UNIVERSITY OF GHANA COLLEGE OF BASIC AND APPLIED SCIENCES DEPARTMENT OF NUTRITION AND FOOD SCIENCE THE ASSOCIATION BETWEEN SKIPPING BREAKFAST AND ACADEMIC PERFORMANCE AMONG ADOLESCENTS (10 - 16 YEARS) IN TAMALE METROPOLIS, NORTHERN GHANA BY HAMDIYATU ABUBAKARI (10876798) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FUFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL IN NUTRITION DEGREE. i DECLARATION Apart from citations to other publications that have been properly acknowledged, I hereby certify that the content of this thesis is the result of my research. Additionally, this thesis hasn't been submitted in full or in part to this university or any other institution elsewhere for a degree of any kind. HAMDIYATU ABUBAKARI (STUDENT) SIGNATURE: .......... ............. DATE: 21/12/2023 DR. KEIRON AUDAIN (PRINCIPAL SUPERVISOR) SIGNATURE: DATE: 22/12/2023 DR. HUSEIN MOHAMMED (CO-SUPERVISOR) SIGNATURE: .......... .............. DATE:22/12/2023 ii DEDICATION I dedicate this work to my mother Rukaiyatu Issah, my father Abubakari Amadu and my siblings in gratitude for their unending love, care, and encouragement during my studies at the university. iii ACKNOWLEDGEMENT My sincere gratitude to Almighty Allah for his good health, wisdom, emotional support, and guidance throughout my stay in school. I extend my profound gratitude to supervisors, Dr. Keiron Audain, and Dr. Husein Mohammed for their nurturing, pieces of advice, and suggestions given to me to enable the completion of this work. For their advice and assistance throughout my study years, I am grateful to the entire staff of the Department of Nutrition and Food Science at the University of Ghana. I would like to extend a sincere thank you to my colleagues and ask Allah to generously bless them for their assistance during our studies. I equally acknowledge the Tamale Metro Ghana education service directorate, the Tamale Metro Ghana education service PRO, and the head teachers at my selected schools for their immense contribution and cooperation. I also want to express my gratitude to all my participants for agreeing to participate in the study. Finally, I want to thank everyone who helped make my thesis successful, including my parents, siblings, and other relatives. Their efforts direct or indirect were greatly appreciated. I say Allah bless you all. iv TABLE OF CONTENTS DECLARATION ....................................................................................................................................... i DEDICATION .......................................................................................................................................... ii ACKNOWLEDGEMENT ....................................................................................................................... iii TABLE OF CONTENTS ......................................................................................................................... iv LIST OF FIGURES ................................................................................................................................ vii ACRONYMS AND ABBREVIATIONS .............................................................................................. viii ABSTRACT .............................................................................................................................................. x CHAPTER ONE ............................................................................................................................................... 1 1.0 INTRODUCTION TO STUDY ....................................................................................................... 1 1.1 Introduction .................................................................................................................................... 1 1.2Background ...................................................................................................................................... 1 1.3 Problem statement ......................................................................................................................... 4 1.4 Rationale ......................................................................................................................................... 6 1.5 Objectives ........................................................................................................................................ 8 1.5.1 Main objective ............................................................................................................................. 8 1.5.2 Specific objectives ........................................................................................................................ 8 CHAPTER TWO .............................................................................................................................................. 9 2.0 LITERATURE REVIEW ................................................................................................................ 9 2.1 Introduction .................................................................................................................................... 9 2.2 Conceptual framework ................................................................................................................... 9 2.3 Conceptual review ........................................................................................................................ 10 2.3.1 Breakfast skipping ...................................................................................................................... 10 2.3.2 Academic performance .............................................................................................................. 12 2.4 Empirical literature review ............................................................................................................ 18 2.4.1 Prevalence of breakfast skipping among adolescents ............................................................... 18 2.4.2 Dietary intake and nutritional status of adolescents ................................................................. 21 2.4.3 Factors that influence breakfast skipping among adolescents .................................................. 21 2.4.4 Association between breakfast skipping and nutritional status ................................................ 23 2.4.5 Association between breakfast skipping and academic performance ...................................... 26 CHAPTER THREE .......................................................................................................................................... 28 v 3.0 METHODOLOGY ......................................................................................................................... 28 3.1 Introduction .................................................................................................................................. 28 3.2 Study design .................................................................................................................................. 28 3.3 Study area ..................................................................................................................................... 28 3.4 Study population ........................................................................................................................... 29 3.5 Sample size determination ........................................................................................................... 30 3.6 Selection of participants and sampling technique ........................................................................ 31 3.7 Inclusion and exclusion criteria ..................................................................................................... 31 3.7.1 Inclusion criteria ......................................................................................................................... 31 3.7.2 Exclusion criteria ........................................................................................................................ 32 3.8 Data collection methods and instruments .................................................................................... 32 3.8.1 Training of field assistant and pretesting of tools ..................................................................... 33 3.8.2 Socio- demographic characteristic of participants .................................................................... 33 3.8.3 Breakfast skipping prevalence, and dietary intake .................................................................... 34 3.8.4 Nutritional status of adolescents ............................................................................................... 34 3.8.5 Factors that influence breakfast skipping .................................................................................. 34 3.8.6 Academic performance .............................................................................................................. 35 3.9 Data analysis ................................................................................................................................. 35 3.10 Ethical considerations ................................................................................................................. 36 CHAPTER FOUR ........................................................................................................................................... 37 4.0 RESULTS ........................................................................................................................................ 37 4.1 Introduction .................................................................................................................................. 37 4.2 Socio-demographic characteristics of participants ....................................................................... 37 4.3 Breakfast skipping prevalence among adolescents ...................................................................... 45 4.4 Dietary intake and nutritional status of adolescents .................................................................... 45 4.4.1 Energy and micronutrient intake of respondents ...................................................................... 47 4.4. 2 Nutritional status of adolescents .............................................................................................. 49 4.5 Factors that influence the skipping of breakfast among adolescents .......................................... 51 4.5.1 Predictors of factors that influence breakfast skipping ............................................................. 52 4.5.2 Focus group discussion (FGD) .................................................................................................... 54 4.5.3 Understanding of breakfast ....................................................................................................... 55 4.5.4 Breakfast eaten .......................................................................................................................... 56 vi 4.5.5 Healthy breakfast ....................................................................................................................... 57 4.5.6 Factors influencing breakfast skipping....................................................................................... 58 4.6 Association between breakfast skipping and nutritional status of adolescent ............................ 60 4.6.1 Binary logistic regression analysis of association between nutritional status and breakfast skipping ............................................................................................................................................... 61 4.7 Association between skipping of breakfast prevalence and academic performance of adolescents in public and private schools. ......................................................................................... 62 4.7.1 Linear regression analysis of the association between skipping of breakfast prevalence and academic performance of adolescents in public and private schools ................................................ 63 CHAPTER FIVE ............................................................................................................................................. 65 5.0 DISCUSSION .................................................................................................................................. 65 5.1 Introduction .................................................................................................................................. 65 5.2 Prevalence of skipping breakfast among adolescents .................................................................. 65 5.3 Dietary Intake and Nutritional Status of Adolescents .................................................................. 67 5.4 Factors that influence skipping of breakfast among adolescents ................................................ 69 5.4.1 Focus group discussion .............................................................................................................. 69 5.4.3 Understanding of healthy breakfast .......................................................................................... 72 5.4.4 Factors influencing breakfast skipping....................................................................................... 72 5.5 Association between skipping of breakfast and nutritional status ............................................... 74 5.6 Association between skipping of breakfast and academic performance ..................................... 74 5.7 Limitation of the study .................................................................................................................. 75 CHAPTER SIX ................................................................................................................................................ 76 6.0 CONCLUSION AND RECOMMENDATION ............................................................................ 76 6.1 Conclusion ..................................................................................................................................... 76 6.2 Recommendations ........................................................................................................................ 77 REFERENCES ....................................................................................................................................... 78 APPENDICES ....................................................................................................................................... 82 Appendix ⅰ: Parent or Caregiver Consent form ................................................................................ 82 Appendix ⅱ: Adolescent children and mother or caregiver questionnaire ....................................... 86 Appendix ⅲ: Focus group discussion guidelines ................................................................................ 93 Appendix ⅳ: Ethical approval (ECBAS) ............................................................................................... 95 Appendix ⅴ: Introductory letter (GES) .............................................................................................. 96 vii LIST OF TABLES TABLE 4. 1:SOCIO-DEMOGRAPHIC CHARACTERISTICS OF ADOLESCENTS ........................................ 39 TABLE 4. 2 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANT’S MOTHERS OR CAREGIVERS ............................................................................................................................................... 41 TABLE 4. 3: HOUSING CHARACTERISTICS OF PARTICIPANTS ........................................................... 42 TABLE 4. 4: BREAKFAST PRACTICES OF ADOLESCENTS IN TAMALE METROPOLIS (N = 200) ........... 46 TABLE 4. 5: NUTRIENT INTAKE AMONG IN-SCHOOL ADOLESCENTS ................................................ 48 TABLE 4. 6: NUTRIENT INTAKE BETWEEN ADOLESCENTS WHO CONSUMED BREAKFAST AND ADOLESCENTS ......................................................................................................................... 49 TABLE 4. 7 ASSOCIATION BETWEEN FACTORS THAT INFLUENCE BREAKFAST SKIPPING AMONG IN- SCHOOL................................................................................................................................... 51 TABLE 4. 8: PREDICTORS OF FACTORS THAT INFLUENCE BREAKFAST SKIPPING .............................. 53 TABLE 4. 9:PARTICIPANTS SOCIO-DEMOGRAPHIC CHARACTERISTICS (N= 48) ............................... 54 TABLE 4. 10:THEMES AND SUB-THEMES ........................................................................................ 55 TABLE 4. 11:COMPARING PARTICIPANTS BREAKFAST SKIPPING AND NUTRITIONAL STATUS .......... 60 TABLE 4. 12: BINARY LOGISTIC REGRESSION ANALYSIS OF ASSOCIATION BETWEEN NUTRITIONAL STATUS AND ............................................................................................................................ 61 TABLE 4. 13:CORRELATION ANALYSIS OF THE ASSOCIATION BETWEEN BREAKFAST SKIPPING AND ACADEMIC .............................................................................................................................. 63 TABLE 4. 14:LINEAR REGRESSION COEFFICIENTS OF SKIPPING OF BREAKFAST PREVALENCE AND ACADEMIC .............................................................................................................................. 64 LIST OF FIGURES FIGURE 4. 1: PREVALENCE OF BREAKFAST SKIPPING AMONG ADOLESCENTS 10-16 YEARS............. 45 FIGURE 4. 2: BMI- FOR- AGE OF ADOLESCENT IN TAMALE METROPOLIS ........................................ 50 FIGURE 4. 3: MUAC OF ADOLESCENT IN TAMALE METROPOLIS .................................................... 50 viii ACRONYMS AND ABBREVIATIONS BMI Body Mass index ECBAS Ethics Committee for College of Basic and Allied Sciences FAO Food and Agricultural Organisation of Ghana FGDs Focus Group Discussions GSS Ghana Statistical Service GES Ghana Education Studies AAP Average Academic Performance BFS Breakfast Skipping MUAC Mid-Upper Arm Circumference CI Confident Interval USAID United States Agency for International Development WFP World Food Program WHO World Health Organisation PA Physical Activity HEI Healthy Eating Index SES Socio Economic Status GDHS Ghana Demographic and Health Survey ix NSFP National School Feeding Program B.D.T Basic Design and Technology T. Z Tuo Zaafi J.H.S Junior High School OWOP Our World Our People SBA School-Based Assessment x ABSTRACT Background: Breakfast is thought to be an important source of energy metabolism, which enhances the body's ability to perform effectively throughout the day (Fareed & Waseer, 2017). The adolescent stage requires a lot of energy for growth and development. There is limited information on how breakfast affects the academic performance of in- school adolescents. Objectives: To assess the association between skipping breakfast and the academic performance of adolescents between the ages of 10 - 16 years in the Tamale metropolitan. Methodology: A mixed-method study was used for this study. A semi-structured questionnaire, physical assessment, and focus group discussion were used in the collection of data. The association between breakfast skipping and nutritional status was determined using bivariate and multivariate binary logistic regression analysis. Data were entered and coded in an excel sheet, then later exported onto SPSS software version 26, and WHO Anthro software for cleaning and analysis. Statistical significance was set at p-value of less than 0.05. Factors that influence breakfast skipping was determined through focus group discussion and thematic analysis was used for the analysis. Results: The prevalence of breakfast skipping was 28%. Within those who skipped breakfast, more than half (76.8%) of female participants skipped breakfast than the males (23.2%). Also, breakfast skipping, and gender had a significant association as p = 0. 001. Breakfast skipping was inversely correlated (- 0.29) with academic performance and it had a p-value of 0.000. The factors that influenced breakfast skipping among in-school adolescents were lack of time, economic reasons, social reasons, and health implications. xi Conclusion: Nutrient intake had no significant association with breakfast skipping except for vitamin C and calcium. Breakfast skipping had a weak significant association with academic performance at p = 0.01. 1 CHAPTER ONE 1.0 INTRODUCTION TO STUDY 1.1 Introduction This chapter provides the background of the study and gives a precise and brief understanding of the study. Again, it contains the problem statement, rationale, and study objectives. 1.2Background An adolescent is defined as the stage where one grows from childhood to adulthood. It normally begins with physiologically normal puberty and ends with an adult character. This period of physiologically normal puberty to adult character is between 10 and 19 years (Sacks, 2003). Because adolescence is a process of growth, a nutritious breakfast is extremely important (Khurshid, Mahmood, Chaudhry, & Paracha, 2018). During adolescence, the nutritional status needs to be improved because it will benefit this generation and the next generation (Tumilowicz et al., 2019). Adolescents who practice healthy eating habits are better able to grow physically, psychologically, and cognitively, and they are also less likely to develop chronic disorders related to diet in adulthood. However, since adolescents are moving toward greater independence from their parents about dietary choices, they are more vulnerable to nutrition issues than younger children. After a night's sleep, breakfast is the first meal consumed in the morning. Breakfast is thought to be essential because it replenishes the body's energy and nutrient stores. In this study, breakfast is considered as any food eaten before 10:00am and it contains nutrients. Previous studies have shown that adolescents who eat breakfast regularly are more likely to consume a quality diet and nutrient-dense foods such as dietary fibre, protein, and other nutrients to help them meet the 2 recommended micronutrient for growth (Fayet-Moore et al., 2016). In contrast, an adolescent who skips breakfast regularly would end up consuming energy-dense foods like sugary, salty, and fatty foods (Intiful & Lartey, 2014). Furthermore, studies have associated skipping breakfast with hypertension, diabetes, and cardiometabolic disorders (Odegaard et al., 2013: Geliebter et al., 2014; Ballon et al., 2019). Breakfast is the most popular meal skipped by many people around the world. According to a survey conducted among adolescent school children in Spain, which used data from the 2019– 2020 DESK cohort project showed that the prevalence of skipping breakfast every day was 19.4% in girls and 13.7% in boys (Esquius et al., 2021). Breakfast skipping and the type of breakfast consumed in children and adolescents have been linked to nutritional intake and weight status. Adelle Davis, a nutritionist said in the 1960s “eat breakfast like a king, lunch like a prince, and supper like a pauper” (Sifferlin, 2013). A study shows that breakfast contributes about 300 – 500 (15% – 25%) of our daily calories (Spence, 2017). Faye et al., (2021) conducted a study on adolescent breakfast skipping and its association with poorer academic performance. This study reported that 41.3% of adolescents skipped breakfast and their reasons were lack of access to food, lack of appetite, and concern about gaining weight. Academic performance refers to the accomplishments of a student in their studies, and they are usually assessed using a variety of methods such as tests, assignments, assessments, and final grades. It shows how well a student is doing academically and indicates their level of understanding in a given subject or course, comprehension of the subject matter, and capacity to apply knowledge. The grades a student earns in specific courses or areas are the most direct measure of their academic achievement. Grades are frequently displayed on a scale, and they could also include grade points or other numerical values (Tadese et al., 2022). Several studies have 3 shown that breakfast skipping affect academic performance of children and adolescents (Smith et al., 2017; Boschloo et al., 2012; Adolphus et al., 2016). A study was also done among day and boarding teenage students by Khurshid et al., (2018) on factors related to skipping breakfast and academic performance, which revealed that those who ate breakfast did better academically. Also, breakfast skippers were more likely to feel lazy and have a high level of irritation. In comparison, boarding students may skip breakfast due to inadequate food, poor appetite, late-night dinner, and concern to maintain body shape. Another study conducted among Chilean adolescents showed breakfast skipping to be more strongly associated with lower cognitive performance among adolescents who were overweight or obese and regularly skipped breakfast compared to other adolescents with a normal body mass index (BMI) (Pea- jorquera et al., 2021). Breakfast is an opportunity to consume essential nutrients such as vitamins, minerals, protein, and fiber. Skipping breakfast may lead to insufficient intake of these vital nutrients, contributing to malnutrition over time. The northern region of Ghana, despite numerous interventions at their disposal, the region is the second poorest (50.4%) region in the country, with the highest malnutrition burden (GSS, 2014a; GDHS, 2014). They also experiences a high rate of food insecurity (31%) (WFP, 2020). Households that are food insecure often consume less diverse food groups due to various factors related to limited resources, financial constraints, and access to nutritious foods. This food insecurity can led to breakfast skipping among adolescents, in context to a study conducted in the northern region which proved that adolescents in this region skip breakfast (30%) (Abiba et al., 2012). The region also faces educational disparities, including inadequate parental support, teenage pregnancy, early marriage, poverty, peer influence, and access to quality education (Bariham & Edmond, 2017). Research has shown that there is a significant association between 4 skipping breakfast and academic outcomes, particularly among adolescents. Skipping breakfast may lead to temporary hypoglycemia (low blood sugar), affecting attention, memory, and overall cognitive abilities (Galioto & Spitznagel, 2016).Hence, studying the association between breakfast skipping and academic performance among in-school adolescents in the Tamale Metropolis will provide facts that may be leveraged to develop, prioritize, and implement evidence-based intervention programs targeted at enhancing the nutritional and academic performance of adolescents. 1.3 Problem statement The act of skipping breakfast can have significant negative effects on adolescent due to the importance of proper nutrition during the critical stage of adolescence. However, adolescents are more likely than younger children to be left to make breakfast choices, which leads them to skipping breakfast. Skipping breakfast may have a negative effect on a student's academic performance (Galioto & Spitznagel, 2016). According to studies, adolescents who eat breakfast perform better on assessments and are more likely to be able to concentrate and pay attention in class(Gao et al., 2021). Breakfast's significance in regard to academic performance has been widely studied, but results have been inconsistent. Some studies suggest that consuming breakfast is good for academic performance, while other study showed that it depend on the amount of breakfast taken in terms of calorie and macronutrient composition was related to the participants' academic performance (Feye et al., 2021; Adolphus,2015; Arimi et al., 2018). One reason for the conflicting results may be poor-quality breakfast choices that may not provide the nutrients needed for optimal brain function. Another reason to consider is the timing of breakfast in relation to the start of the school 5 day. In Ghana, breakfast skipping measured among school-going children between the age of 9 to 16 years in the Eastern region showed a prevalence of 14.5 % (Intiful and Lartey 2014). The study limited breakfast skipping prevalence to the day the data was collected and academic performance was not assessed because it was not part of the study objectives. According to a survey conducted in Malaysia among university students to ascertain how frequently breakfast is consumed as well as their knowledge, attitudes, habits, and barriers. Only 35.9% of students, according to the study's findings, ate breakfast six to seven days per week. The study discovered that Malaysian students were significantly less likely to have breakfast (p=0.03) because of expensive breakfasts (Jayaveloo et al., 2021). In the study, the participants were from only one university, which limited the ability to compare other participants from other universities. With northern region having the greatest percentage (33.8%) of malnutrition (GDHS, 2014), and the second poorest region (50.4%) (GSS, 2014a) with 31% of the population suffering from food insecurity. High food insecurity in Tamale Metropolis may led to adolescents skipping breakfast due to limited access, and availability, households struggle to afford nutritious food. Even though much research has been done to evaluate the relationship between skipping breakfast and academic performance both globally and in Africa. There are limited studies conducted on breakfast skipping and academic performance in Ghana. The few ones that were conducted among in-school adolescents only measured breakfast prevalence and nutritional status (Intiful and Lartey 2014; Owusu et al., 2017; Buxton, 2014; Abiba et al., 2012). In the Northern region, no research has been conducted on the relationship between breakfast skipping and academic performance among in-school adolescents. 6 1.4 Rationale Breakfast is recognized as a crucial meal that provides essential energy for daily activities and supports cognitive function, particularly in the learning environment (Adolphus et al., 2013). Understanding the impact of skipping breakfast on academic performance is essential for promoting the overall well-being of in-school adolescents. Existing research, as highlighted by Adolphus et al., (2013), emphasizes the nutritional contributions of breakfast, including energy intake and nutrient consumption. This study aims to explore how skipping breakfast may affect the dietary habits of adolescents in Tamale, with potential implications for their academic performance. Building on Deshmukh-Taskar et al., (2010) findings, the study seeks to investigate the association between breakfast eating habits and dietary patterns among in-school adolescents. Specifically, it aims was to identify variations in carbohydrate, fiber, fat, and cholesterol intake based on breakfast habits. Research has shown that adolescents who skip breakfast may experience a temporary low blood sugar (hypoglycemia) condition that can impair memory, concentration, and cognitive function (Galioto & Spitznagel, 2016). This condition led to in-school adolescent having poor academic performance. The meta-analysis conducted by Ofori-asenso et al., (2019) has shown that there are other health implications to skipping breakfast. Some of these implications are the increased risk of being overweight or obese, high blood pressure, unfavorable lipid profiles, diabetes, and metabolic syndrome. Investigating the nutritional status of in-school adolescents in the Northern Region proved that, 6.3% and 6.0% were underweight and overweight/obese, respectively (Abizari and Ali, 2019). A systematic review was conducted to determine whether there is a relationship between obesity and academic performance. The study revealed an insufficient evidence to support 7 a direct link between obesity and poor academic performance in school age children (Santana et al., 2017) Most previous studies in Ghana focused on breakfast habits among senior high pupils and tertiary students in the southern part of the country. This study uniquely targets in-school adolescents (10- 16 years) in the Tamale Metropolis. Recognizing the cultural and socio-economic diversity of the region is crucial for understanding the specific challenges and opportunities in this situation. Even though, majority of non-governmental organizations in Ghana are headquartered in the northern region and have carried out numerous interventions to improve the nutritional situation of the population, the northern region is the second poorest region (50.4%) (GSS, 2014a) and has the highest burden of malnutrition (GDHS, 2014) in Ghana. Also, regions in the northern part of Ghana, have the highest food insecurity percentage in the country. With the largest population of food-insecure people found in the Northern region, Tamale metropolis was the third region to have high food insecurity (31%) (WFP, 2020). Due to a confluence of access, availability, utilization, and stability issues, the Tamale Metropolis continues to have extremely high levels of food insecurity which may led to breakfast skipping among adolescents (Moses, 2020). As food- insecure households struggled to afford an adequate and nutritious food supply. In these situations, breakfast options may be limited, leading individuals to skip breakfast due to lack of available and affordable of food. According to a study done in the Northern Region, it was proven that 30% of adolescents skipped breakfast, and 37% of them snack twice a day (Abiba et al., 2012). Coupled with all these challenges, the Northern region, also faces educational disparities characterized by various challenges, such as inadequate parental support, instances of teenage pregnancy and early 8 marriage, prevailing poverty, influence from peer groups, and accessing quality education (Bariham & Edmond, 2017). This research endeavors to bridge existing gaps in the literature, provide context-specific insights, and contribute to the development of targeted interventions aimed at improving the nutritional and academic well-being of in-school adolescents in Tamale Metropolis. 1.5 Objectives 1.5.1 Main objective To determine the association between breakfast skipping, nutritional status, and academic performance of adolescents between the ages of 10 - 16 years in Tamale Metropolis. 1.5.2 Specific objectives 1. To determine breakfast skipping prevalence among in-school adolescents in public and private schools in Tamale Metropolis. 2. To determine the dietary intake and nutritional status (BMI-for-age and MUAC) of in-school adolescents in public and private schools in Tamale Metropolis. 3. To determine factors that influence the skipping of breakfast among in-school adolescents in public and private schools in Tamale Metropolis. 4. To determine the association between skipping breakfast and the nutritional status of in-school adolescents in public and private schools in Tamale Metropolis. 5. To determine the association between skipping breakfast and academic performance among in-school adolescents in public and private schools in Tamale Metropolis. 9 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introduction In this chapter, relevant literature that relates to the topic under study is discussed. There is an overview of the concept of skipping breakfast among adolescents, breakfast and academic performance of adolescents, breakfast skipping, and nutritional status of in-school adolescents. The empirical literature related to the study and the conceptual framework guiding the study is further discussed. 2.2 Conceptual framework Figure 2. 1: Conceptual framework Breakfast consumption Improve dietary intake and energy Improve school attendance Improve school performance Enhance nutritional status Better-quality capacity for learning Factors influencing breakfast consumption (Socio-economic, and demographic factors, Food Security, Hunger, Taste, and time) 10 The conceptual framework above illustrates factors that influence breakfast skipping, dietary intake, nutritional status, and school attendance of in-school adolescents. Breakfast is a crucial meal for everyone, but especially for young children and adolescents. Adolescents require a lot of energy to support rapid growth. The growth of adolescents is significantly influenced by the availability of micronutrients such as calcium, vitamin D, vitamin A, and iron. Adolescents' nutritional status is also influenced by their food intake and other elements like hygiene and sanitation. By enhancing appetite, food diversity is a major factor that influences an individual's nutrient consumption. A diverse diet increases the bioavailability of some micronutrients in addition to boosting food consumption. For instance, iron and zinc in a diet might be more completely absorbed when vitamin C from fruit is consumed. Dietary diversity is influenced by socioeconomic and demographic characteristics like income, education, age, and household size in many ways. The variety and quantity of food that makes up a household's diet can be influenced by household incomes. 2.3 Conceptual review 2.3.1 Breakfast skipping Breakfast skipping is the practice of not eating breakfast on any day during the study or evaluation period, or skipping breakfast on the majority of these days. It is also possible to define breakfast skipping in more qualitative terms, such as if it is typically, regularly, usually, or occasionally skipped (Rampersaud, 2009). According to Rampersaud (2009), it is difficult to compare the findings of different studies since breakfast and breakfast consumption frequency are described in so many ways. The term "breakfast skipping" refers to not eating breakfast on the survey day, which may not accurately reflect one's long-term breakfast consumption patterns. 11 A one-day nutritional survey or a 24-hour meal recall can be used to determine “breakfast consumption” behaviour. In other research, breakfast eating was evaluated regularly, throughout the specified period, or a fixed number of days per week. Breakfast skipping occurs when a person skips breakfast on most days throughout the study or evaluation period or doesn't eat it at all. Due to changes in family life, skipping breakfast has become ordinary in modern society (Nadarajah & Vishnukumar, 2017). When this occurs frequently among school children, it may lead to their having less-than-optimal growth and development, which is crucial for the future expansion of human resources. Breakfast is the first meal of the day usually eaten in the morning. It is said that breakfast is "the most essential meal of the day" (Feye et al., 2021). Breakfast consumption is associated with better nutritional intake in children, including increased intake of dietary fiber, total carbohydrates, and lower total fat and cholesterol (Adolphus et al., 2015). The daily intake of micronutrients is also significantly influenced by breakfast. When compared to children who skip breakfast, children who consistently eat breakfast had higher levels of iron, B vitamins (folate, thiamine, riboflavin, niacin, vitamin B6, and vitamin B12), and vitamin D (Balvin Frantzen et al., 2013). Having breakfast can also help you keep your body mass index (BMI) within the usual range (Nunan et al., 2010). Additionally, 14.0% of young children skipped breakfast on at least one school day, compared to 2.5% of students who skipped breakfast every day (Boschloo et al., 2012; Gibney et al., 2018; Mullan & Singh, 2010). The assumptions on the advantages of breakfast for children’s learning are substantially supported by data from laboratory-based experimental studies that show breakfast has immediate effects on children’s cognitive ability. Despite the conflicting findings, studies typically show that breakfast improves children's cognitive performance, especially in the areas of memory and attention (Wesnes et al., 2012). 12 A study conducted among Ghanaian Junior High School adolescents found that 62.8% usually skipped breakfast (Buxton, 2014). Similarly, a study conducted in Tamale also revealed that 30% skipped breakfast, 73% did not consume eggs and 37% ate twice a day. (Abiba et al., 2012). The northern region is the second poorest region (GSS, 2022) and has the highest burden of malnutrition in the country despite the fact most non-governmental organizations in Ghana are based in the Northern region and have implemented several interventions to improve the nutritional status of the population. This could be because interventions and initiatives implemented so far are not evidence-driven. 2.3.2 Academic performance One of the most changeable lifestyle factors that might affect brain development and, as a result, cognition and academic achievement is nutrition. In this regard, a prior longitudinal study that lasted for three years revealed that adolescent students' cognitive control and academic performance were influenced by lifestyle choices (such as eating breakfast) (Magalhães et al., 2020). Many underdeveloped countries have a wide range of food and health problems that affect school children. A child's ability to learn may also be impacted by the frequent lack of essential utilities in schools (Abebe et al., 2022). According to a study conducted by Rampersaud et al., (2005), having poor behavioral and psychological issues, frequent absences from school, and a decreased likelihood of exercising, children who miss breakfast are more likely to start drinking alcohol and smoking cigarettes. Between 1.7% and 30.0% of people, according to reports, are said to skip breakfast. Forgoing breakfast every school day was a habit for 39% of 13-year-olds and 45% of 15-year-olds, respectively (Abebe et al., 2022). 13 Furthermore, breakfast's benefits are more readily apparent in undernourished young children, which is typically defined as having a height or weight that is one standard deviation below what is considered normal for their age according to the US National Center for Health Statistics (NCHS) reference. Evidence from a more recent study contrasts breakfast foods with varying glycaemic loads (GL), glycaemic indices (GI), or both. Children's cognitive function is often improved with a reduced postprandial glycaemic response (Hallström et al., 2011). Additionally, it is still not apparent whether this effect is directly brought on by GI, GL, or both, and by additional effects unrelated to the glycaemic response. Academic results and cognitive-behavioral outcomes are not separate variables. Behavioral changes will likely reflect changes in cognitive ability. Lesson on-task behavior may rise if students pay more attention after breakfast than they would have otherwise. Like how school performance and academic results may vary, changes in cognitive performance may similarly have a cumulative effect on children (Annan et al., 2020). The benefits of having breakfast on cognitive performance are anticipated to be transient, particularly in the morning in which breakfast is consumed, and to certain types of cognitive processes. These instantaneous or acute results may result in advantages for academic performance with habitual or regular breakfast eating, however, this has not been assessed in most studies (Annan et al., 2020; Jayaveloo et al., 2021; Owusu et al., 2017; Tandoh et al., 2021). Therefore, with regular breakfast eating, short-term changes in cognitive function during lessons (such as memory and attention) may translate to significant changes in academic achievement by improving the ability to pay attention to and retain knowledge. There are significant effects of classroom behavior on academic performance (Jayaveloo et al., 2021). This is because maintaining focus and attention in class is a requirement for academic learning. Student's ability to learn may 14 be affected in the long term if they concentrate more in school and engage in active studying (referred to as on-task conduct). These components are probably connected to a school experience which is more effective (Ackuaku-Dogbe & Abaidoo, 2014a; Intiful & Lartey, 2014a). Academic achievement and behavior in the classroom or at school were not considered ecologically meaningful outcomes (Hoyland et al. 2009). Even though direct measures of academic performance are the most ecologically valid, and pertinent to students, parents, teachers, and educational policymakers, they may also have the greatest impact on the personal development of adolescents. The most accurate measurement of the impacts of breakfast may not be crude assessments of academic performance (Adolphus et al., 2015; Nadarajah Vishnukumar, 2017). 2.3.3 Adolescent nutrition Adolescents go through a period of rapid physical, cognitive and psychosocial development, which has an impact on how adolescents interact with their environment and manage their own emotions, thoughts, and decision-making processes (Kanthi & Johnson, 2021). Throughout the life cycle, this stage of development has one of the highest nutrient needs due to the biological and behavioral changes that take place there. Adolescents, however, are more at risk for nutrition problems than younger children due to the move to more independence from their parents regarding dietary choices (Pena-Jorquera, Nunez, Sadarangani, Ferrazi, Aguilera & Cristi-Montero, 2021). Similarly, to this, during adolescence peer and media influences have a significantly bigger influence on dietary choices, frequently favoring items with less good nutritional value (Pena- Jorquera, Nunez, Sadarangani, Ferrazi, Aguilera & Cristi-Montero, 2021). Adolescence is a vital stage in the development of the brain because myelination, synaptic pruning, and several neural 15 connections, especially in the prefrontal cortex, all take place during this time (Adolphus et al., 2015). Adolescents are socially and culturally expected to attend school, healthily interact with their peers physically and socially, and develop to their full potential (Kohl & Cook, 2013). Their rate of growth acceleration as they mature is second only to that seen during the first year of life. They now experience puberty, which is accompanied by menarche, genital growth, and sexual maturation. They also reach their peak bone mass, full body size, and fat deposition at this time (Christie & Viner, 2005). As a result, this stage has extremely high nutritional needs. In addition, a comprehensive analysis found modest correlations between academic performance and healthier eating practices, such as having breakfast every day and consuming fewer energy-dense foods and those with low nutritional content (Intiful & Lartey, 2014; Paul et al., 2020). Nsiah-Asamoah (2017) found that adolescents who usually engaged in unhealthy dietary habits failed to meet their daily nutritional needs. Low nutrient-dense foods are those that contain calories but just trace levels of micronutrients, occasionally none. Those that are high in nutrients include whole and enriched grains, fruits, vegetables, legumes, low-fat versions of dairy products and meat, as well as nutrient-dense foods (Owusu et al., 2017). To help achieve nutritional consumption targets while staying within daily calorie demands, nutrient-dense meals should be picked first from each food group (Tandoh et al., 2021). Typical breakfast foods that would be considered nutrient-dense include whole-grain and fortified cereals or other grains, fruit and 100% fruit juice, low-fat dairy products, and lean meats. On the other hand, foods containing added sugars, saturated fats, and trans fats would not normally be regarded as nutrient-dense (Rampersaud, 2009). Consequently, failure to consume an adequate diet can disrupt normal growth and development (WHO, 2023). According to the Ghana 16 Demographic Health Survey, (2014), 14% of adolescents in Ghana are underweight. Also, a study in the Northern Region revealed that 6.3% and 6% of adolescents were underweight and overweight respectively (Abizari & Ali, 2019). The dietary requirements of adolescents are stated to peak at the rate of development (weight and height), which varies depending on the individual but is believed to occur at a mean age of 13.5 years for males and 12 years for girls (Story & Stang, 2005). Males experience this stage later in puberty than females do, and it lasts for around six to twelve months before female menarche (Jenkins, 2005). At the end of this development phase, female adolescents gain a mean of 17.5 kg and gain 120% body fat, whereas male adolescents gain 23.7 kg and shed 12% body fat, resulting in a gender-based difference in body mass index between the sexes (Story & Stang, 2005). The adiposity rebound, also known as fat gain, can increase the chance of becoming overweight in people who encounter it early in life (Olatona et al., 2022). The nutritional effects of breakfast on brain activity and related cognitive, behavioral, and academic consequences may be particularly susceptible in children. Compared to adults, children have a higher rate of brain glucose metabolism. Additionally, the nightly depletion of glycogen stores might occur due to the extended overnight fasting phase brought on by the higher sleep demands of youth and adolescents than those of adults. Breakfast eating may be crucial in ensuring sufficient energy for the morning because this greater metabolic rate requires a continual supply of energy produced from glucose (Wesnes et al., 2012). However, breakfast is the meal that is most usually skipped. Hoyland, Dye & Lawton (2009) were only able to locate 45 studies on the effects of breakfast on objectively measured cognitive performance in the period of 1950-2008 in their systematic review, despite intense public and scientific interest and a widely promoted consensus that breakfast improves concentration and alertness. They concluded that eating 17 breakfast improves cognitive outcomes more than skipping it and that these advantages are particularly pronounced in children who are regarded to be undernourished. There is evidence that adolescents and children who eat breakfast are more likely to absorb more nutrients and maintain appropriate and healthy diets. Compared to non-consumers, breakfast consumers tend to intake more calories per day, and while some research suggests that breakfast eaters had greater absolute intakes of carbohydrates, protein, and total fat, other studies find no differences between the groups (Fareed & Waseer, 2017). Breakfast consumption is regularly linked to greater intakes of various nutrients, including vitamin A, vitamin C, riboflavin, calcium, zinc, and iron, in studies that compare the daily intakes of breakfast eaters and non-eaters. Higher daily nutrient intakes expressed as a percentage of nutrient intake guidelines (such as the Recommended Dietary Allowance) have also been linked to eating breakfast more frequently (Rampersaud, 2009). Regular breakfast consumption has generally been linked to better appetite, weight, and blood sugar control, fewer chronic disease markers, cognitive alertness, and academic performance in adults (Adolphus et al. 2016, Purslow et al. 2008, Rong et al. 2019), as well as academic performance in younger adults, such as in-school adolescents (Pengpid and Peltzer 2020). It should be noted, however, that most of these studies have been carried out in higher educational institutions. Understanding how and where to implement interventions is important for enhancing both in LMICs when undernutrition is a problem (as is the case in nations in sub- Saharan Africa). Additionally, breakfast eaters ingest more fiber than skippers, a nutrient that both children and adults in developed nations significantly lack. According to numerous studies, eating breakfast increases calcium intake, an essential vitamin for adolescent’s bone development. The importance of breakfast as a chance to assist young children and adolescents in fulfilling daily nutrient intake 18 objectives is highlighted by the fact that youth who skip breakfast typically do not make up for missed energy or nutrient intake through other daily meals. Higher Healthy Eating Index (HEI) scores 51 or other diet quality indices show that adolescents and children who eat breakfast more frequently have diets that are more likely to be healthy (Rampersaud, 2009; Fareed & Waseer, 2017; Tandoh et al, 2021). Breakfast eaters make better eating choices, such as consuming more fruits, vegetables, dairy products, or high-fiber, low-fat foods, and they may choose healthier snacks less frequently. Compared to girls who typically skipped breakfast, those who ate breakfast more frequently reported decreased intakes of sweets, salty snacks, and non-alcoholic beverages (Rampersaud, 2009). 2.4 Empirical literature review 2.4.1 Prevalence of breakfast skipping among adolescents Research conducted in Oslo, Norway, highlighted the prevalent practice of skipping breakfast among adolescent students, suggesting potential emotional distress and compromised academic performance as consequences. This behaviour was noted not only among the general adolescent population but also specifically among medical students, both pre-clinical and clinical (Ackuaku- Dogbe & Abaidoo, 2014; Feye et al., 2021; Khurshid et al., 2018). Globally, 10–30% of adolescents aged 11–18 may skip breakfast, with a higher prevalence among girls and those with lower educational levels. These breakfast skippers often exhibit unhealthy dietary patterns, higher BMI, and more unrestrained behaviour compared to their breakfast-consuming counterparts (Boschloo et al., 2012; Byrne et al., 2012; Keski-Rahkonen et al., 2003; Rampersaud et al., 2005). Adolescents living in hostels or aspiring scholars may adopt irregular breakfast patterns, relying on snacks and fast food, potentially leading to sedentary lifestyles and weight gain. Studies suggest 19 that developing healthy breakfast consumption habits is crucial for weight management and academic success (Khurshid et al., 2018; Rampersaud, 2009). In Ghana and other African regions, breakfast skipping is a phenomenon not restricted to developed countries. Similar prevalence rates are observed, but cultural, socio-economic, and lifestyle factors contribute to variations in outcomes (Olatona et al., 2022; Owusu et al., 2017; Paul et al., 2020; Tandoh et al., 2021). Children and adolescents in Ghana often provide reasons such as time constraints, lack of hunger, or a preference for sleep when explaining their breakfast- skipping behaviour. Dieting practices, particularly among females aiming to lose weight, are also identified as contributing factors (Rampersaud, 2009). A cross-sectional study conducted in a developed setting with 605 adolescents aged 11–18 indicated that regular breakfast eaters tended to outperform breakfast skippers in terms of academic performance. This underscores the significance of breakfast in academic success, with attention- related issues identified as potential mediators (Boschloo, Ouwehand & Dekker, 2012). Globally, skipping breakfast becomes more prevalent as adolescents transition into adulthood, with girls more frequently skipping than boys. Socioeconomic factors, such as poor socioeconomic backgrounds, are associated with an increased likelihood of breakfast skipping (Rampersaud, 2009). Also, in developed nations like the USA and Canada, patterns of breakfast skipping among comparable age and gender populations align with global trends. However, variations in lifestyle, food choices, and cultural factors contribute to distinctions between developed and developing countries (Olatona et al., 2022; Owusu et al., 2017; Paul et al., 2020; Tandoh et al., 2021). The prevalence of skipping breakfast among adolescents is a global concern with implications for health and academic performance. While international patterns are evident, the literature emphasizes the need to consider regional nuances in Ghana and Africa, where cultural, 20 socioeconomic, and lifestyle factors contribute to distinct breakfast habits. Understanding these dynamics is crucial for designing targeted interventions that address the specific challenges faced by adolescents in different contexts. According to the 2018 Global Nutrition Report, data from 195 countries show both male and female adolescent obesity rates are increasing by 6.5% and 4.7%. Also, 15% of adolescents in Africa are overweight. Ghana is one of the few sub-Saharan African countries at a later stage of the nutrition transition where diet changes are already affecting the academic performance of school children. In Tamale, the dietary habits of adolescents are influenced by poverty, educational environment, and cultural practices (Abubakar and Yussif, 2023). Adolescents from resource- constrained households have limited access to healthy foods which puts them at risk of malnutrition. A study conducted by Abiba et al., (2012), revealed that about 73% of adolescents in Tamale do not get to eat eggs and meat occasionally while 56% of them also consume both light and heavy food as snacks. The dietary intake among adolescents in the Northern region especially Tamale is of concern as most traditional diets predominantly cereal and tuber-based, fresh fruits and vegetables, and foods low in fat) are gradually being replaced with more Westernized diets which lack diversity and are high in calories (Ochola & Masibo, 2014). Adolescents spend most of their time in school coupled with the autonomy to make food choices while in school making them vulnerable to sub-optimal dietary habits. (Abdulai & Yussif, 2023). Adolescents who spend most of their time in school with their peers are usually left with no option but to eat what is available to them. 21 2.4.2 Dietary intake and nutritional status of adolescents Smith et al., (2022) demonstrated that individuals skipping breakfast in adulthood, whether consistently or sporadically, exhibited concerning dietary patterns. They were more likely to consume fast food, fall short of recommended fruit and dairy intake, and neglect lean meat. These findings underscore the lasting impact of breakfast habits on dietary choices in adulthood. The study by Smith et al., (2022) revealed the detrimental effects of breakfast skipping on cardio- metabolic health. Participants skipping breakfast in both childhood and adulthood showed adverse indicators, including larger waist circumference, higher fasting insulin levels, and unfavourable cholesterol concentrations. Despite study limitations, these findings emphasize the need for holistic health interventions. Nutrient deficiencies, particularly affecting adolescent females in sub-Saharan Africa, contribute to anaemia (Feye et al., 2021; Khurshid et al., 2018; Tandoh et al., 2021). Breakfast skippers are reported to consume more fat, cholesterol, and energy but less fiber, vitamins, and minerals, elevating their risk of gastrointestinal diseases (Fareed & Waseer, 2017). Ghana faces severe nutritional challenges, ranking 135th out of 187 nations in terms of malnutrition severity. The prevalence of stunting, low serum retinol, iron deficiency anaemia, and undernutrition is alarming (Tandoh et al., 2021). Effective interventions are crucial to address these issues and enhance the overall well-being of adolescents. 2.4.3 Factors that influence breakfast skipping among adolescents Khurshid et al., (2018) conducted a study in Australia, identifying multiple factors influencing breakfast skipping among adolescents. Key determinants included Body Mass Index (BMI), language spoken at home, and childhood smoking. Adolescents who consistently skipped breakfast were more likely to come from non-English-speaking households, specifically with parents born 22 in Southern Europe or Asia. In adulthood, skipping breakfast correlated with single marital status, lower education levels, smoking, sedentary behaviour, and television watching. The study acknowledged a constraint in sample size, affecting the prevalence understanding of breakfast skipping. In a similar study in Ethiopia, breakfast skipping was significantly associated with worse academic performance. Factors that influenced breakfast skipping among adolescents in Ethiopia included socio-economic background, lifestyle choices and time (Feye et al., 2021). Contrarily, among adolescents living in hostels in a study in Nigeria, reasons for breakfast skipping were distasteful food, uncooked well, and inadequate amount of time (Olatona et al., 2022). Dogbe & Baidoo, 2014 also identified time constraints as the main factor that influenced breakfast skipping among medical students. A study in Kuala Lumpur explored the reasons behind breakfast skipping among university students, revealing that personal preferences and time constraints were the primary factors. Lack of appetite, oversleeping, and morning lectures contributed to students missing breakfast. A separate survey highlighted various issues, including health problems, laziness, and time constraints (Moy et al., 2009). Lack of time before the first lecture emerged as a predominant reason for breakfast omission (Moy et al., 2009). Olatona et al., (2022) also, conducted a study in Nigeria, revealing insufficient knowledge of breakfast among adolescents. While most students maintained stable nutritional status, breakfast skippers exhibited lower dietary intake. However, the study faced limitations due to a small sample size and a questionnaire originally designed for English participants. Replicability in an African context may be challenging due to the study's original design. In Ghana, Owusu et al., (2017) investigated undernutrition among adolescents participating in school feeding programs. The study highlighted a high occurrence of undernutrition, with age identified as a significant predictor of 23 stunting. However, the research's scope was limited to two schools in the capital city. Limited generalizability due to the study's exclusive focus on two schools. Contrarily, Fareed & Waseer, 2017 identified the causes of breakfast skipping as more personal choices by adolescents such as having no time, having no appetite, did not like to take it early and oversleeping in the morning. Pena-Jorquera et al., (2021) also explored the impact of breakfast on cognitive performance globally, emphasizing its influence on adolescents with different BMI categories. While those with normal BMI and overweight or obesity exhibited higher performance when having breakfast, the study lacked specificity in assessing breakfast composition and quantities, and it did not explore causality among the variables. Lack of in-depth analysis regarding the specific components of breakfast. In a similar vein, Smith et al (2022) identified that adolescents who skipped breakfast had a lower cognitive development while the adolescents who consumed breakfast had a higher cognitive performance. Understanding the factors influencing breakfast skipping among adolescents requires a nuanced perspective that considers cultural, socioeconomic, and regional variations. Global insights contribute to a comprehensive understanding, allowing for tailored interventions to promote consistent and healthy breakfast habits among adolescents in diverse contexts. Future research should address the limitations identified in existing studies, aiming for broader generalizability and a more in-depth exploration of the factors at play. 2.4.4 Association between breakfast skipping and nutritional status According to Annan et al., (2021), the prevalence of being overweight surpasses thinness in children, and 40% of adolescents exhibit poor physical fitness. The presence of a double burden of malnutrition during adolescence poses long-term health risks. This situation can persist into 24 adulthood, emphasizing the need for targeted interventions. In Jayaveloo's, (2021) study, adolescents demonstrated good knowledge about breakfast consumption but struggled to translate this awareness into healthy eating habits. Financial constraints, existing unhealthy eating patterns, and food preferences emerged as critical determinants of nutritional status. The cross-sectional design of the study, however, limited its ability to establish causation among the identified variables. Food accessibility was the main reason people missed breakfast. Sixty-six percent of pupils reported having easy access to breakfast, twenty-eight percent reported having trouble getting it, and sixteen percent reported having no access to it (Feye et al., 2021). In contrast to this argument, students enrolled in institutions, and students who lived with their families did not experience any availability issues (Fareed & Waseer, 2017). However, the gap that exists in this study is the use of convenient sampling as a result of proximity. Purposeful in-school adolescents who mostly skipped breakfast were excluded. Studies have shown that regularly skipping of breakfast has been associated with unhealthy lifestyle choices, including poor dietary habits and reduced physical activity. Smith et al., (2022) highlighted that breakfast skippers tend to have higher daily intakes of fat, cholesterol, and energy, coupled with lower intakes of fiber, vitamins, and minerals. These patterns may contribute to an increased body mass index (BMI) and cardiometabolic risk factors. This assertion is supported by Adolphus et al., (2015) who investigated the repercussions of skipping breakfast on the nutritional status and cognitive function of school-aged children. Significant differences were noted between breakfast-skippers and non-skippers, affecting parameters such as memory, concentration, academic grades, and attendance. The study emphasized the dual impact of skipping breakfast on both nutritional well-being and academic performance. Similarly, Ackuaku-Dogbe & Abaidoo, (2014) conducted a descriptive cross-sectional study on breakfast consumption patterns among 25 medical students at Korle Bu-Accra, University of Ghana Medical School. The study revealed a high prevalence (71.92%) of students skipping breakfast, with associated consequences like fatigue and decreased attention during clinical sessions. Studies conducted by Adolphus et al., (2015), Intiful & Lartey (2014), and Paul et al., (2020) emphasized the difficulty of compensating for lost energy and nutrients when breakfast is skipped. Micronutrient deficiencies, including vitamin A, thiamine, vitamin C, iron, calcium, and zinc, were more pronounced in individuals who skipped breakfast. Notably, breakfast consumption did not significantly impact calcium intake, possibly attributed to cost barriers and dietary patterns in Ghana's rural areas. This study is supported by another finding from Rampersand (2007) which concluded that eating breakfast more often helps adolescents to maintain a healthy weight. It also provides benefits for cognitive function and academic achievement. Encouraging breakfast consumption among in-school adolescents is a way to ensure that adolescents meet their daily nutrient and energy intakes (Intiful & Lartyey, 2014). The literature suggests a complex association between skipping breakfast, nutritional status, and broader health outcomes among adolescents globally. From disparities in overweight prevalence to the impact on cognitive function and micronutrient intake, breakfast emerges as a pivotal factor in shaping the health trajectory of adolescents. The challenges identified, including knowledge- practice gaps and socioeconomic barriers, necessitate holistic strategies for promoting regular and nutritious breakfast consumption, particularly in diverse contexts such as Ghana and other international settings. 26 2.4.5 Association between breakfast skipping and academic performance Numerous studies highlight the widespread practice of skipping breakfast among young individuals, particularly adolescents. In Oslo, scientists observed a prevalent trend of breakfast omission among adolescents, raising concerns about potential impacts on mental well-being and academic performance (Lien, 2007). In a similar vein, Ackuaku-Dogbe & Abaidoo (2014a) also identified a connection between weariness experienced by medical students and eating behaviors, especially breakfast skipping. The study suggested a potential link between skipping breakfast and subpar academic performance among medical students. These findings were supported by experimental studies, such as the one conducted by Widenhorn-Muller et al., (2008), involving boarding school students which revealed the negative effects of skipping breakfast on mood and short-term memory. Verbal memory in girls and visuospatial memory in boys were primarily impaired, accompanied by lower mood and decreased alertness. Adolescents who skip breakfast often exhibit unhealthy lifestyles, including habits such as drinking, drug use, smoking, and infrequent exercise. These lifestyle choices can have broader implications for their overall well- being (Widenhorn-Muller et al., 2008). Similarly, So (2013) study in Korea explored the association between breakfast frequency and academic performance. Increased breakfast consumption was positively correlated with improved academic performance in both male and female healthy adolescent populations, considering various covariates. However, the study's limitation lies in its country-specific focus, limiting generalizability to other regions like Ghana. Male in-school adolescents skipped breakfast more than female in-school adolescents. As a result, female in-school adolescents had a higher academic performance than male school children (Fareed & Waseer, 2017). There is a high prevalence of undernutrition in males compared to females in a study conducted in Ghana in the school-feeding 27 program (Owusu et al., 2017). In a related study, Akeredolu et al., (2015) used a descriptive survey in Lagos State, Nigeria, to reveal a substantial correlation between skipping breakfast and academic achievement, particularly in English language and Mathematics. The limitation of the study was the sample size and limitation in geographical location. Active class participation was identified as a positive outcome of not skipping breakfast, contributing to improved academic success. This assertion is supported by Paul (2020) who highlighted a high prevalence of habitual breakfast skipping among medical students, leading to neuroglycopenic symptoms that impact lesson performance. The limitation of the study was its focus on one university, reducing its generalizability. Similarly, Khurshid et al., (2018) also, found a prevalence of negative emotional status among breakfast skippers, leading to poor class assessment and academic results. The study acknowledged limitations related to self-reporting and the narrow focus on a single day of breakfast skipping. The association between skipping breakfast and academic performance in adolescents is a global concern, as evidenced by studies spanning Oslo, Korea, Nigeria, and beyond. While positive correlations between regular breakfast consumption and academic achievement have been identified, the challenge lies in addressing this issue comprehensively, considering diverse socio- cultural contexts, such as those in Ghana and other African nations. Strategies to promote regular breakfast habits may contribute not only to improved academic outcomes but also to overall adolescent well-being. 28 CHAPTER THREE 3.0 METHODOLOGY 3.1 Introduction This chapter presents various methods that were used in carrying out this study. The chapter consists of the study design, the study area, the study population, sample size determination, selection of participants and sampling techniques, inclusion and exclusion criteria, data collection methods, data analysis and ethical considerations. 3.2 Study design This mixed method study, including both quantitative (cross-sectional) and qualitative (focus group discussion) components, was conducted in both private and public schools in the Tamale metropolis. Using a convenient sampling technique, four schools from the Tamale metropolitan area were selected as potential study area. Based on the school’s desire to participate in the study, the decision was taken. 3.3 Study area The research was conducted at the Tamale metropolis in the Northern region of Ghana. The Tamale Metropolitan Assembly developed the district analytical report based on the 2010 population census through a legislative instrument (LI 2068) which elevated the then Municipal Assembly into a Metropolis in 2004. From the 2021 population census, the Tamale metropolis has a population of 730,000. In the country, Tamale Metropolis is currently one of the six Metropolitan Assemblies and the only one among the five regions in Northern Ghana. Northern region’s capital city is Tamale, 29 which has 16 districts. It is situated in the region's center, bordering the Sagnarigu District to the west and north, Mion District to the east, East Gonja to the south, and Central Gonja to the southwest. Although the Dagombas make up the majority, the Metropolis is also a home to various ethnic groups from the Upper East region, including the Gonjas, Mamprusis, Akan, and Ewe. Other Africans and citizens of other nations can also be found in the Metropolis. According to the census, there are just 8.8% of Christians and 90.5% of Muslims in the Tamale Metropolis. Only 0.2% of people identify as being atheist. Catholics (3.0%) make up the largest percentage of Christians followed by Pentecostal/Charismatics (2.4%) and Protestants (2.4%). Traditionalists make up 0.3% of the population of the Metropolis. Approximately 5.7% of the metropolis's population aged three and above presently attends an institution of higher education. There are 304 primary schools, 94 kindergartens, 112 junior high schools, and 14 senior high schools in Tamale, for a total of 524 basic schools. According to the 2014 GSS survey, 81.5 percent of students were enrolled in basic education (kindergarten, primary, JHS) and 11.6 percent are enrolled in secondary school (SHS). According to the same research, males are enrolled in all levels of school at a higher rate than females. 3.4 Study population The participants for this study were adolescents between the ages of 10 to 16 years who were attending schools, as well as their mothers or caregivers for data collection and analysis. The study worked with these age group because they can remember what they ate the previous day and are of age where they are allowed to make their own food choices. It also works with ages between 10 to 16 and not 10 to 19 because from age 17 in-school adolescents will be in senior high school. And the senior high schools in Ghana breakfast are being provided for them. Enrollment of 30 participants was done individually in each school and it was done on the second visit to the school. Participants of this study leaved in either Tamale metro or Sarnarigu district but schooled in Tamale metro. 3.5 Sample size determination In calculating the sample size, the estimated proportion of population based on previous studies (14.5%), confidence level of 95% and a desired level of precision of 0.05 was used (Charan and Biswas 2013). 𝑁 = 𝑍₁₋ₐ2𝑝(1−𝑝) 𝑑2 Where; N is the sample size 𝑍₁₋ₐ2 = standard normal curve that cut-off an area at the tail (1-equals the desired confidence level, 95%) which is the critical value of 1.96. P = estimated proportion of population based on previous studies = 14.5%. Which is the prevalence of people who skipped breakfast. Therefore, the prevalence (p) of skipping breakfast is equal to 14.5% (P=0.145) (Intiful and Lartey, 2014). d = the desired level of precision was 5% = 0.05 N = 1.962∗ 0.145(1−0.145) 0.052 N = 3.8416 ∗ 0.145(0.855) 0.0025 31 N = 3.8416 ∗ 0.123975 0.0025 N = 0.47626236 0.0025 N = 190.504944 The sample size (N) of the study was 191 but after a 10% contingency rate, it was rounded up to 200 participants. Based on the sample size (200), 48 participants were randomly selected for the focus group discussion (qualitative). 3.6 Selection of participants and sampling technique The selections were done using a convenient and simple random sampling. A convenient sampling method was used in selecting the schools and a simple random sampling method was further used to choose the participants for the study based on their attendance. In selecting the adolescents, a simple random sampling was done by giving the adolescents a paper to choose. The paper contained a yes or no response. Those who chose yes and had their consent letter signed by parent were selected. 3.7 Inclusion and exclusion criteria 3.7.1 Inclusion criteria Adolescents who were within the study age range of 10 to 16 years and have been in the selected schools for at least two terms before the study and their parents or caregiver have consented for them to participate in the study were included. Furthermore, as part of the inclusion criteria, the chosen schools were required to adhere to the new GES curriculum School-based assessment 32 (SBA). Additionally, the teachers within these schools were mandated to hold a minimum qualification of a diploma or bachelor's degree and possess a valid teaching license. 3.7.2 Exclusion criteria Schools that have not recently evaluated the academic performance of their students were excluded. Also, participants who were not in the study age range and whose parents or caregivers refused to sign the consent form were excluded. 3.8 Data collection methods and instruments The data of the study was collected through primary source and secondary source of data collection. Primary data served as the main source of data for the study. The collection of primary data was done using semi-structured questionnaires, 24-hour recall, anthropometric measurement, and a focus group discussion (FGD). The data was collected among the in-school adolescents in Police Barracks Basic school, Elsie Lund’s school, Tishigu Anglican school, and SOS Hermann Gmeiner school in Tamale metropolis. The questionnaire was in English, and the researcher administered the questionnaires to the participants in their various schools. The questionnaire for this study was designed based on previous studies by Feye et al., (2021). The semi-structured questionnaire was adapted and used in the context of Ghana to collect complete and accurate information regarding the association of skipping of breakfast and academic performance. An introductory letter from GES was submitted to the selected schools and base on that, the schools approved for the study to be conducted and a date was scheduled for the administration of the questionnaires. Before the questionnaire was administered, a simple random sampling was done to select participants. After the adolescents were selected, they were given consent form for their 33 parents or caregivers to sign before they can partake in the survey. Selected adolescents, were asked to send the questionnaires home for their parents to sign the consent form. The data was then collected through the questionnaire and 8 FGDs which formed the main data for analysis of the study. 3.8.1 Training of field assistant and pretesting of tools Two field assistants were recruited and trained for the data collection. The field assistants were fluent speakers in English, Twi, Ga and Dagbani. They received a three-day training that covered all the research tools needed to properly gather the necessary data. A pilot study was initiated and carried out by testing the instrument on some few students. This help to understand the perceptions and challenges in responding to the instrument by adolescents. 3.8.2 Socio- demographic characteristic of participants The age, marital status, level of education, occupation and monthly income of mother or caregiver was collected through phone interview and was filled in the questionnaire. For in-school adolescents, their age, gender, grade, ethnicity was all collected using a semi- structured questionnaire. To determine the socioeconomic status, data on the number of rooms in households, the source of drinking water, the type of bed, the type of kitchen and toilet facility, the source of lighting, the source of energy for cooking, the type of building materials, and the ownership of specific items were gathered. 34 3.8.3 Breakfast skipping prevalence, and dietary intake The prevalence of breakfast skipping was done with the questionnaire and when someone stated that they skipped breakfast for more than three times in a week, was referred to as breakfast skipping. For participants dietary intake a 24- hour dietary recall was done where participants listed the time and type of food, they had consumed for the past 24 hours. In the dietary measurement the quantity of the food was measured with the help of the food model. 3.8.4 Nutritional status of adolescents Body mass index for age and MUAC were used to assess the nutritional status of in-school adolescents. Anthropometry of adolescents were measured, where the weight and height of adolescent were taken with the help of a bathroom weighing scale and stadiometer. It was ensured that things such as shoes, heavy cloths, and hair accessories that will affect the measurements were removed and the scale was adjusted to the nearest 0.1kg. for the weight of the adolescent. The height of adolescents was measured in centimetres and later converted to meters. The measurement for both weight and height were taken three time and later the average value was calculated. 3.8.5 Factors that influence breakfast skipping A focus group discussions (FGDs) comprising of 12 adolescents each from the selected schools was also conducted to gather relevant data for the study. These 48 participants were selected from the sample size (200) using a simple random sampling. In selecting the adolescent, they were given paper to choose which contained a yes or no response. Those who picked the paper were then selected for the FGDs. In the FGDs,12 participants were selected and divided into two subgroups. 35 Six participants were from upper primary and the other six from junior high. The first subgroup consisted of 1 female and male each from grade 4,5, and 6 while the other subgroup had 2 females and 1 male each from grade 7,8, and 9. The FGD was conducted between 1st to 18th of August 2022. 3.8.6 Academic performance The assessment of participants' academic performance relied on secondary data obtained during data collection. The sample included participants from various schools with varying teaching and learning conditions. Specific criteria were applied in the selection of these schools, requiring adherence to the new GES curriculum School-based assessment (SBA), a minimum qualification of a diploma or bachelor's degree for teachers, and possession of a valid teaching license. To measure academic performance, subject scores for both the first and second terms were systematically gathered, aggregated, and subsequently averaged for each individual. This averaged score was then used for the analysis. 3.9 Data analysis The data collected were entered and coded in an excel sheet. After it was coded it was then exported into the statistical package for social sciences (SPSS) software version 26 for cleaning and analysis. WHO Anthro plus was used to classify adolescent BMI- for-age into various undernutrition cut-offs such as underweight, normal, overweight, or obese. Descriptive statistics were used to summaries the data: continuous variables were summarized as mean ± SD and categorical variables as frequencies and percentages. Bivariate (Chi-square) and 36 multivariate binary logistic regression analysis were used to determine factors that influence the skipping of breakfast among adolescents and the association between skipping breakfast and the nutritional status (BMI- for-age and MUAC) of adolescents. A focus group discussion (FGD) was used in the qualitative study to determine factors that influence the skipping of breakfast among adolescents and a thematic analysis was used. It was done by coding the data, reviewing the codes and organised them into groups then later themes and subthemes were developed. In the analysis of academic performance, to compensate for variability exposure of adolescent in different school, a standardizing procedure was done on the grades of each participant to facilitate a fair comparison. The standard deviation and the average grade scores of each participant was then used for the analysis. Multiple linear regression analysis was also used to assess the association between skipping breakfast and academic performance among in- school adolescents in public and private schools. Results with a p-value <0.05 were considered statistically significant. 3.10 Ethical considerations Ethical approval was obtained from the University of Ghana's Basic and Applied Science ethical committee. Permission was soughed from the Tamale metro education service and head teachers at various schools. During data collection, privacy and confidentiality were upheld, and one-on-one interviews were held at a location far from where academic activities were taking place. Before conducting the interviews, parents or other caregivers of the selected participants provided a signed informed consent. 37 CHAPTER FOUR 4.0 RESULTS 4.1 Introduction This chapter presents the data gathered through the questionnaire and focused group discussion. It also describes the procedures used in the analysis of the data collected. The most appropriate statistical technique that was used for the quantitative section of this study was descriptive statistics, regression, and correlation. For the qualitative section, thematic analysis was used. All the participants in this study were eligible subjects and all participants’ information was included in the analysis. Findings were then used to answer the research objectives. In addition, tables are included to present the data collected. 4.2 Socio-demographic characteristics of participants The study consisted of 200 in-school adolescents aged 10 -16 years and their caregivers. The study comprised 116 (58.0%) females and 84 (42.0%) males. The mean age of the adolescents was 13.43 ± 1.792 and that of caregivers was 40.95 ± 6.264. The grade or class of adolescents was grouped into two, with each having the same frequency (100) and percentages (50%). Majority of the participants (60.5%) were Dagombas, with 80% being Muslims, and 20% being Christians. Most caregivers (75.5%) of participants were married. Many caregivers had education till junior high school (21.5%) and 60% were traders. With their income, 37.5% had a monthly income of >600 – 990 cedis, 30.5% had 1000 to 3000 cedis, 24.4% had no idea or nothing, and 7.5% received more than 3000 cedis for monthly incomes. Majority (65.5%) of adolescents were taken care of by both parents. In determining the household size of participants, 76.5% had a household number of 1-5, 38 21.0% were having 6-10 members, and 2.5% were having a household of >10. Almost all (97.0 %) all the adolescents attended school seven days in a week. Most houses (86.5%) had 1 to 4 bedrooms. Also, many participants had indoor kitchens, and a private pipe served as their primary supply of drinking water (62.5%). According to table 4.1 below, 33.5% of participants were categorized as low, middle and high class in terms of socio- economic position. 39 Table 4. 1:Socio-demographic characteristics of adolescents Variables Frequency (N) Percentage (%)/Mean ± SD Age of child (years) 200 13.43 ± 1.79 Gender Female 116 58.0 Male 84 42.0 Grade 4 & 6 100 50.0 7 – 8 100 50.0 Religion Christians 40 20.0 Muslims 160 80.0 Adolescent lives with Both parent 131 65.5 Single parent 36 18.0 Other relatives (auntie, uncle, grandparents, stepmother) 33 10.5 Household size 1-5 153 76.5 6-10 42 21.0 >10 5 2.5 S.D: Standard deviation 40 Table 4. 1: Continued Variables Frequency (N) Percentage (%)/Mean ± SD Ethnicity Dagomba 121 60.5 Moshi 19 9.5 Akan 17 8.5 Frafra 14 7.0 Ewe 9 4.5 Gonja 8 4.0 Others (Ga, kasina and waala) 12 6.0 Weekly school attendance two times a week 1 0.5 three times a week 1 0.5 four times a week 4 2.0 five times a week 194 97.0 S.D: Standard deviation 41 Table 4. 2 Socio-demographic characteristics of participant’s mothers or caregivers Variables Participants (N) Percentage (%)/Mean ± SD Age of mother/caregiver (years) 200 40.95 ± 6.264 Marital status Single 19 9.5 Married 151 75.5 Divorced 18 9.0 Others (widowed and co-habiting) 12 6.0 Educational level None 40 20.0 Primary 42 21.0 Middle /JHS 43 21.5 S.H. S 37 18.5 Tertiary 23 11.5 Vocational training 15 7.5 Occupation None 21 10.5 Professional 20 10.0 Military service 8 4.0 Trader/business 120 60.0 Manual worker 31 15.5 Household monthly income Nothing or had no idea 49 24.5 > 600 to 990 75 37.5 1000 to 3000 61 30.5 More than 3000 15 7.5 S.D: Standard deviation 42 Table 4. 3: Housing characteristics of participants Variables Frequencies (N) Percentages (%) Building materials used for the walls Cement 190 95.0 Tiles/terrazzo 7 3.5 Mud 3 1.5 Building materials used for the windows Louvre blades 107 53.5 Wood 47 23.5 Glass 46 23.0 Building materials used for the roof Aluminum sheet 189 94.5 Bricks 4 2.0 Galvanized sheet 7 3.5 Building materials used for the floor Cement 101 50.5 Tiles/terrazzo 96 48.0 Dirty floor 1 0.5 Others (wood) 2 1.0 Type of bed used in household Mattress 182 91.0 Mat 18 9.0 Source of drinking water Public pipe 73 36.5 Borehole 7 3.5 Purchase from tanker 14 7.0 Private Pipe 106 53.0 43 Table 4.3: Continued Variables Frequencies (N) Percentages (%) The main source of energy for lighting Electricity 196 98.0 Lantern 3 1.5 Torchlight/rechargeable light 1 0.5 The main source of energy for cooking Charcoal 109 54.5 Gas 87 43.5 Electricity 4 2.0 What type of kitchen does the household have? Outdoor Kitchen 75 37.5 Indoor Kitchen 125 62.5 Type of toilet facility in household Private flush toilet 97 48.5 Private pit latrine/ KVIP 19 9.5 Public flush toilet 34 17.0 Compound pit latrine/ KVIP 21 10.5 No toilet facility 29 14.5 Number of rooms in the household 1 – 4 173 86.5 5 -8 19 9.5 9 and above 8 4.0 Car Yes 53 26.5 No 147 73.5 44 Table 4. 3: Continued Variables Frequencies (N) Percentages (%) Motorcycle Yes 168 84.0 No 32 16.0 Generator Yes 22 11.0 No 178 89.0 Computer Yes 63 31.5 No 137 68.5 SES Low 53 26.5 Medium 103 51.5 High 44 22 45 4.3 Breakfast skipping prevalence among adolescents The prevalence of breakfast skipping among adolescents was 28.0% as shown in figure 4.1. From table 4.12, among those who skipped breakfast 76.8% of females skipped breakfast as compared with 23.2% males. Figure 4. 1: Prevalence of breakfast skipping among adolescents 10-16 years 4.4 Dietary intake and nutritional status of adolescents Of the participants who consumed breakfast, 68.8% had breakfast six to seven time during the week. When students were asked the reason for not consuming breakfast among those who skipped breakfast, 46.4% mentioned they had no time to eat whiles 16.1% stated that they did not feel hungry. For those who stated that they were not pleased with the food choices, breakfast makes them feel lazy and less energetic in class, and others and their family who did not eat breakfast were 14.3%, 10.7%, 7.1%, and 5.4% respectively. Many (39.5%) students said breakfast consumption makes them energetic in class when asked about the benefit of breakfast consumption. Based on those who consumed breakfast, 29.0% of the respondents bought from food vendors. The majority (43%) of adolescents consumed their breakfast dishes at home. 28.0% 72.0% YES NO 46 Table 4. 4: Breakfast practices of adolescents in Tamale metropolis (N = 200) Variables Frequency Percent (%) Weekly consumption of breakfast Two to three times a week 5 3.5 Four to five times a week 40 27.8 Six to seven times a week 99 68.8 Reason for skipping breakfast No time to eat breakfast 26 46.4 Don’t like the food choices 8 14.3 Don’t feel hungry 9 16.1 My family doesn’t eat breakfast, so I don’t also eat 3 5.4 Breakfast makes me feel lazy and less energetic in class 6 10.7 Others (inadequate feeding money, stomach upset) 4 7.1 The benefit of eating breakfast Breakfast consumption helps me grow and increase in weight 53 26.5 Breakfast consumption makes me energetic in class 79 39.5 Breakfast consumption increases my concentration in class 51 25.5 Others (prevent me from being weak, me lively and active, satisfy hunger) 17 8.5 Where breakfast was taken None 56 28.0 Home 86 43.0 Outside 58 29.0 47 Table 4. 4: Continued Variables Frequencies (N) Percentages (%) Who prepares breakfast for you? None 55 27.5 Mother 45 22.5 Sister 8 4.0 Self 28 14.0 Food Vendors 58 29.0 Others (aunties, stepmothers) 6 3.0 4.4.1 Energy and micronutrient intake of respondents The respondents' dietary intake over the previous 24 hours was assessed for two macronutrients and seven micronutrients (Table 4.5). The energy and nutrient intakes of those who ate breakfast and those who skipped breakfast were compared. In general, vitamin C and calcium were significant at a p-value of < 0.05 when nutrients intake of individuals who ate breakfast and those who did not was compared. 48 Table 4. 5: Nutrient intake among in-school adolescents Nutrients Mean ±SD (Total) Mean ±SD (Female) Mean ±SD (Male) Energy (kcal) 1913.87 ± 670.60 1909.51 ± 666.89 1919.90 ± 679.93 Protein (g) 51.41 ± 22.23 51.25 ± 23.62 51.63 ± 20.29 Vitamin A (mcg) 323.67 ± 480.06 337.54 ± 492.89 304.50 ± 464.00 Vitamin C 82.65 ± 51.75 89.24 ±57.66 73.56 ± 40.88 Calcium (mg) 321.92 ± 142.27 307.86 ± 134.70 341.33 ± 150.79 Iron (mg) 13.06 ± 6.66 12.90 ± 6.47 13.28 ± 6.95 Riboflavin (mg) 1.17 ± 1.11 1.17 ± 1.04 1.16 ± 1.21 Thiamine (mg) 1.38 ± 1.05 1.35 ± 0.98 1.43 ± 1.15 Zinc (mg) 8.68 ± 5.59 8.55 ± 5.49 8.87 ± 5.75 49 Table 4. 6: Nutrient intake between adolescents who consumed breakfast and adolescents who skipped breakfast (N=200) Nutrients Consumed breakfast (N=144) (Mean ±SD) Skipped breakfast (N=56) (Mean ±SD) Energy (kcal) 1918.01 ± 652.60 1903.25 ± 720.87 Protein (g) 50.93 ± 19.52 52.64 ± 28.20 Vitamin A (mcg) 316.36 ± 481.74 342.45 ± 475.54 Vitamin C 95.85 ± 64.95 77.52 ± 44.83 Calcium (mg) 338.54 ± 141.82 279.16 ± 135.51 Iron (mg) 13.21 ± 6.60 12.69 ± 6.87 Riboflavin (mg) 1.17 ± 1.10 1.16 ± 1.17 Thiamine (mg) 1.39 ± 1.04 1.37 ± 1.09 Zinc (mg) 8.61 ± 5.34 8.86 ± 6.23 4.4. 2 Nutritional status of adolescents Most of the in-school adolescents were classified as normal in figure 4.2 below. However, when their BMI -for- age was compared among gender, the findings showed that 27.4% and 7.1% of male were overweight/obese and thin (underweight) respectively. For their MUAC, 25% of males and 21.15% females are moderately at risk of developing malnutrition. 50 Figure 4. 2: BMI- for- age of adolescent in Tamale metropolis Figure 4. 3: MUAC of adolescent in Tamale metropolis 5 69.5 25.5 7.1 65.5 27.4 3.4 72.4 24.1 0 10 20 30 40 50 60 70 80 Thinness(<-2 ) Normal(>-2.00 - 0.99 ) Overweight(1.00 - 1.99 ), Obese(≥ 2) P er ce n ta g es Total Male Female 82.5 87.9 75.0 17.5 21.1 25.0 0 10 20 30 40 50 60 70 80 90 100 Total Female Male P er ce n ta g es Normal (≥18.5cm - ≥22.0cm) Moderate(16.0cm - 22.0cm) 51 4.5 Factors that influence the skipping of breakfast among adolescents In looking at fa