Skipping Breakfast and its Associated Factors among Undergraduate Students

Breakfast, which literally means breaking the overnight fast, is the day's �rst meal. Objective: To determine the factors associated with skipping breakfast among undergraduate students of Akhtar Saeed Medical and Dental College located at Canal Campus Lahore, Pakistan. Methods: A cross-sectional survey was conducted using a self-designed health assessment questionnaire in which demographic pro�le, anthropometric measurements, open-ended and close-ended questions were included which noted the major physiological and psychological aspects of skipping breakfast. The study was conducted on the total sample of 180 students both adult males and females of age ≥18years of age which were selected in the Akhter Saeed Medical and Dental College, Canal Campus Lahore, Pakistan. Results: Out of total sample 180, only 62 participants (34%) were consuming breakfast and 118 participants (66%) were not having breakfast in morning. The highest recorded reason for skipping of breakfast was 29 participants (16%) do not like to eat in morning also do not have enough time to consume breakfast in morning and 62 participants (34%) had no reason for not consuming breakfast. Skipping of breakfast was also associated with (91%) feeling hungry, not having energy, feeling headaches, grumpy, lethargic, trouble paying attention in class and tired whereas 17 participants (9%) had stomachache and dizziness. Conclusions: Participants agreed that breakfast is the important meal of every morning. They found consumption of breakfast consisting of more fruits and vegetables, dairy products and �bers are proved to make an individual healthy as it provides enough energy to stay focused and active throughout the day.

quality [4]. Moreover, a healthy breakfast consumer eliminates the food which is high in calories, saturated fat or sugar such as soft drinks, junk foods and unhealthy snacks [5]. A study conducted in Pakistan shows that 46% of the students eat their breakfast daily and 54% did not consume breakfast on daily basis [6]. The researchers conducted on children and adolescents have shown that breakfast has a positive in uence enhancing intellectual performances. A fresh meta-analysis observed the literature on breakfast consumption versus breakfast skipping and also inspected the nutritional composition of disbursed breakfasts which proved that skipping breakfast leads to poor mental health [7]. At the University of Ghana Skipping Breakfast and its Associated Factors

I N T R O D U C T I O N
Breakfast, which literally means breaking the overnight fast, is the day' s rst meal. Objective: To determine the factors associated with skipping breakfast among undergraduate students of Akhtar Saeed Medical and Dental College located at Canal Campus Lahore, Pakistan. Methods: A cross-sectional survey was conducted using a self-designed health assessment questionnaire in which demographic pro le, anthropometric measurements, open-ended and close-ended questions were included which noted the major physiological and psychological aspects of skipping breakfast. The study was conducted on the total sample of 180 students both adult males and females of age ≥18years of age which were selected in the Akhter Saeed Medical and Dental College, Canal Campus Lahore, Pakistan. Results: Out of total sample 180, only 62 participants (34%) were consuming breakfast and 118 participants (66%) were not having breakfast in morning. The highest recorded reason for skipping of breakfast was 29 participants (16%) do not like to eat in morning also do not have enough time to consume breakfast in morning and 62 participants (34%) had no reason for not consuming breakfast. Skipping of breakfast was also associated with (91%) feeling hungry, not having energy, feeling headaches, grumpy, lethargic, trouble paying attention in class and tired whereas 17 participants (9%) had stomachache and dizziness. Conclusions: Participants agreed that breakfast is the important meal of every morning. They found consumption of breakfast consisting of more fruits and vegetables, dairy products and bers are proved to make an individual healthy as it provides enough energy to stay focused and active throughout the day.
School of Medicine, some faculty members have observed that a signi cant number of medical students on rotation to the ophthalmology subspecialty become restless and disinterested long before the end of the session at half past twelve in the afternoon. Informal discussions with the students revealed that some of them have a constant habit of skipping breakfast. The reasons for skipping breakfast were not disclosed in this study. The study showed that among college students (pre-clinical rst-year medical students) there was a very high prevalence of skipping breakfast Breakfast can inhibit the activity of the [8]. hypothalamic-pituitary-adrenal axis and consequently reduce the release of stress hormones such as cortisol, which contribute to the occurrence of primary headaches [9]. University students often skip breakfast, the connection between breakfast consumption and primary headache is of great importance. Therefore, the prevalence of primar y headache among them is considered to be high [10]. The most frequently skipped meal is breakfast rather than lunch or dinner in the young adults of the Universities. The main reason behind skipping meals is lack of time. Other reasons include: lack of appetite, inability to cook and not being hungry. It is understandable that the irregular omission of breakfast greatly affects the energy intake over the next 24 hours and during the day, exercise performances were also compromised [11]. Breakfast pattern reduced evening intake of high-carbohydrate and high-fat foods, furthermore, eating a nutritious breakfast daily improves satiety, appetite and diet quality, and may help improve some aspects of sleep health in healthy young adults [12]. Many people believe that skipping of breakfast may contribute to weight control but skipping breakfast actually increases the prevalence of obesity and its complications [13]. However, regular consumption of breakfast decreases the risk of obesity e ciently [14]. There is a signi cant relationship between skipping breakfast and lack of physical activity with depression. Strong evidence proved that a regular breakfast boosts the person's self-esteem, mood and its capability to cope with stress, depression and insomnia [15]. Skipping breakfast leads to postprandial hyperglycemia after having lunch and dinner in association with impaired insulin response in patients with type 2 diabetes mellitus (T2DM). As a result, it can worsen glycemic load [16]. Study suggests that the effects of missing breakfast persist throughout the day and simply consuming a morning meal is probably a bene cial method to lessen postprandial hyperglycemia in patients with T2DM [17]. Coronary artery disease and hypertension are great risk factors caused by skipping breakfast on daily basis and its negative association is even greater than obesity [18]. A dietar y weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women research described that those dietary habits which includes, choosing right frequency of carbohydrates, proteins, fats, vitamins and minerals in daily routine are fundamental factors that in uence human life style and its quality of life [19]. The frequent occurrence of weight problems amongst adolescents and adults are associated with short-term and long-term morbidity and mortality which is causing serious public health problems. Skipping breakfast and eating more energy dense snacks might be related to obesity [20]. In addition, a high-protein breakfast reduces daily food intake and prevents long-term body fat gain [21]. University students tend to have an unhealthy life style and their breakfast habits usually consists of processed or packaged food such as snacks, beverages, desserts, junk food which has high content of saturated fat which also contributes to obesity [22]. A study showed that regular breakfast eaters have less abdominal obesity only if their breakfast comprises of cereals, yogurt, fruits, nuts or milk [23]. Breakfast plays an important role in maintaining well-being and health of an individual. It has been proven that eating food rich in bers, vitamins and minerals improves the nutritional status of an individual throughout their lives and it also prevents chronic diseases [24]. A study conducted in female university students of middle east region highlighted that those educational programs which emphasize the importance of eating breakfast and reading food and nutrition labels should be promoted in order to educate the students regarding nutritious breakfast [25].

M E T H O D S
This study was conducted from June 2021 to October 2021 on the undergraduate students from three colleges of Akhtar Saeed Group located at Canal Campus, Lahore. It is a cross-sectional study on randomly selected respondents among 337 students studying in three colleges of Akhtar Saeed Group located at Canal Campus. Considering 95% con dence interval with 5% margin of error and 54% prevalence [6], the sample size comes to be 180 respondents. Undergraduate students studying in three colleges of Akhtar Saeed Group Canal Campus, Lahore were included with respect to age and gender. Doctors, faculty members and students from other campuses of Akhtar Saeed College were excluded from this study. The questionnaire is designed to ful ll the objectives of the study. The Questionnaire was in English and was verbally explained by the researcher to the participants. Open and close ended questions were asked and noted down accordingly. The questionnaire was divided into following parts: Demographic Pro le includes age, gender and level of education, anthropometric Measurements includes weight, height and BMI, Open and Close-ended Questions includes questions related to the consumption and skipping of breakfast, food group and area selected to eat breakfast and a view on importance of breakfast was asked. All data collected were analyzed by latest version of SPSS software and statistical computer program. Data were presented in the form of bar charts and pie charts to present frequencies and percentages of variables. Qualitative variables were presented in the form of themes. The consumers were given their written consent form to participate in the study. In case of unwilling participants more consumers were randomly selected and contacted to achieve desired results. Google forms were also used and the link was sent only to the willing participants. Table 2 shows the list of questions that were included in questionnaire. The participants who skipped breakfast was 66% and their number of reasons for it. Among them students don't like to eat in morning and they skipped the breakfast for no reason ranked the top. The question about where and frequency of consuming of breakfast was asked and most students rarely eat their breakfast that in college timings too. 69% of students identi ed breakfast as nonappetite regulator (69%) while choosing bread & cereal group as the selected food group to start their day with (82%). Table 1 shows the ratio of male and female that were assessed during the study. The percentages of both the genders are 50% with the frequency of 90. Anthropometric measurements were also included which helped in categorizing individuals into underweight, normal overweight or obese.     (7) 30 (17) 18 (10) 3 (2) 6 (3) 15 (8) 29 (16) 62 (34) At Home

Where Do You Usually Eat Breakfast
Rarely2-3

Usually Have to Like for Breakfast
Helps to pay attention, helps to feel powerful, helps to be in better mood, helps to improve memory and helps to be healthy  . This study depicts that 12 participants (7%) were having bread and cereals, 9 participants (5%) preferred milk and milk products, 148 participants (82%) preferred mixture of food groups that is bread and cereals, milk and milk products, meat and meat products and 11 participants (6%) usually chose bread and cereals and meat and meat products in morning. A study was conducted school going children and adolescents across the state of Utah to examine parent perceptions of school breakfast and identify relationships between those who consume breakfast at school and those who do not. A total of 448 parents lled the survey. It was concluded that children who perceive bene ts from school breakfast programs were more likely to eat breakfast at school [31]. This study nding depicts that 54 participants (30%) in the study preferred to have their breakfast at home, 59 participants (33%) in car whereas 67 participants (37%) usually have their breakfast at their college. A cross sectional study was conducted in Egypt to assess prevalence of obesity and overweight. A total of 398 students were assessed. It was concluded that 28.9% of the students were overweight, 11.8 % were obese, while (55.8%) were of normal weight (49.6% of males compared

D I S C U S S I O N
A cross-sectional study was conducted among 100 undergraduate students of University of Lahore, Pakistan. It was concluded that 46% of the students eat their breakfast daily and 54% did not take breakfast on daily basis [6]. This current study indicates that out of total sample 180, only 62 participants (34%) were consuming breakfast and 118 participants (66%) were not having breakfast in morning. Scienti c studies have proved that consumption of healthy breakfast is associated with greater intake of nutrients and it also maintains the better quality of the whole diet. A nutritious breakfast is also linked with healthy body weight and strong cardiovascular system, both in adults and children. Studies have shown that breakfast plays a huge role in improving mental and cognitive function of all age groups [26]. However, our study showed that 180 participants (100%) out of total 180 sample agreed that breakfast is important meal of daily morning and 46 participants (26%) feel active, 92 participants (51%) feel attentive and focused and 42 participants (23%) feel to be in good mood throughout the day due to having breakfast. A cross sectional study was conducted on the adolescents of Aligarh, India to explore the relationship of breakfast skipping and effects of breakfast on obesity. It was concluded that there was a very high frequency of breakfast skipping among these students and the rate of obesity/overweight has a signi cant relation with the intake of breakfast. Furthermore, the BMI of breakfast skipper was found out to be high than the breakfast consumers [27]. Our ndings shows that there were 14 participants (8%) falling in underweight category, 77 participants (43%) were found to be within normal ranges, 11 participants (6%) were overweight and 78 participants (43%) were falling in obese criteria. A cross sectional study was conducted on 60,800 Japanese adults of age 20-75 years to explore the association between breakfast skipping related to late night dinner eating (LNDE) followed by metabolic syndrome and proteinuria. A total of 14,068 (23.1%) adults skipped breakfast of whom half (52.8%) skipped their breakfast alone without LNDE. It was concluded that skipping breakfast followed by LNDE is associated with metabolic syndrome and proteinuria. In contrast, LNDE alone which is more common than skipping breakfast ( The study also suggests that skipping breakfast is signi cantly linked with irregular m e n st r u a l cyc l e a n d i n c re a s e t h e i n c i d e n ce of premenstrual pain and cramps, oligomenorrhea, dysmenorrhea and anorexia. However, there has been no impact at the other objects of premenstrual syndromes [33]. This study concluded that having breakfast helped 91 participants (51%) with paying attention, feeling powerful and energetic, improves mood and memory and stays healthy, whereas having breakfast helped 4 participants (2%) with their weight loss and 85 participants (47%) experienced it helps with their active routine and in trying new foods. A cross sectional study was conducted to explore the association between breakfast consumption pattern and primary headaches in the University students of Iran. 83,677 students were assessed among which 54.7 % were females. It was concluded that there is an inverse relationship between primary headaches and breakfast consumption in female students as well as in those students with BMI < 25 kg/m2 [34]. Another crosssectional study was conducted among 350 University students aged 19-25 years in Malaysia. The students received structured questionnaire of Breakfast information and Habitual physical exercise questionnaire.
The study suggested that in order to improve mental health of the students a balanced meal should be taken at proper time, especially a healthy breakfast and participate regularly in exercise to increase mental health [15]. Our study ndings indicate that 163 participants (91%) feel hungry, do not have energy, feel headaches, grumpy, lethargic, trouble paying attention in class and tired when they do not have breakfast whereas 17 participants (9%) had stomachache and dizziness when not having breakfast.
Participants agreed that breakfast is the important meal of every morning. They found consumption of breakfast consisting of more fruits and vegetables, dairy products and bers are proved to make an individual healthy as it provides enough energy to stay focused and active, throughout the day whereas Majority of participants showed they feel grumpy, lethargic, energy less, trouble paying attention, having headaches, stomachaches and dizziness due to breakfast skipping.

C o n  i c t s o f I n t e r e s t
The authors declare no con ict of interest.

S o u r c e o f F u n d i n g
The authors received no nancial support for the research, authorship and/or publication of this article.