Breakfast patterns in relation to physical activity among School Adolescents in Karachi, Pakistan

doi:10.21203/rs.3.rs-3096878/v1

Download PDF

Research Article

Breakfast patterns in relation to physical activity among School Adolescents in Karachi, Pakistan

https://doi.org/10.21203/rs.3.rs-3096878/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 30 Oct, 2023

Read the published version in Journal of Health, Population and Nutrition →

You are reading this latest preprint version

BACKGROUND

Breakfast is an essential meal of the day that plays important role in balanced diet of an individual. Studies have been conducted in developed countries; however, literature is scarce on breakfast consumption patterns among South Asian adolescents. Data about breakfast patterns may help in improving unhealthy breakfast habits and enhance the diet patterns of adolescents.

METHODS

This is a secondary study of a Higher Education Commission-funded project. The research participants, aged 11 to 17, were drawn from lower-middle-income secondary schools using multistage random selection. Socio-demographic and breakfast consumption were determined through interview cum questionnaire and food frequency survey.

RESULTS

The frequency of daily breakfast consumption was 82% among the total participants. 72.2% students considered chapatti as a primary meal for breakfast. Physically active children were less likely to skip breakfast 15.9%, whereas 27.6% were skipping breakfast less physically active group. 11.6% of participants were underweight who skipped breakfast.

CONCLUSIONS

According to the findings, the majority of Pakistani schoolchildren like to have breakfast, though their meal choices do not meet basic standards. Therefore, health promoter’s efforts should aim to counsel parents regarding awareness for healthy breakfast choices.

Breakfast

School adolescents

food choices

Physical activity

Breakfast is considered the most important meal of the day; it plays an integral role in a balanced diet of an individual. Skipping breakfast among adolescents may lead to nutrition deficiency and poor nutritional status. Information regarding breakfast patterns may help in improving unhealthy breakfast habits and enhance the overall diet patterns of adolescents, thereby improving the quality of life.

During the growth and development of an individual from childhood to adulthood, an intermediate period of drastic changes occurs, which is defined as Adolescence. It is the most critical period of time that requires intensive mental and physical care of an individual. More specifically, physical growth, mental development, physiological and psychological changes occur at their peak between the shifts from childhood to adulthood. Ultimately affecting the nutritional demands while at the same time environmental influences, changes in behaviours and emotional distress also influence the dietary habits (1)

Nutritional demands are primarily dependent on eating preferences and meals, and breakfast is considered as the most important meal of the day, providing adequate nutritional demands (2) Many studies identified the role of breakfast with the enhanced level of cognition and academic achievements. Regular breakfast is associated with optimal nutritional demand and ultimately satiates the energy demands for mental and physical problem solving, thus improving the level of cognition in those adults (3). At this phase of life, puberty changes are equally important while considering the diet and dietary choices. An increase in body size, muscular development, sexual maturation, bone metabolism depends on adequate nutrition and physical activity. It is proven that intake of breakfast provides energy with enhanced mental activity, focus and behaviour. Researches especially show young children with regular breakfast habits have improved physical activities and learning behaviours (4)

Most of the studies suggest a strong correlation of missing breakfast with increased body weight, increased junk food intake, and a high-fat diet at inappropriate timings in a day (5). Unhealthy behaviours are responsible for skipping breakfast in adolescents, such as smoking, lack of exercise, and substandard diet (6). Moreover, unhealthy lifestyles, health-compromising behaviours and health hazards are also responsible for breakfast skipping among adolescents (7)

Studies reported that adolescent’s like “ready-to-eat” foods or are already prepared by someone else at home and are usually influenced by choices among peers and other family members. Regarding food choices of adolescents, other views suggest that cultural trends, socio-economic status and family influence are major determinants of choice rather than personal perceptions or taste (8)

There are no studies published on breakfast consumption patterns among Pakistani adolescents. Information regarding breakfast patterns may help in improving unhealthy breakfast habits and enhance the overall diet patterns of adolescents, thereby improving their quality of life. Therefore, the aim of this study was to explore breakfast consumption patterns among school-going adolescents in Karachi, Pakistan.

Participants

The participants were from different classes within the age of 11–16 years whose parents had signed the consent form. November 2017 to November 2018 was study duration. The sample size for this study has been calculated by using the Open Epi calculator, taking a 95% confidence interval. The total sample size was calculated as 334 adolescents.

Instrumentation

The data was collected through a questionnaire that included personal information, socio-demographic information, health-related and lifestyle behaviour, dietary information, anthropometric measurements, and food choices information through a food frequency questionnaire (FFQ) from the participants. In anthropometric measurement, we took Height, Weight, BMI and Waist circumference. After this, participants were asked to choose their choices from the list of five food groups that are dairy group, grain group, fat group, fruits/vegetable and fruit juices group and meat and poultry group.

Procedure

This was a cross-sectional study. In this project, lower-middle-income secondary school’s children were used as a study population from six districts in Karachi. Multistage random sampling was employed to identify the study population. From each district, one town was randomly chosen, equal representation of boys’ and girls’ schools were selected. Participants were included if they had signed parent consent. Boys and girls between the ages of 11 and 17 were included, and their general health was good with (in the vision of the investigator/ co-investigator) no clinically significant and related abnormalities of medical history. The exclusion criteria were current or relevant history of any serious, chronic or unstable physical or psychiatric illness or any medical disorder in the opinion of the research associate and coordinator

Data Analysis

Data analysis was performed by using SPSS version 24. Descriptive statistics were calculated for demographic information of children like age, gender, parent’s educational status, physical activities, substance abuse and BMI. For quantitative study variables, the mean and standard deviation was calculated, and for qualitative study variables, frequency and percentages were computed. Study outcome “Breakfast consumption” was presented in bar diagram with frequency and percentages and frequency of food item preference also presented in frequency and percentages. A Chi-square test was applied for observing the statistical significance between breakfast consumption and other study variables, with the statistical significance set at a p-value ≤ 0.05.

A total of 334 participants were included in the study, out of which 29.6% (99) were younger adolescents, and 70.4% (235) older adolescents and the gender distribution was 42.5% (142) males and 57.5% (192) females. The demographic characteristics of the study are presented in Table 1. The educational status of fathers showed that 12% (40) of them had no formal education, 7.5% (25) had completed primary level, 4.5% (15) had done secondary level, 19.5% (65) metric, 15.9% (53) intermediate and 21.6% (72) were graduates.

Table 1

Baseline Characteristics of Study Population (N = 334)
Variables		N	%
Age (years)
	Younger adolescents	99	29.6
	Older adolescents	235	70.4
Gender
	Male	142	42.5
	Female	192	57.5
Father's Education
	No Formal Education	40	12
	Primary	25	7.5
	Secondary	15	4.5
	Matric	65	19.5
	Intermediate	53	15.9
	Graduate	72	21.6
	Don’t Know	64	19.2
Mother’s Education
	No Formal Education	58	17.4
	Primary	30	9
	Secondary	26	7.8
	Matric	73	21.9
	Intermediate	51	15.3
	Graduate	51	15.3
	Don’t Know	45	13.5
Physical Activity
	No	87	26
	Yes	189	56.6
	Sometimes	58	17.4
Substance Abuse
	No	200	59.9
	Occasionally (< 3/week)	90	26.9
	Often (> 5/week)	13	3.9
	Everyday	31	9.3
BMI(Kg/m2)
	Underweight	69	20.7
	Normal	233	69.8
	Overweight	32	9.6

Table 2

Food Item preferences at breakfast (N = 334)
Variables		N	%
Food group 1: Grains
	Chapatti	241	72.2
	Bread	253	75.7
	Rusk	203	60.8
	Paratha Whole Wheat	128	38.3
	Paratha Refined Flour	248	74.3
	Puri	243	72.8
	Tandoori Naan	278	83.2
	Porridge	99	29.6
	Cereal	54	16.2
	Beans	255	76.3
	Lentils	293	87.7
Food Group 2: Dairy
	Milk Whole	121	36.2
	Milk Without Cream	119	35.6
	Milk Powder	70	21
	Cream	146	43.7
	Yoghurt	270	80.8
	Sweet Lassi	198	59.3
	Saltish Lassi	116	34.7
Food Group 3: Fat
	Margarine/Butter	229	68.6
Food Group 4: Fruits/Vegetables & Fruit Juices
	Mixed Vegetable	231	69.2
	Potato Bhujiya	269	80.5
	Apple	305	91.3
	Banana	302	90.4
	Guava	217	65
	Grapes	279	83.5
	Melon	248	74.3
	Orange	282	84.4
	Mango	314	94
	Pomegranate	268	80.2
	Peach	180	53.9
	Fresh Juice	244	73.1
	Fruit Drinks	292	87.4
	Milk Shake	274	82
Food Group 5: Meat/Poultry and Seafood
	Red Meat	294	88
	White Meat	308	92.2
	Organ Meat	187	56
	Fish	255	76.3
	Egg Whole	278	83.2
Miscellaneous
	Bakery Items	279	83.5
	Tea Brewed	289	86.5
	Honey/Jam Or Jelly	202	60.5

Table 3

Frequency of Breakfast Consumption among all subgroups
		NO	YES
Variables		N (%)	N (%)	P-VALUE
Age (years)				0.316
	Younger adolescents	21.2	78.8
	Older adolescents	16.6	83.4
Gender				0.061
	Male	13.4	86.6
	Female	21.4	78.6
Father’s Education				0.285
	No Formal Education	27.5	72.5
	Primary	16	84
	Secondary	13.3	86.7
	Matric	21.5	78.5
	Intermediate	9.4	90.6
	Graduate	13.9	86.1
	Don’t Know	21.9	78.1
Mother’s Education				0.793
	No formal Education	24.1	75.9
	Primary	20	80
	Secondary	19.2	80.8
	Matric	17.8	82.2
	Intermediate	11.8	88.2
	Graduate	15.7	84.3
	Don’t Know	17.8	82.2
Physical Activity				0.11
	No	16.1	83.9
	Yes	15.9	84.1
	Sometimes	27.6	72.4
Substance Abuse				0.592
	No	17.5	82.5
	Occasionally (< 3/week)	15.6	84.4
	Often (> 5/week)	23.1	76.9
	Everyday	25.8	74.2
BMI(Kg/m2)				0.248
	Underweight	11.6	88.4
	Normal	20.2	79.8
	Overweight	15.6	84.4

While the educational status of mothers of the study participants showed 17.4% (58) had no formal education, 9% (30) had completed primary education, 7.8% (26) had done secondary schooling, 21.9% (73) were matriculate, 15.3% (51) had done intermediate and similar numbers had completed graduate studies. The remaining numbers chose not to answer this question.

Among the participants, 56.6% (189) reported doing regular physical activity, while 17.4% (58) were doing it sometimes, and 26% (87) of the participants had no physical activity. There were 20.7% (69) participants who were underweight, 69.8% (233) had normal BMI, and 9.6% (32) participants were found to be overweight/ obese.

The frequency of daily breakfast consumption was reported by 82% (274) participants, and the remaining did not consume breakfast on a daily basis (Fig. 1). We have assessed the preference of breakfast items according to different food groups from the participants.

Majority of children (72.2%) considered chapatti as a primary and main meal for breakfast. 75.7% use baked bread for breakfast. Rusk was a popular choice for breakfast among 60.8% (203) participants. Whole wheat, refined flour was also used by 38.3% (128), 74.3% (248) children. Puri was consumed by 72.8% (243), porridge by 29.6% (99), cereal by 16.2% (54), beans by 76.3% (255) and lentils by 87.7% (293) were considered a good source of breakfast. In addition to this, tandoori naan was also preferred by 83.2% (278) participants. The pattern of preference also depended on the socio-economic status of the participant.

In dairy products, whole milk consumption was preferred by 36.2% (121), milk without cream 35.6% (119), milk powder 21% (70), only cream 43.7% (146), yoghurt 80.8% (270), sweet lassi 59.3% (198) saltish lassi 34.7% (116) participant of the study. The most preferred dairy products were yoghurt, milk and lassi in this study. While in fat, margarine/ butter was the only choice which was preferred by 68.6% (229) participants.

Assessment for preference of consuming fruits and vegetables among the students showed, 69.2% (231) participants preferred consuming mixed vegetables, 80.5% (269) potato bhujiya, more than 80% of the students preferred to have fruits in breakfast, same as for fruit drinks like juice /shakes etc.

In meat/poultry and seafood, participants who preferred to have red meat in the breakfast, 88% (294), chicken meat, 92.2% (308), fish/seafood, 76.3% (255) and 83.2% (278) of them preferred to keep eggs in their breakfast routine. In other foods, 83.5% (279) participants took bakery items, 86.5% (289) participants consumed tea (brewed), and 60.5% (202) participants preferred using honey/ jam or jelly in the breakfast.

The frequencies of (daily) breakfast consumption in different age groups vary. 78.8% younger adolescents and 83.4% older adolescent population were consuming breakfast daily. There was no significant difference found between both age groups with (p-value 0.316). Out of the total, 13.4% male participants and 21.4% female participants skipped breakfast which also showed the non-significant effect of gender on skipping breakfast (p-value 0.06). Comparison between breakfast consumption with parent’s education status showed no significant association. (p-values 0.285 & 0.793) respectively. 15.9% of participants who were physically active skipped breakfast, whereas 27.6% of those who were sometimes physically active skipped breakfast and 16.1% physically inactive skipped breakfast in their routine life. Substance abuse also showed insignificant association with (P-value 0.592). Body mass index and breakfast consumption status showed that 11.6% of underweight participants skipped breakfast, 79.8% with normal BMI and 84.4% overweight participants consumed breakfast daily with insignificant effect (p-value: 0.248). Further, it was observed that skipping breakfast was nearly associated with being younger, a girl, low educational status, and occasional physical activity pattern. (Table: 3)

Literature review showed that breakfast consumption had a great impact on energy levels regardless of the food eaten at breakfast. In this study, 82% of our participants consumed breakfast daily. In line with the results of the study, numerous studies around the world also showed breakfast consumption has increased, which might be due to a variety of factors like availability of different foods for breakfast and awareness from social media may have played an important role in having breakfast (9) On the contrary, a study conducted in the United States showed, breakfast consumption has been reduced over a period of time (10)

Moreover, a survey conducted in Canada also reported that school children skipped their breakfast due to a lack of parents education (11). Similar, Japanese studies also reported that the majority of school children did not prefer to take breakfast because they consumed snacks during lunch break (12). The present study results reveal that majority of younger adolescents and older adolescent age group population prefer to have breakfast daily. However, there is a slight difference between the frequencies of both groups. In another study concluded that 88 per cent of US Adolescent tends to skip breakfast more than Australian adolescent (13)

In the current study, more boys consumed breakfast as compared to girls. The results are analogous to a study conducted in Punjab, where more boys tend to eat breakfast as compared to girls (14). It can be said that boys feel hungrier in the morning as compared to girls because the number of boys is engaged in physical activity like playing sports as compared to girls. The girls are more homebound, and that could be the reason they don’t feel hungry in the morning to consume breakfast. The results were in agreement with a study conducted in the Netherlands which found that females, vocational school students and participants belonging to minorities have a lesser frequency of breakfast consumption (15)

The study also found that the school children did not eat breakfast from all the five food groups: fruit and fruit juice, grains, dairy products, and fats and oils. The majority of school children preferred whole bread followed by semi-skimmed milk (15). Though, the present study results showed very different food choices preferred by school children. Most of the school children choose lentils with tandoori naan in the grains. This is because Pakistani food choices are entirely different from western culture. In the west, cereals and whole bread are preferred at breakfast, whereas in Pakistan, parathas and naan are preferred. This is why the school children chose lentils with tandoori naan in their breakfast. The comparison among different food group consumption also showed that 86% school children had tea with milk which showed us that tea is a more common beverage in the east whereas children in the west preferred semi-skimmed milk.(15)

Furthermore, the results also showed that socio-demographic factors did not have any effect on breakfast consumption. Similarly, in a study, mothers’ education did not play any role in their children breakfast consumption. It can be said that breakfast consumption of school children is entirely individual’s own choice. Hence, the present study did not show any significance (14) To the best of our knowledge, no such study has been carried out on Pakistani adolescents. There is a dire need of assessing food choices for breakfast as it is the most important meal of the day and leads to a healthy lifestyle.

Implications for School Health

Although there are various studies in Pakistan regarding breakfast patterns, however, the current study showed basic food choices among school children, and there is no significant association with any of the demographic characteristics. School children should be counselled to adopt healthy food choices in their breakfast. There should be measures to prevent unhealthy eating during breakfast, and parents should be targeted for this health promotion (16–18).

More focus should be given to breakfast intake among older students in secondary schools, though, as rates of breakfast consumption decline throughout childhood and adolescence. The amount of kids skipping breakfast can be greatly reduced through school meal programmes. Families should also be the focus of the campaign because family mealtimes are crucial for developing good eating habits in adolescents. Interventions should emphasise the inclusion of fruit, vegetables, and drinks while encouraging a high-quality breakfast.

Limitations

All the previous literature regarding breakfast consumption assessed different trends and impacts of breakfast; however, the food choices were never assessed. However, the study did not promote any health measures or create awareness regarding different healthy breakfast patterns to individuals or their families. Therefore, we recommend conducting more studies on this crucial topic and promoting health for the benefit of our young population.

The study revealed that there is no significant association among food choices of school children with age, gender, socio-economic status, and education of mother and father. Overall this study focused on food choices that were not previously studied in Pakistan. Therefore, health promotion agendas and educational intervention policies should be placed for healthy breakfast consumption and more emphasis on food choices. Hence parents should be counselled regarding awareness for healthy breakfast choices, and henceforth school children should be taught regarding the importance of each micronutrient. Therefore, a healthy breakfast tradition should be incorporated into Pakistani society.

DATA AVAILABILITY

The data that support the findings of this study are available from the corresponding author upon reasonable request.

HUMAN SUBJECTS APPROVAL STATEMENT

The study was conducted according to the guidelines laid down in the Declaration of Helsinki and the Institutional Review Board of Dow University of Health Sciences (DUHS), Karachi, Pakistan (IRB-345/DUHS /-16), approved all procedures involving human subjects.

FUNDING

This study was funded by the National Research Program for Universities (NRPU) grant no.

4489 by Higher Education Commission (HEC) of Pakistan

ACKNOWLEDGEMENT

The authors would like to acknowledge faculty and BS Nutrition students of DUHS for assisting in data collection. Thanks to all study participants, schools, parents for their willingness to participate.

AUTHORS CONTRIBUTIONS

Dr Mehak Muhammad Ashfaq designed and conducted the research; Dr Nilofer Fatimi Safdar supervise the research; Nida Jawed helped in wrote the manuscript; Dr Adnan Ahmed Bhutto helped in language editing. All authors reviewed and approved the final manuscript.

CONFLICT OF INTEREST DISCLOSURE STATEMENT

All authors of this article declare no conflicts of interest in this work.

Paracha P, Bakht S, Paracha S, Vriesekoop F, Alam I, Din Z, et al. Nutritional Status, Dietary Practices and Physical Activities of Adolescents in Public and Private Schools of Karachi, Pakistan. Obesity Research-Open Journal. 2016;3(2):30–9.
Rampersaud GC. Benefits of breakfast for children and adolescents: update and recommendations for practitioners. American Journal of Lifestyle Medicine. 2009;3(2):86–103.
Zullig K, Ubbes VA, Pyle J, Valois RF. Self-reported weight perceptions, dieting behavior, and breakfast eating among high school adolescents. Journal of School Health. 2006;76(3):87–92.
Keski-Rahkonen A, Kaprio J, Rissanen A, Virkkunen M, Rose RJ. Breakfast skipping and health-compromising behaviors in adolescents and adults. European journal of clinical nutrition. 2003;57(7):842–53.
Alexy U, Wicher M, Kersting M. Breakfast trends in children and adolescents: frequency and quality. Public health nutrition. 2010;13(11):1795–802.
Smith KJ, Gall SL, McNaughton SA, Blizzard L, Dwyer T, Venn AJ. Skipping breakfast: longitudinal associations with cardiometabolic risk factors in the Childhood Determinants of Adult Health Study. The American journal of clinical nutrition. 2010;92(6):1316–25.
Shaw ME. Adolescent breakfast skipping: an Australian study. Adolescence. 1998;33(132):851–61.
Cogan T. The Haven of Health: Chiefly Made for the Comfort of Students, and Consequently for All Those that Have & Care of Their Health: Imprinted by Thomas Orwin, for William Norton.
Story M, Harris LJ. Food preferences, beliefs, and practices of Southeast Asian refugee adolescents. Journal of School Health. 1988;58(7):273–6.
Siega-Riz AM, Popkin BM, Carson T. Trends in breakfast consumption for children in the United States from 1965–1991. The American journal of clinical nutrition. 1998;67(4):748S-56S.
Murata M. Secular trends in growth and changes in eating patterns of Japanese children. The American journal of clinical nutrition. 2000;72(5):1379s-83s.
Singleton N, Rhoads DS. Meal and snacking patterns of students. Journal of School Health. 1982;52(9):529–34.
Mullan B, Wong C, Kothe E, O’Moore K, Pickles K, Sainsbury K. An examination of the demographic predictors of adolescent breakfast consumption, content, and context. BMC Public Health. 2014;14(1):264.
Adeel FFA, Awan MA, Anjum N, Ahmed H, Ahmed Z, Afreen A. Dietary practices among adolescents: do boys eat better than girls? NURTURE: Journal of Pakistan Home Economics Association. 2012;6(1).
Raaijmakers LG, Bessems KM, Kremers SP, van Assema P. Breakfast consumption among children and adolescents in the Netherlands. European journal of public health. 2010;20(3):318–24.
Mushtaq MU, Gull S, Mushtaq K, Shahid U, Shad MA, Akram J. Dietary behaviors, physical activity and sedentary lifestyle associated with overweight and obesity, and their socio-demographic correlates, among Pakistani primary school children. International Journal of Behavioral Nutrition and Physical Activity. 2011;8(1):130.
Aziz A, Pervaiz M, Khalid A, Khan AZ, Rafique G. Dietary practices of school children in Sindh, Pakistan. Nutrition and health. 2018;24(4):231–40.
Iftikhar F, Chughtai A, Iqbal S, Tahir SK. Impact of school-based nutrition education intervention on consumption of fruits and vegetables among middle school children (age 7–10 years). Life Science Journal of Pakistan. 2019;1(1):10–8.

No competing interests reported.

Download PDF

Journal Publication

published 30 Oct, 2023

Read the published version in Journal of Health, Population and Nutrition →

Editorial decision: Major revision
05 Aug, 2023
Reviews received at journal
03 Aug, 2023
Reviewers agreed at journal
24 Jul, 2023
Reviews received at journal
22 Jul, 2023
Reviewers agreed at journal
05 Jul, 2023
Reviewers agreed at journal
04 Jul, 2023
Reviewers invited by journal
04 Jul, 2023
Editor assigned by journal
23 Jun, 2023
Submission checks completed at journal
23 Jun, 2023
First submitted to journal
22 Jun, 2023

You are reading this latest preprint version

Breakfast patterns in relation to physical activity among School Adolescents in Karachi, Pakistan

Status:

Journal Publication

Version 1

Abstract

Figures

BACKGROUND

METHODS

Participants

Instrumentation

Procedure

Data Analysis

RESULTS

DISCUSSION

Implications for School Health

Limitations

CONCLUSIONS

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1