Lifestyle, Self-medication and Use of Nutraceuticals in a Population of Italian and Spanish Students
Lifestyle, Self-medication and Use of Nutraceuticals in a Population of Italian and Spanish Students
University students are considered a population class with a high risk of malnutrition and/or
 obesity, metabolic and cardiovascular diseases, with a tendency to misuse drugs and
 self-medication.

 The interest in a healthy diet can lead to a psychological obsession known as orthorexia,
 frequent among students in the biomedical field and in the sports context.

 The high levels of stress recorded in university students have been related to the use of
 drugs to enhance their cognitive abilities. The phenomenon of self-medication is one of the
 main problems for public health, with high levels recorded among students of health
 professions.

 A high adherence to the Mediterranean diet seems to bring health benefits, with an impact
 even on the intestinal microbiota composition. Although several studies have investigated the
 effect of the Mediterranean diet on intestinal microbiota, little attention has been paid to
 the effect of this diet on the oral microbiota, one of the most relevant microbial habitats
 from a clinical point of view.

 The aim of this study is to evaluate self-medication, adherence to the Mediterranean diet,
 the relationship between lifestyle and biomarkers of the metabolic and immunological status,
 and impact of eating habits on the oral microbiota composition.

 Students, doctoral students, post-docs and specialists in the biomedical and pharmaceutical
 fields will be recruited in Italy (N = 200) and in Spain (N = 200). Data will be collected
 through questionnaires in order to evaluate self-medication, eating habits, level of physical
 activity, orthorexia and lifestyle of the subjects. The entire group will be evaluated with
 clinical parameters of metabolic status and the quality of saliva and urine. The latter will
 be determining factors for the selection of 50 Italian and 50 Spanish students, on which
 parameters of immunological and antioxidant status, cortisol, urinary phenols, and the
 composition of the oral microbiota will be evaluated.

 Italian and Spanish students may have different eating habits and lifestyles. It is assumed
 that subjects with high adherence to the Mediterranean diet have a better metabolic and
 immunological status. Moreover, high rates of orthorexia are expected among students who
 practice sports. The composition of the oral microbiota could vary depending on the type of
 diet and consistently with the immunological status markers.
Young people are considered a population at risk of nutritional deficiencies due to bad
 eating habits, found especially among university students. In fact, the latter tend to change
 their eating habits when they begin their university studies, with adherence to a typically
 western diet that includes low consumption of fish, fruit and vegetables, monounsaturated and
 polyunsaturated fatty acids, and an increase in consumption of sugars, alcohol and "fast
 food", with the consequent increase in this population class of the risk of malnutrition
 and/or obesity, metabolic and cardiovascular diseases. These changes are due to the lack of
 experience in meal planning, with a consequent increase in the frequency of meals away from
 home, to the increase in the number of snacks or meals skipped to respect the timetable of
 the lessons, to the easier access to the fast food and limited economic resources. Among the
 unhealthy behaviors adopted by the students, in addition to the wrong eating habits, there
 are also reduced physical activity, increased sedentariness, alcohol consumption and smoking.

 Over the past 20 years there has been an increase in obesity rates among university students
 who, especially for medical students, are closely related to specific habits such as:
 skipping breakfast, attending fast food, low fruit and vegetables consumption, and easy
 access to unhealthy foods from the machines. Among the freshmen, especially those who live
 far from families and find themselves independent for the first time in their lives, higher
 rates of weight gain and higher levels of stress have been reported, responsible for changes
 in food choices. In fact, to control stress levels, individuals are encouraged to prefer
 foods that are high in fat. Therefore, university students should be seen as a group that
 requires special attention regarding health promotion, especially food.

 However, the interest in a healthy diet can lead to a psychological obsession known as
 orthorexia (ortho = just, oreksis = appetite), which consists in the persistent concern of
 maintaining the self-imposed diet to improve one's health. Nutritionists/dieticians and
 students are the categories of population most affected by orthorexia, with a prevalence in
 Italian nutrition science students of 35.9%. The typical behaviors of orthorexia can be
 associated with a negative image of one's own body, despite the subject's strong interest in
 appropriate and healthy food choices. However, as a result of extreme restriction/concern
 over one's diet, orthorhexics would tend to eliminate whole groups of foods with consequent
 nutritional deficiencies, malnutrition and weight loss. Furthermore, the typical eating
 behavior of orthoressia is associated with intense physical activity, suggesting that
 students who practice sports have a greater tendency to develop this disorder.

 The high levels of stress recorded in university students were also related to the use of
 smart drugs and "smart nutrients", which university students, especially those in medicine
 (74.7%), use to enhance their cognitive abilities. The phenomenon of self-medication is one
 of the main problems for public health, with only 48% of the population of the European Union
 using prescribed drugs. Among the students of health professions high levels of
 self-medication with antibiotics are recorded in the absence of indication. Another trend
 that is of particular concern is the increase in the use of antidepressants among young
 people, which many of them take after disappointments in academic performance and which have
 negative side effects such as weight gain , altered lipid profile and risk of diabetes.
 Another category of substances that young people abuse or otherwise misuse are amphetamines,
 and the co-intake of stimulants, alcohol or other drugs is also of concern. Indeed, a recent
 study carried out on Italian and Spanish pharmacy students showed that Spaniards have a high
 percentage of drug use and that 38.4% of subjects take them in conjunction with alcohol;
 instead, Italian students have revealed that they rarely turn to the pharmacist and rely more
 on the advice of family or friends.

 The university years therefore represent a period marked not only by food problems but also
 by stress, anxiety, depression and other psychological problems. However, it emerged that a
 high adherence to the Mediterranean diet would bring benefits at the cognitive level, with an
 improvement in the states of depression and anxiety and a better academic result. In addition
 to a healthy diet, even moderate and regular physical activity (90 minutes a week) has been
 shown to reduce levels of anxiety and depression with improved well-being and self-esteem.
 For this reason it is essential to promote this lifestyle among university students.

 Different types of diet and bioactive compounds taken with the diet can also have an impact
 on the composition of the intestinal microbiota. In particular, the Mediterranean diet has
 been associated with a greater abundance of Bacteroidetes, Prevotellacea and Prevotella and a
 lower concentration of Firmicutes and Lachnospiraceae. Although several studies have
 investigated the eating habits of Spanish university students, only Scuri et al. investigated
 the use of drugs in Italian and Spanish university students, but limited the study to a
 well-defined sample represented by students of the only pharmacy faculty, because they were
 considered particularly careful and involved on this topic. It would therefore be interesting
 to evaluate this behaviour, including the tendency to self-medication, between Italian and
 Spanish students, including biomedical and not just pharmaceutical faculties, in order to
 have an overview of the behaviour of university students who support scientific studies, that
 should lead them to acquire more awareness of health problems, including the correct use of
 drugs. Furthermore, although several studies have investigated the effect of the
 Mediterranean diet on intestinal microbiota, little attention has been paid to the effect of
 this diet on the oral microbiota, despite the oral cavity being one of the most relevant
 microbial habitats from a clinical point of view, and it has been shown to be a significant
 risk factor for cardiovascular diseases, diabetes mellitus, bacteraemia and tumors. It is
 therefore interesting to analyse and investigate these aspects.

 The aim of this study is to evaluate self-medication, adherence to the Mediterranean diet,
 the relationship between lifestyle and biomarkers of the metabolic and immunological status,
 and impact of eating habits on the oral microbiota composition.

 Primary goals:

 -  Compare the prescription of drugs and the use of alcohol, energy drinks, supplements,
 dietary products and/or other types of nutraceuticals in Italian and Spanish university
 students.

 -  Compare the adherence to the Mediterranean diet in Italian and Spanish university
 students.

 -  Compare cardiovascular risk factors (obesity, hypertension, hyperglycemia, dyslipidemia
 and smoking habits) and ketosis in Italian and Spanish university students.

 Secondary goals:

 -  Compare and evaluate the level of physical activity and the percentage of subjects with
 orthorexia nervosa in Italian and Spanish university students.

 -  Compare the frequency and type of meals consumed outside home, the type and consumption
 of food/beverages and adherence to special dietary regimes (vegetarian diet, ketogenic
 etc), in Italian and Spanish university students.

 -  Register other characteristics of interest (pathologies, anxiety/depressive symptoms,
 food neophobia, eating disorders, vaccinations and opinion on vaccines).

 -  Compare eating habits, salivary microbiota and salivary immunoglobulin A (IgA),
 interleukin-6 (IL-6) and cortisol levels in a sub-group of non-smoking Italian and
 Spanish students.

 In the recruitment phase it will be sent to the subjects by e-mail:

 -  "The" INFORMATION NOTE AND CONSENT "

 -  "Food Diary" (optional completion)

 From the time of recruitment to enrolling (first meeting) the volunteers will be able to
 calmly and carefully read the "INFORMATION AND CONSENT NOTE". The subjects may also request
 clarifications or details from the recruiter and/or the person in charge of the study.
 Moreover, before deciding, the volunteers will have time to ask an opinion to family or to a
 doctor of their trust.

 The recruiters will make contact with the volunteers, collect the data and assign a code to
 the volunteer.

 The standard data flow at the first, second and third meeting will be as follows:

 First meeting:

 1. Signed informed consent at the time of enrollment.

 2. Compilation of the "Code sheet"

 3. Withdrawal and control of the "food diary"

 4. Filling in questionnaires

 5. Anthropometric and arterial pressure measurements

 Second meeting:

 1. New notice of the information note and informed consent signature

 2. Administration of the Food Frequency Questionnaire (FFQ)
 (http://www.sisdca.it/public/pdf/IDAO---testistica.pdf) with the aid of the Scotti
 Bassani portant atlas (http: // www .giorgiobedogni.it / archives / text / atlas /
 patlante.html)

 3. Collection of saliva samples to assess their quality and for subsequent analysis

 4. Delivery container for collection of urine and those for the collection of saliva for
 circadian cortisol.

 Third meeting:

 1. New notice of the information note and informed consent signature

 2. Delivery of urine and saliva samples collected

 3. Measurement of metabolic state parameters (cholesterol, triglycerides, glycemia and
 ketones)

 An in-depth analysis of the lifestyle of Italian and Spanish university students will be
 carried out for the first time, with assessment of the frequency of self-medication and use
 of drugs and supplements/nutraceuticals. The composition of the oral microbiota in relation
 to eating habits will be determined for the first time. This study should also confirm the
 results of previous studies on the high rate of orthorexia in biomedical faculty students,
 especially among nutritionists and sports practitioners. The results of this study will also
 be useful for designing promotion programs for the correct use of drugs/supplements and for
 healthy diets and lifestyles in university students, and will also provide a potentially
 useful basis for the recruitment of subjects in additional/future intervention studies.
Inclusion Criteria:

 -  university students, doctoral students, post-docs and post-graduate students in
 biomedical and pharmaceutical sciences

 Exclusion Criteria:

 -  age <18 years or inability to sign informed consent.