Overall, males had higher BMI than females and shisha smoking, alcohol, family history, daily number of meals, weekly number of high-fat meals, weekly number of fast food, eating after midnight, not exercising and having either moderate to severe depression, anxiety and/or stress were all significantly associated with higher BMI. Furthermore, when regressing on BMI score with gender, economy status, university average, marital status and smoking, we figured that gender, shisha and cigarette smoking were significant, but gender had an R2 = 16.6% which signifies that gender is one of the major factors to affect BMI. However, economic status, mean grades, marital status, living conditions, eating vegetables regularly, number of daily snacks consumed, daily hours of studying, posture or eating while studying, time of studying, having naps after eating and the number of cigarettes and/or shisha consumed were not associated with different BMI. The mean BMI in our sample was 23.5 ± 4.2 kg/m2.
Anxiety and depression scores increased with the increased BMI while stress score was not significantly associated with BMI.
High PA was significantly associated with male gender, while it was not significantly associated with economic status, economic status, mean grades, marital status, smoking shisha or cigarettes, alcohol, living circumstances, family history of obesity, studying, depression, anxiety, or stress. Our study showed that around 60% of participants had moderate to severe depression, 50% had moderate to severe anxiety and 50% had moderate to severe stress. Furthermore, 33% did low PA, around 50% did moderate PA, while only 16% did high PA. Finally, 240 (47.9%) had one or less fast meals every week and 321 (64%) had two snacks or less every week.
Low PA is considered one of the established risk factors for many medical condition such as cardiovascular disease, cancer and diabetes (17). Furthermore, it is associated with worse mental health and quality of life. One large study that included 358 population-based surveys found the prevalence of insufficient PA to be around 27·5% with age-standardising (18). Another systemic study that included studies from 20 countries declared that low PA varied from 9–43% and was slightly higher in males (17). Finally, levels of inadequate PA was twice as much in high income countries (31.6%) when compared to low income countries (16.2%) (18). With these numbers we find that 23.2% who had low PA is considered moderate when compared to other countries. This can be particularly significant at this time as low PA is associated with a higher risk for having severe coronavirus disease 19 (COVID-19) and meeting PA guidelines strongly decrease the risk of severe COVID-19 (19).
Generally speaking, obesity and income association is not constant as the curve line the represents obesity rates increase with income at the beginning. However, it then flattens and decreases in high-income countries. Furthermore, obesity is more prevalent among the rich in low-income countries, but among the poor in high-income countries. Women in low- and middle-income countries also suffer more from obesity, whereas the gap diminishes in high-income countries. Finally, urban areas comprise more obesity in low-income countries compared to the rural areas in high-income countries, which has more obesity (20). We had higher prevalence of obesity among males and could not find an association with the income or living circumferences which contradicted the previous study. Syria is considered among the low-income countries where at least 80% of the population are under poverty line (14). Moreover, a study from Pakistan found that among medical students, females suffered from obesity more than males (21). However, in our study, males had higher BMI and we could not use a validated SES tool. One study that combined data from 2004 and 2006 that included 2536 participants from Syria found that the mean BMI was 30.2 ± 6.3 kg/m2, but the mean age was 40.8 ± 10.5 years. Moreover, shisha smoking was associated with nearly a threefold-increase in the odds of being obese. Finally, they found the women had higher BMI (12). The BMI in our study is lower, but the mean age is lower as well. Shisha was also associated with increased BMI. Another study from Karachi from Pakistan found that the mean BMI among medical students was 21.72 ± 4.33 kg/m2 (21) which is closer to our study.
Shisha was found by other studies that is associated with higher BMI and increased waist circumference (22, 23). In contrast, cigarette smoking is associated with lower BMI (13). These are particularly concerning for Syria as one study found that among under graduate students, 51.4% smoked tobacco, 23.8% smoked cigarettes and 18.0% smoked water pipe in 2019, but this study was conducted in a private university setting (24). Another study found that smoking prevalent in Syria was 20.75% (25) while another one which was conducted in 2019 and used similar online methods to this study found that 37.9% were smokers (26). Finally, shisha link to obesity was found in our study. However, it was not clear for cigarettes.
A published study shows that marital status affects weight, being divorced or never married is related with lower BMI(27), another study from Syria before war found that BMI is associated with marital status(12). However, we did not find an association in our study, maybe due to our sample which is taken from university students and they are mostly not married. Furthermore, alcohol consumption and certain foods, such as food that was fatty or contained oil, were linked with obesity in our study and the previous study as well (12). However, we did not find an association with snakes and vegetables. Seong Ah Ha et al.(4) reported that overweight school students eat snacks less frequently than normal weight which is somewhat similar to our findings
Depression was associated with increased BMI in the previous study in Syria (12), which is also true in our study. In a Pakistani study, 56.9% of the medical students, who declared that they tended to binge eat when stressed, were obese (21).
It was noted that among obese and pre-obese Pakistani medical students that 55% of them rarely had breakfast, 47.9% took four meals or more daily, 39.3% had fast-food meals for at least three times a week and 58.1% drank soft-drinks or juices almost every day. Moreover, obesity was associated with a decreased consumption of red meat (21).
Results of PA show that normal weight people who do moderate and severe differed significantly from overweight/ obese people (p < 0.001). This indicates the importance of sport in preventing obesity. thus, this variable was similar regarding to males’ PA results While the same reported study did not find a relationship between obesity and PA among females(28).
A published study among university students in Mexico City(29) showed that waist circumference was associated with parents’ obesity, which is consistent with our study. The family history of obesity is necessary because it may be correlated with genetic propensity(30, 31).
Living with parents was also associated with higher nutritional status (21), which is different from our study.