Relationship between Student Diet and Academic Performance

1.0   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

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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 generated 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: “student”, “university student”, “diet quality”, “health behaviour”,
“eating pattern”, “academic performance” and “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   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   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, where 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   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   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.
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