Sequential mediation analysis of physical activity, healthy diet, BMI, and academic burnout in the Pakistani educational landscape

Abstract

Research has indicated a negative impact of physical activity on academic burnout among students, however, there is a paucity of evidence about the underlying mechanism of this association in Pakistani students. The present research seeks to investigate the relationship between physical activity and academic burnout by investigating the potential mediating effects of adherence to the Mediterranean diet (MD) and body mass index (BMI). A sample of 596 students using a cross-sectional survey design was gathered from two public universities (Riphah International University and Mohammed Ali Jinnah University) in Rawalpindi, Pakistan from June to July 2022. The study participants were asked to fill out the Physical Activity Rating Scale-3, the Learning Burnout Scale, and the Test of Adherence to MD questionnaires. The study employed descriptive, bivariate, and path analysis through regression utilizing the SPSS software version 27. The findings demonstrated a negative correlation between academic burnout and BMI, physical activity, and adherence to the MD. The relationship between physical activity and academic burnout was mediated by BMI. Physical activity and academic burnout were inversely correlated, with adherence to the MD and BMI interacting as sequential mediators. The outcomes of this research have expanded our knowledge of the association between physical activity and academic burnout and have suggested crucial and appropriate strategies for addressing student academic burnout.

Full text

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Sequential mediation analysis
of physical activity, healthy diet,
BMI, and academic burnout
in the Pakistani educational
landscape
Shazia Rehman
1,2, Abdullah Addas
3,4, Md Anisur Rahman
5, Muhammad Ali Shahiman
6 &
Zexuan Li
1,2*
Research has indicated a negative impact of physical activity on academic burnout among students,
however, there is a paucity of evidence about the underlying mechanism of this association in
Pakistani students. The present research seeks to investigate the relationship between physical
activity and academic burnout by investigating the potential mediating eects of adherence to
the Mediterranean diet (MD) and body mass index (BMI). A sample of 596 students using a cross-
sectional survey design was gathered from two public universities (Riphah International University
and Mohammed Ali Jinnah University) in Rawalpindi, Pakistan from June to July 2022. The study
participants were asked to ll out the Physical Activity Rating Scale-3, the Learning Burnout Scale,
and the Test of Adherence to MD questionnaires. The study employed descriptive, bivariate, and
path analysis through regression utilizing the SPSS software version 27. The ndings demonstrated
a negative correlation between academic burnout and BMI, physical activity, and adherence to
the MD. The relationship between physical activity and academic burnout was mediated by BMI.
Physical activity and academic burnout were inversely correlated, with adherence to the MD and BMI
interacting as sequential mediators. The outcomes of this research have expanded our knowledge
of the association between physical activity and academic burnout and have suggested crucial and
appropriate strategies for addressing student academic burnout.
Keywords Physical activity, Obesity, BMI, Healthy diet, Public health, Students, Academic burnout,
Nutrition
e term "academic burnout" describes a condition of extreme emotional, mental, and physical tiredness brought
on by persistently high academic pressure. Feelings of extreme fatigue, cynicism or disengagement from scho-
lastic pursuits, and a diminished sense of personal achievement are its dening characteristics1. Academic envi-
ronments such as universities or schools, where people are under constant stress from performance expecta-
tions, academic demands, or an excessive workload, are the typical places where academic burnout happens.
Individuals can exhibit avoidance behaviors, procrastination, or disengagement from academic responsibilities,
such as skipping classes or showing disinterest in previously enjoyed academic activities and extracurriculars2,3.
e phenomenon of academic burnout has been associated with adverse eects on physical and mental health,
OPEN
1Department of Psychiatry, National Clinical Research Center for Mental Disorders, National Center for Mental
Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China. 2Mental
Health Institute of Central South University, China National Technology Institute on Mental Disorders, Hunan
Technology Institute of Psychiatry, Hunan Key Laboratory of Psychiatry and Mental Health, Hunan Medical Center
for Mental Health, Changsha 410011, Hunan, China. 3Department of Civil Engineering, College of Engineering,
Prince Sattam Bin Abdulaziz University, 11942 Al-Kharj, Saudi Arabia. 4Landscape Architecture Department,
Faculty of Architecture and Planning, King Abdulaziz University, P.O. Box 80210, 21589 Jeddah, Saudi
Arabia. 5Department of Accounting, Data Analytics, Economics and Finance, La Trobe University, Melbourne,
Australia. 6Department of Urology and Renal Transplantation, Benazir Bhutto Hospital, Rawalpindi Medical
University, Rawalpindi, Pakistan. *email: l_zx2000@163.com
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academic performance, and overall well-being4,5. Recognizing indicators of burnout and seeking appropriate
assistance are imperative in eectively addressing this phenomenon. To eectively manage and prevent academic
burnout, employing strategies such as prioritizing self-care, seeking academic support, establishing realistic
goals, utilizing stress management techniques, and seeking professional assistance when necessary is essential.
e Coronavirus disease 2019 (COVID-19) pandemic has brought about signicant changes to the global
education sector, leading to an urgent transition to online learning and presenting unparalleled diculties for
students6. Research has indicated an increase in stress, anxiety, and burnout among students in the aermath
of COVID-19, underscoring the importance of investigating potential mitigating factors for these negative
impacts7,8. is context establishes the foundation for examining the potential impact of physical activity on
mitigating academic burnout among students in Pakistan. One of the notable issues pertains to the interruption
of physical activities, which has garnered attention due to its potential inuence on academic achievement9.
e measures implemented in response to the COVID-19 pandemic, such as school closures, social distancing
requirements, and lockdowns, have restricted students’ opportunities to utilize sports facilities, participate in
physical education classes, and engage in extracurricular activities10. e cumulative impact of these alterations
leads to a decrease in students’ physical activity levels, prompting concerns about potential consequences for
their academic achievement.
ere are lots of dierent theories that say physical activity is good for your academic performance. One of
the most popular is called arousal and attention. is means that when you exercise, your body is more likely to
be excited and you’ll release more of the neurotransmitters that are involved in focusing and paying attention.
is includes dopamine, which is linked to attention and focus11,12. Another theory says that exercise is good
for your cognitive abilities because it helps you focus on both your cognitive and motor tasks at the same time.
is could mean that exercise can help improve your executive function13. Physical activity is consistently linked
with enhanced cognitive functioning, including attention, memory, and information processing. Research has
shown that students who exercise regularly have better academic performance, including higher grades and
standardized test scores14,15. ese cognitive outcomes are particularly important in academic contexts, where
sustained attention, ecient information processing, and memory recall are essential components of learning
and academic success.
e exploration of the relationship between physical activity and academic performance holds signicant
implications for the improvement of educational practices. Incorporating physical activity into the school day,
such as through physical education classes, active breaks, or extracurricular sports, has the potential to provide a
comprehensive strategy for enhancing students’ cognitive development and academic achievement. Policymak-
ers and educators may wish to explore the integration of evidence-based physical activity programs as a means
to enhance learning environments and foster the holistic well-being of students. In a nutshell, an abundance
of theoretical frameworks and empirical data indicate a signicant association between academic success and
physical activity. Better academic results are a result of physical activity’s neurobiological, psychological, and
cognitive advantages. Understanding the complex interactions that exist between physical activity and cognitive
function highlights the need to encourage students to lead active lifestyles to improve their physical health as
well as their cognitive capacities and academic performance.
e Mediterranean diet (MD), widely acclaimed for its favorable impact on physical health, has recently
attracted interest for its potential eects on mental well-being16. e MD is characterized by a high content of
antioxidants, omega-3 fatty acids, and various nutrients that have been linked to enhanced cognitive function
and psychological health17. Prior literature has examined the association between dietary intake and mental well-
being, highlighting the signicance of nutrition in alleviating manifestations of depression and anxiety18,19. e
correlation between adherence to the MD, levels of physical activity, and academic burnout has received limited
attention in current research20–22. Research has shown that maintaining the MD is associated with heightened
energy levels and enhanced physical well-being. On the contrary, consistent physical activity may augment the
benecial impacts of the MD, establishing a synergistic interplay between dietary choices and exercise that sup-
ports holistic health16,23. e prospective inuence of the MD on academic burnout represents a unique focus
of investigation in this study. Academic burnout has been linked to a range of lifestyle-related factors24. Com-
prehending the relationship between adherence to the MD and its potential role as a mitigating factor against
academic burnout is essential for the formulation and implementation of comprehensive interventions aimed
at supporting students in their pursuit of academic achievement.
e existing literature highlights the individual relationships between physical activity, diet, BMI, and their
impact on mental health and academic outcomes. However, there is a notable dearth of research that explores
the interconnectedness of these factors. e current research aims to ll this lacuna by examining the sequential
mediation of adherence to the MD and BMI in the association between physical activity and academic burnout.
e objective of the present investigation is to explore the intricate mechanisms by which engaging in regular
physical activity can potentially contribute to the improvement of students’ mental health and academic achieve-
ment in the post-COVID-19 era. Subsequently, we posit the following hypotheses:
Hypothesis 1 ere exists a negative association between Physical activity and academic burnout.
Hypothesis 2 Adherence to the MD plays a mediating role in explaining the relationship between physical
activity and academic burnout.
Hypothesis 3 BMI plays a mediating role in explaining the relationship between physical activity and academic
burnout.
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Material and methods
Participants and study design
A cross-sectional survey study was conducted employing a convenience sampling method, utilizing a single
survey instrument within a single cohort. During June and July in the year 2022, a sample comprising 596 stu-
dents from two public universities located in Rawalpindi, Pakistan, was collected for the investigation. e study
participants’ ages ranged from 18 to 26years. e proportion of male students to female students was 49.23%
and 507.7%, respectively.
Eligibility criteria
Participants were eligible for the study if they were older than 18 and younger than 30 and had no diagnosed
mental illness. Participants under the age of 18 were not allowed to participate in the study.
Questionnaire
e following main scales were adopted to collect the information to run the analysis.
1. Participants’ physical Activity based on intensity, duration, and frequency was evaluated through Physical
Activity Rating Scale-3 revised by Liang25. e responses were recorded on a 5-point Likert scale, with the
total score estimated by the product of physical intensity, duration, and frequency. e scale showed an
internal consistency with an alpha coecient of 0.87 for the current research.
2. e status of academic burnout was assessed through the Learning Burnout Scale for College Students26.
is scale consisted of 20 questions in total that assess three distinct dimensions of academic burnout i.e.,
emotional exhaustion, and low personal achievement. e responses are recorded on a 5-point Likert-type
scale, with higher scores indicating higher academic burnout. e scale showed an internal consistency with
an alpha coecient of 0.91 for the current research.
3. A scale consisting of sixteen dichotomous items i.e., Test of Adherence to Mediterranean Diet (KIDMED)27,
was adopted to record the responses of participants which consisted of 16 dichotomous. e scale showed
an internal consistency with an alpha coecient of 0.86 for the current research.
4. BMI was assessed based on the self-administered response on body weight (kg) divided by squared height
(m2)
Ethical consent
e study was granted ethical approval from the Ethics Review Committee of Benazir Bhutto Hospital, Raw-
alpindi, Pakistan (March 2022/07613) and was conducted according to the guidelines and regulations of the
Declaration of Helsinki and its later amendments. e participants provided their written informed consent to
participate in this study.
Data analysis
Descriptive and Pearson correlation analyses were utilized to estimate the associations among study scales. SPSS
macro-PROCESS 4 with a 95% condence interval and 5000 bootstrap iterations were performed to investigate
the study hypotheses. A p-value of < 0.05 was considered to be signicant statistically.
Descriptive and pairwise correlation analysis
Table1 presents the ndings of descriptive and bivariate correlation analysis about the selected study variables.
e ndings of this study indicated a positive connection between physical activity and adherence to the MD,
whereas, BMI and physical activity showed a signicant negative association. Similarly, there was a positive cor-
relation between adherence to the MD and BMI. Furthermore, it was found that engaging in regular physical
activity and maintaining adherence to the MD was negatively associated with academic burnout. ese organi-
zations initially oered support for the proposed indirect eects. Figure1 represents a graphical representation
of bivariate correlations among study variables.
Regression analysis
e ndings of the regression analysis are presented in Table2. e initial model revealed that there is a signi-
cant independent predictive relationship between physical activity and BMI (β = − 0.40, p < 0.001) and academic
burnout. Both physical activity and BMI were found to be signicant determinants of adherence to the MD, with
statistical beta coecients of 0.32 and 0.20, respectively. e study progressed to the third step where physical
activity, BMI, and adherence to the MD were incorporated into the regression model. e ndings indicated that
Table 1. Bivariate interconnections of the study variables. ***p < 0.001, **p < 0.01, *p < 0.05.
Mean ± SD Academic burnout Physical activity BMI Adherence to Mediterranean diet
Academic burnout 56.72 ± 9.68 1
Physical activity 25.12 ± 11.08 − 0.22** 1
BMI 3.50 ± 1.26 − 0.31*** -0.48*** 1
Adherence to Mediterranean diet 2.67 ± 0.98 − 0.18** 0.35** 0.23** 1
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physical activity, BMI, and adherence to the MD were signicant predictors of academic burnout, with respective
beta coecients of − 0.51 (p < 0.001), − 0.15 (p < 0.001), and − 0.07 (p < 0.01) (Fig.2). e aforementioned research
ndings indicate that physical activity exerts a partial mediating inuence on academic burnout.
e serial mediation analysis
We estimated a sequential mediation model for the association between physical activity and academic burnout,
adherence to the MD, and BMI using a bias-corrected nonparametric test with 95% condence intervals (Table3).
e estimated direct eect of physical activity on academic burnout was observed to be 0.51, accounting for 85%
of the overall eect. e study found that adherence to the MD, BMI, and engagement in physical activity were
connected to the total indirect eect of 0.09 on academic burnout accounting for 15% of the overall eect. e
mediating eect comprises two indirect pathways: one involving the relationship between physical activity and
Figure1. Bivariate correlation among study variables.
Table 2. Regression analysis results. **p < 0.01 and ***p < 0.001.
Regression equation Fitting indices Regression
coecient
Response variable Predictor variable R2F
β
t
BMI 0.14 62.17***
Physical activity − 0.40 − 9.06***
Adherence to
Mediterranean diet
0.10 41.75***
Physical activity 0.32 3.95***
BMI 0.20 14.35**
Academic burnout
0.37 83.06***
Physical activity − 0.51 − 11.19***
BMI − 0.15 − 7.13***
adherence to Mediterranean diet
− 0.07 − 1.17**
Figure2. β-coecient among study variables.
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BMI, accounting for 10% of the total eect; and the other involving the indirect eects of physical activity on
adherence to the MD, which in turn aects BMI and subsequently impacts academic burnout, representing 2%
of the total eect. e schematic diagram for the mediation analysis of the study can be seen in Fig.3.
Explained variance and eect size
e assessment of the structural model was conducted with consideration of the explained variance and eect size
criteria. e ndings of this evaluation are demonstrated in Table4. e aforementioned criteria were employed
to evaluate the integrity and reliability of the structural model. e overarching model exhibited a moderate
eect, as evidenced by an explained variance of 37%. We assessed the moderate eects of explicative variables
in the associations between physical activity and adherence to the MD, physical activity, and BMI, and their
relatively weak eect on academic burnout. e outcomes indicated that physical activity could potentially exert
a signicant inuence on academic burnout, potentially mediated by adherence to the MD and BMI.
Ethics review statement
e study was granted ethical approval from the Ethics Review Committee of Benazir Bhutto Hospital, Raw-
alpindi, Pakistan (March 2022/07613) and was conducted according to the guidelines and regulations of the
Declaration of Helsinki and its later amendments.
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Table 3. e results of the path analysis. e bold shows a signicant eect based on Bootstrapped 95%
condence interval with 5000 iterations.
Path Eect SE Bo ots 95% (lower–upper) Outcome
Physical activity →
adherence to the Mediterranean diet
→ Academic burnout − 0.02 0.02 − 0.03–0.04 Insignicant
Physical activity
→
BMI →
Academic burnout − 0.06 0.03 0.03–0.11 Signicant
Physical activity
→
adherence to Mediterranean diet
→BMI
→
Academic
burnout − 0.01 0.02 0.01–0.09 Signicant
Indirect eects − 0.09 0.006 0.05–0.16 Signicant
Direct eects (Physical activity → Academic burnout) − 0.51 0.005 0.03–0.15 Signicant
Total eect − 0.60 0.03 0.58–0.66 Signicant
Figure3. e path mediation analysis.
Table 4. e outcomes of explained variance and eect size.
Paths Explained variance Eect size
Physical activity
→Adherence to Mediterranean diet
0.14 0.22
Physical activity → BMI 0.10 0.29
Adherence to Mediterranean diet
→ BMI 0.10
Physical activity → Academic burnout 0.37 0.11
Adherence to the Mediterranean diet
→ Academic burnout 0.13
BMI → Academic burnout 0.09
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Discussion
e present research empirically investigated the sequential mediating role of adherence to the MD and BMI on
the potential correlations between physical activity and academic burnout. e regression analysis elucidated a
sequential mediation model of the relationship between adherence to the MD and BMI. Our research demon-
strated that physical activity was negatively associated with burnout among students. is implies that students
who engage in consistent physical activity possess a lower risk of developing academic burnout. Moreover, these
results align with earlier studies carried out within this area of research28–30. A plausible rationale could be that
physical activity is linked to a considerable elevation in armative eect, resulting in enhanced productivity
and less exhaustion during educational responsibilities31. Our hypotheses are supported by the considerable
Pearson’s pairwise correlation analysis that was found signicant between BMI, academic burnout, physical
activity, and adherence to the MD.
Our rst hypothesis was supported by our ndings, which showed that BMI served as a mediator in the
association between physical activity and academic burnout. e benecial eect of physical exercise on BMI
was in line with other research suggesting that anxiety related to stressful events may change dietary behaviors,
which in turn may alter a person’s body composition32–34. In particular, anxiety will cause the parasympathetic
nervous reex to become active, which can speed up metabolism and stimulate appetite35. Furthermore, pro-
longed periods of stress have been associated with increased food intake, which may be explained by changes in
the hypothalamus’ ability to produce neurotransmitters that regulate one’s appetite36. Additionally, adherence to
the MD and BMI were found to have a serial mediation impact in this research, thereby supporting our second
hypothesis. Integrating therapeutic and preventative opinions it is crucial to emphasize two aspects regarding
the signicance of eating behaviors at this juncture. First and foremost, maintaining an adequate diet can help
lower stress levels since it provides the human system with the necessary nutrients and prevents irregularities
in neurotransmitter generation, which can exacerbate anxiety. Additionally, existing evidence indicates that the
stressors themselves may contribute to maladaptive behaviors associated with the consumption of unhealthy
foods37. Hence, there exists an enthusiasm for aligning actions with the requirements of the academic framework,
aiming to cultivate adaptable methodologies and pedagogical approaches that mitigate levels of stress38. However,
the following regression model examined the correlation among all variables while considering the inuence
of gender and BMI. e present investigation did not exhibit any statistically signicant dierences between
academic stress and diet, contrasting with the ndings reported in the previous study37.
e analysis revealed a signicant nding, demonstrating a statistically signicant direct negative relation-
ship between physical activity and academic burnout. is nding is consistent with previous literature that has
established an inverse correlation between these two factors. e literature indicates that there is a reduction in
levels of anxiety and stress among individuals who engage in regular physical activity39,40. e ecacy of physi-
cal activity in reducing energy levels, providing a release for frustration, and alleviating muscle tensions is well
documented41. Furthermore, it has been found to elevate endorphin levels, known as the "happiness hormone",
as well as cortisol and norepinephrine levels, both are associated with mental disorders42. Furthermore, it has
been demonstrated that physical activity facilitates the amelioration of depressive symptoms and the regulation
of intricate emotional mechanisms43. Balanced eating habits play an important role in well-being and stress
management among individuals, especially students. Healthy eating patterns, characterized by healthy eating
rich in nutrients, vitamins, and minerals, have been correlated with better mental well-being. Proper nutrition
may mitigate the eects of academic burnout, potentially interacting with the inuence of physical activity.
Research suggests that increased physical activity is potentially associated with a healthier BMI and improved
body composition. Maintaining a healthy weight and a healthy diet can positively impact mental well-being and
stress management, which may indirectly aect academic stress.
No nation has been able to eectively halt or counteract the increasing rate of weight, because it has been
documented to increase consistently over the past 40years. e notion of thermodynamics is frequently applied
to provide a fundamental description of gaining weight, where weight prot or loss is equal to the energy in
minus energy out. When interventions halt the weight increase, both of these processes appear to be function-
ing unfavorably. On the contrary, improving standards of living and well-being are linked to a rise in sedentary
lifestyles, a tendency that is also seen in low-income nations and is typied by urbanization, a shi in food
culture, and a decrease in quiet time.
Public health implications
ese ndings have signicant public health ramications because they draw attention to the growing prevalence
of overweight and obesity among college students over the recent decade. Because this group is unable to meet
the prescribed amount of weekly exercise frequency, duration, and intensity. Our ndings have clear ramica-
tions both from a public health perspective and for student societies and educational settings. Our ndings
suggest that these organizations and establishments should move swier in encouraging and facilitating their
students’ participation in a variety of sports and physical activities. ere exists a paucity of evidence regarding
the ecacy of extensive awareness campaigns in promoting increased physical activity among the general public.
However, research suggests that personalized media messages in various formats have the potential to eectively
raise awareness, enhance knowledge, and motivate individuals to engage in higher levels of physical activity.
In 2010, the WHO issued a set of guidelines to inform national policymakers about the necessary levels of
physical activity required to prevent noncommunicable diseases, such as overweight and obesity, in light of
concerning trends of physical inactivity. e study’s results indicate that a signicant proportion of young adults
continue to not adhere to these guidelines and that the guidelines themselves may not be adequate in address-
ing the issue of obesity on a population level. e aforementioned predicament emphasizes the necessity for a
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more comprehensive strategy, and the WHO has recently initiated a worldwide action plan on physical activity
spanning from 2018 to 2030 intending to promote increased levels of physical activity among individuals44.
Limitations
ere are several limitations to consider when interpreting the results of our investigation. First and foremost,
it is important to note that the study’s cross-sectional design poses a restriction in that causal interactions were
not substantiated. It would be benecial to draw attention to the adoption of BMI as an overall health determi-
nant, as opposed to body composition metrics like lean and fat mass. However, the main shortcoming of this
study is that it did not consider some factors that can inuence stress levels, such as family income or health
level. Potential next directions for this research include doing a similar analysis with a broader population of
university students. To acquire accurate body composition and BMI results, it is also recommended to utilize a
bioimpedance instrument. To further enhance data collection, the use of equipment to monitor physical activity
would be crucial since it would yield more accurate estimates of the individuals’ activity levels.
Conclusions
e present study demonstrates that a signicant ratio of students do not adhere to global exercise guidelines
and that the prevalence of overweight individuals is on the rise among both males and females in various age
brackets. Hence, interventions focused on reducing academic burnout through physical activity may be enhanced
by employing a multifaceted approach that therapeutically addresses the promotion of adherence to the MD and
attainment of a healthier BMI. An imperative demand exists for a comprehensive strategy to eect a fundamental
change in promoting the increased engagement of college and university students, a responsibility shared among
governmental and educational organizations, as well as student welfare associations. Further research is required
to investigate the potential mediating impacts of adherence to the MD and BMI in the relationship between
physical activity and academic burnout within more diverse populations.
Data availability
e raw data supporting the conclusions of this article will be made available by the authors upon reasonable
request.
Received: 29 November 2023; Accepted: 26 March 2024
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Author contributions
S.R.: Conceptualization, Data curation, Formal analysis, Methodology, Visualization, Writing—original dra,
Writing—review and editing. A.A.: Formal analysis, Methodology, Visualization, Writing—original dra, Writ-
ing—review and editing, Funding. M.A.R.: Conceptualization, Data curation, Formal analysis, Methodology,
Visualization, Writing—original dra, Writing—review and editing. M.A.S.: Conceptualization, Data curation,
Formal analysis, Methodology, Visualization, Writing—original dra, Writing—review and editing. Z.L.: Concep-
tualization, Data curation, Formal analysis, Methodology, Visualization, Writing—original dra, Writing—review
and editing. All authors read and approved the nal version of the manuscript for publication.
Funding
e authors extend their appreciation to Prince Sattam bin Abdulaziz University for funding this research
through the Project Number (PSAU/2023/01/8910).
Competing interests
e authors declare no competing interests.
Additional information
Correspondence and requests for materials should be addressed to Z.L.
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