lowest amount of participants with medium adherence were Others and Panama with 36.4% and 33.3% respectively. In low adherence, most of the participants were between 57.1 and 50% (Colombia, El Salvador, Nicaragua, Others and Panama). Additionally, very low adherence was obtained in 5 countries: Panama, Guatemala, Honduras, El Salvador, and Ecuador. Regarding gender, 56.8% of men and 53.8% of women had medium adherence (Table 3). 29 Table 3. Distribution of adherence levels across countries and gender. Total observations Very low Low Medium High (n = 21) (n = 105) (n = 167) (n = 6) n % n % n % n % Country Bolivia 7 0 0 1 14.3 6 85.7 0 0 Colombia 7 0 0 4 57.1 3 42.9 0 0 Ecuador 65 2 3.1 21 32.3 40 61.5 2 3.1 El Salvador 34 2 5.9 17 50 15 44.1 0 0 Guatemala 37 4 10.8 10 27 22 59.5 1 2.7 Honduras 116 11 9.5 34 29.3 68 58.6 3 2.6 Nicaragua 11 0 0 6 54.5 5 45.5 0 0 Others* 11 0 0 6 54.5 4 36.4 1 9.1 Panamá 12 2 16.7 6 50 4 33.3 0 0 Gender Male 183 10 5.5 63 34.4 104 56.8 6 3.3 Female 117 11 9.4 42 35.9 63 53.8 1 0.9 * Countries with less than 5 participants were grouped into Others: Belize, Costa Rica, the United States, Haiti, Mexico, Paraguay, Peru, and the Dominican Republic. Eating behaviors. According with the ANNOVA, there was a significant difference between each level of eating behaviors (P <0.001). The mean for the eating behaviors of the 300 participants was 14.85, ranking in unhealthy behaviors (Table 4). Table 4. Mean separation for eating behaviors. Very unhealthy (n=1) Unhealthy Moderately healthy (n = 126) Healthy Total (n = 171) (n = 2) (n = 300) Mean S.D. Mean S.D. Mean S.D. Mean S.D. P value 7 d * 12.74 c 1.8 17.76 b 1.7 23.5 a 0.71 <0.001 S.D: Standard deviation. Lowercase letters a-c shows mean separation. The percentage scale was made for each country and for each gender based on the four levels of eating behaviors (Table 5). Healthy behaviors were obtained only in 1.7% of the Honduran students and moderately healthy behaviors in all countries except Panama. Panama was the country with the highest proportion of students with unhealthy behaviors with 100% of the participants, and the 1.5% of Ecuadorians presented very unhealthy behaviors. 30 For the gender, 1.7% of the women presented healthy behaviors. The 47