Exploring the Co-Structure of Physical Activity and Dietary Patterns in Relation to Emotional Well-Being: A Tanglegram-Based Multivariate Approach

<b>Background/Objectives</b>: Psychological distress is common among university students and often co-occurs with unhealthy lifestyle patterns. However, most studies examine physical activity (PA) and dietary intake (DI) in isolation, overlooking how these behaviors interact under stress. This study aimed to identify and compare integrated PA and DI behavior patterns among students with low vs. high psychological distress. <b>Methods</b>: A cross-sectional case-control design was used with 209 students (aged 19-21). Questionnaires included the International Physical Activity Questionnaire (IPAQ), Questionnaire of Eating Behavior (QEB), and Depression Anxiety Stress Scales-21 items (DASS-21). Behavioral patterns were assessed using a cophylogenetic approach (tanglegrams, cophenetic statistics), and predictive behaviors were analyzed using stepwise logistic regression. <b>Results</b>: Permutational Multivariate Analysis of Variance (PERMANOVA) revealed significant group differences in PA-DI structure (F = 3.91, R² = 0.0185, <i>p</i> = 0.001). Tanglegram and PACo analyses showed tighter PA-DI alignment in high-distress individuals, suggesting more rigid, compensatory behavior profiles. Logistic regression identified vigorous PA (OR = 1.80, 95% CI: 1.33-2.50, <i>p</i> < 0.001) and fast food intake (OR = 1.43, 95% CI: 1.05-1.98, <i>p</i> = 0.026) as significant distress indicators. Sweets intake showed a non-significant trend (OR = 1.33, <i>p</i> = 0.064). <b>Conclusions</b>: Students with higher psychological distress exhibit complex lifestyle co-patterns combining risk (e.g., fast food) and compensatory behaviors (e.g., vigorous PA). Health promotion should address PA and DI jointly, and screening for distress should be integrated into student wellness programs.