Association of Meal Timing with Sleep Quality and Anxiety According to Chronotype: A Study of University Students 根據時間類型進餐時間與睡眠質量和焦慮的關聯：一項針對大學生的研究
Cristina Souza da Silva Luz ^(1)^((1)){ }^{1}{ }^{(1)}, Ana Elizabeth Teixeira Pimentel da Fonseca ^(1){ }^{1}, Jefferson Souza Santos ^(1,2){ }^{1,2}, John Fontenele Araujo ^(3)(D:}{ }^{3}\left(\mathbb{D}\right., Leandro Lourenção Duarte ^(4){ }^{4} (D) and Claudia Roberta de Castro Moreno ^(1,**)^((D)){ }^{1, *}{ }^{(\mathbb{D})} 克莉絲蒂娜·索薩·達·席爾瓦·盧斯 ^(1)^((1)){ }^{1}{ }^{(1)} ， 安娜·伊莉莎白·特謝拉·皮門特爾·達·豐塞卡 ^(1){ }^{1} ， 傑斐遜·索薩·桑托斯 ^(1,2){ }^{1,2} ， 約翰·豐特內勒·阿勞霍 ^(3)(D:}{ }^{3}\left(\mathbb{D}\right. ， 萊昂德羅·洛倫桑·杜阿爾特 ^(4){ }^{4} （D） 和克勞迪婭·羅伯遜·德·卡斯特羅·莫雷諾 ^(1,**)^((D)){ }^{1, *}{ }^{(\mathbb{D})}1 Department of Health, Life Cycles, and Society, School of Public Health, University of São Paulo, São Paulo 01246-904, Brazil; cristinaluz@usp.br (C.S.d.S.L.); anaelizabethts@hotmail.com (A.E.T.P.d.F.); jeffersonsouza@usp.br (J.S.S.) 1 聖保羅大學公共衛生學院衛生、生命周期和社會系，巴西聖保羅 01246-904;cristinaluz@usp.br （C.S.D.S.L.）;anaelizabethts@hotmail.com （A.E.T.P.d.F.）;jeffersonsouza@usp.br （JSS.）2 Department of Theory and Foundations of Education, Education Sector, Federal University of Paraná, Curitiba 80230-130, Brazil 2 巴拉那聯邦大學教育部門教育理論與基礎系，巴西庫里蒂巴 80230-1303 Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal 59078-900, Brazil; johnfontenelearaujo@gmail.com 3 北里奧格蘭德聯邦大學生理學和行為系，巴西納塔爾 59078-900;johnfontenelearaujo@gmail.com4 Department for Health Sciences, Federal University of Recôncavo da Bahia, Cruz das Almas 44380-000, Brazil; duartleandro@gmail.com 4 巴伊亞州雷康卡沃聯邦大學健康科學系，巴西 Cruz das Almas 44380-000;duartleandro@gmail.com* Correspondence: crmoreno@usp.br * 對應方式：crmoreno@usp.br
Duarte, L.L.; Moreno, C.R.d.C. 杜阿爾特，LL;莫雷諾，C.R.D.C.
Association of Meal Timing with Sleep Quality and Anxiety According to Chronotype: A Study of University Students. ClocksESleep 2024, 6, 156-169. https://doi.org/ 根據時間類型，進餐時間與睡眠質量和焦慮的關聯：一項針對大學生的研究。時鐘 ESleep 2024， 6， 156-169。https://doi.org/
10.3390/clockssleep6010011
Academic Editor: Etienne Challet 學術編輯： Etienne Challet
Received: 4 December 2023 收稿日期： 2023-12-04
Revised: 3 March 2024 修訂日期：2024 年 3 月 3 日
Accepted: 8 March 2024 錄用日期： 2024-03-08
Published: 11 March 2024 出版日期：2024 年 3 月 11 日
There are several determinants of mental health symptoms, ranging from individual characteristics to social factors. Consistent with patterns in the general population, students with evening characteristics tend to exhibit more anxiety symptoms and poorer sleep quality compared to morning students. Meal timing also appears to affect sleep and may be associated with mental health symptoms. In this context, the aim of the present study was to investigate the association of the timing of the main and last meals of the day with sleep quality and anxiety levels, according to the chronotype of university students. This study was conducted in colleges in São Paulo, Brazil, and involved application of a questionnaire to 162 university students. The questionnaire collected sociodemographic information meal and study times, and included scales assessing eveningness and morningness, sleep quality, and anxiety. Students demonstrating a phase delay in both chronotype and dinner timing exhibited higher levels of anxiety compared to morning-type students. Although no associations were observed between meal timing and sleep quality, sleeping later was associated with poorer sleep quality. The study suggests that evening students and those who eat late at night are more prone to presenting mental health symptoms. More studies are needed to further investigate this association. 心理健康癥狀有幾個決定因素，從個人特徵到社會因素。與一般人群的模式一致，與早起的學生相比，具有晚間特徵的學生往往表現出更多的焦慮癥狀和更差的睡眠品質。進餐時間似乎也會影響睡眠，並且可能與心理健康癥狀有關。在這種情況下，本研究的目的是根據大學生的時間類型，調查一天中主餐和最後一餐的時間與睡眠品質和焦慮水準之間的關聯。這項研究是在巴西聖保羅的大學進行的，涉及對162名大學生進行問卷調查。問卷收集了社會人口學資訊、進餐和研究時間，並包括評估傍晚和早晨、睡眠質量和焦慮的量表。與晨型學生相比，在時間型和晚餐時間方面表現出相位延遲的學生表現出更高水準的焦慮。雖然在進餐時間和睡眠質量之間沒有觀察到關聯，但晚睡與較差的睡眠質量相關。研究表明，晚上的學生和深夜吃飯的學生更容易出現心理健康癥狀。需要更多的研究來進一步調查這種關聯。
Keywords: chrononutrition; sleep quality; meal time; chronotype; students 關鍵詞：計時營養學;睡眠品質;用餐時間;時間型;學生
1. Introduction 1. 引言
Circadian rhythms are involved in several aspects of an individual’s life. These rhythms represent the frequency of physiological, behavioral, and biochemical events that occur in the human body over a 24 h period, in synchrony with the sleep-wake cycle. This cycle, in turn, is synchronized with the alternation between light and dark during 24 h and is internally synchronized, as occurs with melatonin secretion. However, it is important to note that the sleep-wake cycle can undergo temporal shifts according to age. Additionally, there is interindividual variation in the acrophase of several biological rhythms and preferences for the timing of sleep onset and wake-up, referred to as an individual’s chronotype. Thus, individuals with a morning chronotype (morningness) prefer to both wake up and sleep early, and generally exhibit better physical and mental performance in the morning. By contrast, evening-type individuals (eveningness) prefer to both wake up and sleep later, typically reaching their peak mental and physical performance in the late afternoon/early evening [1-3]. 晝夜節律涉及個人生活的多個方面。這些節律代表在 24 小時內人體發生的生理、行為和生化事件的頻率，與睡眠-覺醒週期同步。反過來，該迴圈與 24 小時內明暗交替同步，並且在內部同步，就像褪黑激素分泌一樣。但是，重要的是要注意，睡眠-覺醒週期會根據年齡發生時間變化。此外，幾種生物節律的頂期存在個體間差異，以及對入睡和醒來時間的偏好，稱為個體的時間類型。因此，具有早晨時間型 （morningness） 的人更喜歡早起和早睡，並且通常在早上表現出更好的身體和心理表現。相比之下，傍晚型個體（傍晚）更喜歡晚起和晚睡，通常在下午晚些時候/傍晚達到其精神和身體表現的高峰[1-3]。
Sleep duration, chronotype, and sleep quality are significant determinants of adolescents’ mental health [4]. Most classes at universities and schools take place in the morning, yet most adolescents and young adults have a biologically based sleep-phase delay. The evening chronotype at this stage of life can be a problem when these individuals are required to engage in early school/college schedules [5]. Furthermore, evening-type individuals tend to nap more during the day and may be more susceptible to emotional disturbances compared to morning-type individuals [6,7]. 睡眠時長、睡眠類型和睡眠品質是青少年心理健康的重要決定因素 [4]。大學和學校的大多數課程都在早上進行，但大多數青少年和年輕人都有基於生物學的睡眠階段延遲。當這些人需要參加早期的學校/大學時程表時，這個生命階段的晚上時間型可能是一個問題 [5]。此外，與晨起型個體相比，晚型個體往往在白天小睡更多，並且可能更容易受到情緒障礙[6,7]。
Tan et al. [8] suggested that evening-type students tend to be unhappier than morning types. In another study [9], high levels of anxiety and poor sleep quality were observed among evening-type students. Increased anxiety among students can be related to several factors, including chronotype. Age is associated with changes in chronotype, where the chronotype is later for younger individuals, becoming an increasingly morning chronotype with advancing age; hence, it is expected to find more evening chronotype adolescents than morning chronotype ones [10]. Adolescents with an evening chronotype tend to exhibit more anxiety than their morning chronotype counterparts [11]. Generally, there is a higher prevalence of anxiety in younger age groups and females compared to older individuals and males [12]. Evening-type young adults are more likely to have anxious temperaments, while morning-type young adults are more prone to have a hyperthymic temperament [11,13]. A study of medical students conducted in Asia revealed that 54.5% exhibited anxiety [14]. These anxiety-related findings are not limited to medical students, where undergraduates in general also exhibit high anxiety levels [9]. Tan 等人 [8] 認為，晚上的學生往往比早上的學生更不快樂。在另一項研究 [9] 中，在晚班學生中觀察到高水平的焦慮和較差的睡眠品質。學生焦慮的增加可能與幾個因素有關，包括時間類型。年齡與時間型的變化有關，其中年輕人的時間型較晚，隨著年齡的增長而成為越來越早晨的晨型;因此，預計晚上的 Chron 型青少年會比晨型 的青少年多 [10]。具有夜間時間型的青少年往往比早晨型的青少年表現出更多的焦慮 [11]。一般來說，與老年人和男性相比，年輕群體和女性的焦慮患病率更高 [12]。晚型年輕人更易出現焦慮型氣質，而晨型年輕人更易出現心境亢進型氣質[11,13]。在亞洲進行的一項針對醫學生的研究顯示，54.5% 的人表現出焦慮 [14]。這些與焦慮相關的發現不僅限於醫學生，本科生通常也表現出很高的焦慮水準 [9]。
Meal timing can influence circadian rhythms, with emerging evidence suggesting that human molecular clocks may be regulated by feeding schedules, thereby synchronizing peripheral clocks [15]. These peripheral clocks coordinate environmental, metabolic, and behavioral cues, highlighting the significant impact of meal timing on metabolism and health [16]. Specific nutrients and meal times can also modulate the circadian timing system [15]. For instance, research by Wright et al. [17] demonstrated that evening caffeine consumption delays the human circadian melatonin rhythm and lengthens the circadian period of molecular oscillations [in vitro/in vivo]. In a recent population-based study involving over 20,000 participants, we observed a link between later meal times and increased obesity risk [18]. 進餐時間會影響晝夜節律，新出現的證據表明，人類的分子鐘可能受到進食時程表的調節，從而使外周生物鍾同步[15]。這些外周時鐘協調環境、代謝和行為線索，突出了進餐時間對新陳代謝和健康的重大影響 [16]。特定的營養物質和進餐時間也可以調節晝夜節律計時系統[15]。例如，Wright 等人 [17] 的研究表明，晚上攝入咖啡因會延遲人類的晝夜節律褪黑激素節律，並延長分子振蕩的晝夜節律 [體外/體內]。在最近一項涉及 20,000 多名參與者的人群研究中，我們觀察到晚餐時間與肥胖風險增加之間存在聯繫 [18]。
These studies are particularly interesting for night workers, as they remain awake throughout the night. However, the question of whether night workers should eat during their shifts remains contentious [19]. In a study conducted by Crispim’s group [20], various scenarios involving fasting and standardized meals for shift workers revealed that fasting during the night shift led to heightened energy and macronutrient intake in the early morning and throughout the day, alongside lower insulin levels and HOMA-IR in the morning. This suggests that consuming a controlled-calorie meal at night may be a more effective strategy for these workers, aligning with Gupta and colleagues’ proposal of a small snack comprising 10%10 \% of the daily energy requirement as a practical option. They argue that such a snack could provide essential energy for work and enhance the pleasurable aspects of eating, crucial for regulating food intake [21]. Moreover, the consumption of healthy foods has been associated with better sleep quality, while the intake of processed and free sugar-rich foods has been linked to poorer sleep [22]. Also, effects on the quality and quantity of sleep can be observed with the consumption of diets rich in foods that may influence serotonin and melatonin activity [23]. Furthermore, some studies have linked diet to anxiety levels, such as the association of anxiety with vitamin deficiencies, specifically vitamin B6 [24]. There is also evidence that dietary-related reductions in anxiety occur, for example, after interventions with probiotics. These findings may be related to the beneficial effect of probiotics on the gut-brain system [25]. 這些研究對夜班工人特別有趣，因為他們整夜都保持清醒。然而，夜班工人是否應該在輪班期間進食的問題仍然存在爭議[19]。在 Crispim 小組進行的一項研究中 [20]，涉及輪班工人禁食和標準化膳食的各種情況表明，夜班期間的禁食會導致清晨和全天的能量和常量營養素攝入量增加，同時早上的胰島素水準和 HOMA-IR 降低。這表明，對於這些工人來說，晚上吃一頓控制卡路里的飯菜可能是一種更有效的策略，這與 Gupta 及其同事提出的將每日能量需求作為 10%10 \% 實用選擇的小零食的建議一致。他們認為，這種零食可以為工作提供必要的能量，並增強飲食的愉悅感，這對調節食物攝入量至關重要 [21]。此外，食用健康食品與更好的睡眠質量有關，而攝入加工食品和不含糖的食物與較差的睡眠有關[22]。此外，食用富含可能影響血清素和褪黑激素活性的食物的飲食可以觀察到對睡眠質量和數量的影響 [23]。此外，一些研究將飲食與焦慮水準聯繫起來，例如焦慮與維生素缺乏症（特別是維生素 B6）的相關性 [24]。還有證據表明，例如，在使用益生菌干預后，與飲食相關的焦慮會減少。這些發現可能與益生菌對腸腦系統的有益作用有關[25]。
However, in a review of the relevant literature, no studies investigating the relationship between meal timing and anxiety were found. Although some evidence is available on the effect of nutrients or meal timing on circadian rhythms, chrononutrition is a relatively unexplored area [26]. 然而，在對相關文獻的回顧中，沒有發現調查進餐時間與焦慮之間關係的研究。儘管有一些證據表明營養或進餐時間對晝夜節律的影響，但定時營養是一個相對未開發的領域[26]。
In this context, the aim of the present study was to analyze the association of meal timing and sleep quality with anxiety levels according to the chronotype of university students. This study sought to test the hypothesis that morning chronotype students, who have earlier meal times, exhibit better sleep quality and lower levels of anxiety than evening chronotype students. 在這種情況下，本研究的目的是根據大學生的時間類型分析進餐時間和睡眠品質與焦慮水準之間的關聯。本研究試圖檢驗這樣一個假設，即與晚上時間較早的學生相比，吃飯時間較早的早晨時間型學生表現出更好的睡眠品質和更低的焦慮水準。
2. Results 2. 結果
A total of 162 students participated in the study. The mean age of the students was 22.2+-5.222.2 \pm 5.2 years. The youngest student was 17 years old, while the oldest was 55 years old. The majority of students were female ( 90%90 \% ). 共有 162 名學生參與這項研究。學生的平均年齡是 22.2+-5.222.2 \pm 5.2 幾歲。最小的學生 17 歲，最大的 55 歲。大多數學生是女生 （ 90%90 \% ）。
Students from several courses participated in the study, with Nutrition (41%), Biomedicine ( 15%15 \% ), and Nursing ( 14%14 \% ) being the predominant courses. Only 11.7%11.7 \% of students were attending in-person classes at the time of data collection due to the COVID-19 pandemic. The second year of college was identified as the median for the study sample. Of the students assessed, 93%93 \% were single. 來自幾門課程的學生參加了這項研究，其中營養學 （41%）、生物醫學 （ 15%15 \% ） 和護理學 （ 14%14 \% ） 是主要課程。由於 COVID-19 大流行，在收集數據時只有 11.7%11.7 \% 學生參加面授課程。大學二年級被確定為研究樣本的中位數。在接受評估的學生中， 93%93 \% 單身。
Most of the students’ families owned their homes (87.7%), and the breadwinner of the household had completed higher education ( 67.3%67.3 \% ). The predominant income level was three or more minimum wages. Of the sample of 162 students, 66.7%66.7 \% reported engaging in physical activities, where the main frequencies reported were more than three times a week ( 33.3%33.3 \% ) and three times a week ( 16%16 \% ), with 9.3%9.3 \% performing physical activities only once a week and 15.4%15.4 \% twice a week. Mean weight reported by students was 66.7+-16.9kg66.7 \pm 16.9 \mathrm{~kg}, and mean Body Mass Index (BMI) was 22.4+-3.95kg//m^(2)22.4 \pm 3.95 \mathrm{~kg} / \mathrm{m}^{2}. 大多數學生的家庭擁有自己的房屋 （87.7%），家庭的經濟支柱已經完成了高等教育 （ 67.3%67.3 \% ）。主要收入水準是 3 個或更多最低工資。在 162 名學生的樣本中， 66.7%66.7 \% 報告了從事體育活動，報告的主要頻率是每周超過 3 次 （ 33.3%33.3 \% ） 和每周 3 次 （ 16%16 \% ），每周 9.3%9.3 \% 只進行一次和 15.4%15.4 \% 每週兩次的體育活動。學生報告的平均體重為 66.7+-16.9kg66.7 \pm 16.9 \mathrm{~kg} ，平均體重指數 （BMI） 為 22.4+-3.95kg//m^(2)22.4 \pm 3.95 \mathrm{~kg} / \mathrm{m}^{2} 。
The students’ routines, based on their course study periods, are presented in Table 1, showing mean times of main and last meals of the day, along with the mean wake-up time and mean start time of the first class of the day (Table 1). 表 1 列出了基於學生課程學習時間的日常活動，顯示了一天中正餐和最後一餐的平均時間，以及當天第一節課的平均起床時間和平均開始時間（表 1）。
Table 1. Average ( 24 h clock) wake-up, first class start, and main and last meal times of students, by course study period (classified according to class start time into morning, afternoon, and evening). 表 1.按課程學習時間劃分的學生平均（24 小時）起床、第一節課開始、主餐和最後一餐時間（根據上課時間分為上午、下午和晚上）。
Course Study Period 課程學習時間
Wake-Up Time (Work/Study Time Days) 起床時間 （工作/學習時間 天）
Course Study Period Wake-Up Time (Work/Study Time Days) First Class Start Time Main Meal Time Last Meal Time
Morning 06:42 h+-50min 07:42 h+-21min 11:42h+-115min 20:36 h+-75min
Afternoon 07:00 h+-66min 13:48 h+-30min 13:48h+-284min 20:42 h+-48min
Evening 07:06 h+-72min 18:54 h+-17min 11:54h+-177min 20:00 h+-98min| Course Study Period | Wake-Up Time (Work/Study Time Days) | First Class Start Time | Main Meal Time | Last Meal Time |
| :--- | :--- | :--- | :--- | :--- |
| Morning | 06:42 $\mathrm{h} \pm 50 \mathrm{~min}$ | 07:42 $\mathrm{h} \pm 21 \mathrm{~min}$ | $11: 42 \mathrm{~h} \pm 115 \mathrm{~min}$ | 20:36 $\mathrm{h} \pm 75 \mathrm{~min}$ |
| Afternoon | 07:00 $\mathrm{h} \pm 66 \mathrm{~min}$ | 13:48 $\mathrm{h} \pm 30 \mathrm{~min}$ | $13: 48 \mathrm{~h} \pm 284 \mathrm{~min}$ | 20:42 $\mathrm{h} \pm 48 \mathrm{~min}$ |
| Evening | 07:06 $\mathrm{h} \pm 72 \mathrm{~min}$ | 18:54 $\mathrm{h} \pm 17 \mathrm{~min}$ | $11: 54 \mathrm{~h} \pm 177 \mathrm{~min}$ | 20:00 $\mathrm{h} \pm 98 \mathrm{~min}$ |
With regard to students’ sleep, 67.3%67.3 \% reported no health problems or sleep disorders. However, 32.7%32.7 \% reported one or more symptoms, with the most common being sleep problems (such as insomnia), excessive sleep, and endocrine problems. Also, 56.8%56.8 \% of the students were not in use of any medications, whereas the remainder used one or more medications, primarily contraceptives and hormone replacements (thyroxine). 關於學生的睡眠， 67.3%67.3 \% 沒有報告健康問題或睡眠障礙。然而， 32.7%32.7 \% 報告了一種或多種癥狀，最常見的是睡眠問題（如失眠）、睡眠過多和內分泌問題。此外， 56.8%56.8 \% 的學生沒有使用任何藥物，而其餘的學生使用一種或多種藥物，主要是避孕藥和激素替代物（甲狀腺素）。
Concerning eating behavior, the majority of students had breakfast every day ( 68.5%68.5 \% ), 23.5%23.5 \% only a few days a week, 2.5%2.5 \% only on weekends, and 5.6%5.6 \% never had breakfast. Students who considered breakfast their main meal woke up earlier than students who considered lunch their main meal. However, most students ( 73%73 \% ) considered lunch their main meal. Those who had dinner before 20:00 h went to bed earlier than those who had dinner after 20:00 h. The meal times of students who dined later were associated with later bedtime hours ( r=0.51;p <= 0.001\mathrm{r}=0.51 ; p \leq 0.001 ) (Figure 1). Going to bed late was associated with poor sleep quality ( r=0.22;p=0.007\mathrm{r}=0.22 ; p=0.007 ). Additionally, earlier dinner times were associated with the morning type, while later dinner times were associated with the evening type (r=-0.43;p <= 0.001)(\mathrm{r}=-0.43 ; p \leq 0.001). Having lunch early was associated with the morning type ( r=0.32\mathrm{r}=0.32; p <= 0.001)p \leq 0.001). 關於飲食行為，大多數學生每天都吃早餐 （ 68.5%68.5 \% ）， 23.5%23.5 \% 每周只有幾天， 2.5%2.5 \% 只在週末吃，從來沒有 5.6%5.6 \% 吃過早餐。將早餐視為主餐的學生比將午餐視為主餐的學生起得早。然而，大多數學生 （ 73%73 \% ） 認為午餐是他們的主餐。在 20：00 之前吃晚飯的人比在 20：00 之後吃晚飯的人早睡。晚用餐的學生的用餐時間與較晚的就寢時間 （ r=0.51;p <= 0.001\mathrm{r}=0.51 ; p \leq 0.001 ） 相關（圖 1）。晚睡與睡眠品質差有關 （ r=0.22;p=0.007\mathrm{r}=0.22 ; p=0.007 ）。此外，較早的晚餐時間與早上類型相關聯，而較晚的晚餐時間與晚上類型 (r=-0.43;p <= 0.001)(\mathrm{r}=-0.43 ; p \leq 0.001) 相關聯。早點吃午飯與早上型 （ r=0.32\mathrm{r}=0.32 ; p <= 0.001)p \leq 0.001) 。
Figure 1. Mean dinnertime (last meal) and bedtime, stratified by students who dine before and after 20:00 h. 圖 1.平均晚餐時間（最後一餐）和就寢時間，按 20：00 之前和之後用餐的學生分層。
The majority of students reported poor sleep quality ( 71%71 \% ), followed by good sleep quality ( 17%17 \% ). Overall, 12%12 \% of participants presented signs suggestive of sleep disorder, all of whom were female. Analysis by gender revealed that 23%23 \% of male students reported good sleep quality and 77%77 \% poor sleep quality, whereas 17%17 \% of female students reported good sleep quality, 69%69 \% poor sleep quality, and 14%14 \% sleep disorders. 大多數學生報告睡眠品質差 （ 71%71 \% ），其次是睡眠品質好 （ 17%17 \% ）。總體而言， 12%12 \% 參與者表現出提示睡眠障礙的跡象，所有參與者均為女性。按性別分析顯示， 23%23 \% 男學生報告睡眠品質好和 77%77 \% 睡眠品質差，而 17%17 \% 女學生報告睡眠品質好、 69%69 \% 睡眠品質差和 14%14 \% 睡眠障礙。
Based on tertiles, 36%36 \% of students were classified as evening types, 33%33 \% as intermediate, and 31%31 \% as morning types. Additionally, 9%9 \% reported going to bed at 20:00-22:00 h, 59% at 22:00-12:00 h, 24%24 \% at 12:00-2:00 h, and 8% at 2:00-4:00 h. Regarding wake-up times, 12%12 \% reported waking up at 3:00-6:00 h, 61% at 6:00-8:00 h, 19% at 8:00-10:00 h, and 8% at 10:00-15:00 h. 根據三分位數， 36%36 \% 學生分為晚上型、 33%33 \% 中級型和 31%31 \% 早晨型。此外， 9%9 \% 報告在 20：00-22：00 上床睡覺，59% 在 22：00-12：00,12 24%24 \% ：00-2：00,8% 在 2：00-4：00。關於起床時間， 12%12 \% 報告在 3：00-6：00 醒來，61% 在 6：00-8：00 醒來，19% 在 8：00-10：00 醒來，8% 在 10：00-15：00 醒來。
Concerning anxiety levels, trait anxiety, related to an individual’s personality, was higher than state anxiety, defined as a transient reaction related to a specific adverse event an individual experiences at a given time, with 17%17 \% of the students exhibiting high trait anxiety and 13%13 \% high state anxiety, while 19%19 \% had low trait anxiety and 32%32 \% low state anxiety. Furthermore, 64%64 \% had moderate trait anxiety and 55%55 \% moderate state anxiety. 關於焦慮水準，與個體性格相關的特質焦慮高於狀態焦慮，狀態焦慮被定義為與個體在特定時間經歷的特定不良事件相關的瞬態反應，其中 17%17 \% 學生表現出高特質焦慮和高 13%13 \% 狀態焦慮，而 19%19 \% 具有低特質焦慮和 32%32 \% 低狀態焦慮。此外， 64%64 \% 有中度特質焦慮和 55%55 \% 中度狀態焦慮。
For gender, moderate and high trait anxiety rates ( 84.2%84.2 \% ) were found to be the greatest among female students (Table 2), this difference was not found for state anxiety (Table 3). In terms of age group, the high trait anxiety rate ( 25%25 \% ) was the greatest in students aged 17-20 years. Students who were not physically active had a high level of both trait and state anxiety (trait: 25.9%25.9 \%; state: 24.1%24.1 \% ). A moderate ( 53.8%53.8 \% ) or high ( 46.2%46.2 \% ) trait anxiety rate was observed in students who reported going to bed later (2:00-4:00 h). Moderate and high trait anxiety was more frequently reported by students with poor sleep quality ( 86%86 \% ) than those with good sleep quality ( 64%64 \% ). 在性別方面，中度和高特質焦慮率 （ 84.2%84.2 \% ） 在女學生中最大（表 2），在狀態焦慮中沒有發現這種差異（表 3）。就年齡組而言，17-20 歲學生的高特質焦慮率 （ 25%25 \% ） 最大。不進行體育鍛煉的學生具有高水準的特質和狀態焦慮 （trait： 25.9%25.9 \% ; 24.1%24.1 \% 在報告較晚睡覺 （2：00-4：00 h） 的學生中觀察到中度 （ 53.8%53.8 \% ） 或高 （ 46.2%46.2 \% ） 特質焦慮率。睡眠品質差的學生 （ 86%86 \% ） 比睡眠品質好的學生 （ ） 更頻繁地報告中度和高度特質焦慮 64%64 \% 。
Table 2. Sample characteristics for trait anxiety. 表 2.特質焦慮的樣本特徵。
The results of grouped analyses of the independent variables (chronotype + meal times) for anxiety and sleep quality are depicted in Figures 2 and 3 respectively. Evening types who reported having their last meal after 20:00 h had higher trait and state anxiety scores compared to morning types, regardless of the meal time in this group. Furthermore, the sleep quality of morning and evening types did not differ for reported meal times (Figure 2). 焦慮和睡眠品質的自變數（時間型 + 用餐時間）的分組分析結果分別如圖 2 和圖 3 所示。報告在 20：00 後吃最後一餐的晚上類型與早上類型相比，無論該組的用餐時間如何，其特徵和狀態焦慮評分都更高。此外，早晚類型的睡眠質量在報告的進餐時間方面沒有差異（圖 2）。
The analysis of trait anxiety by main meal groupings (lunch/dinner versus breakfast) showed that the evening group differed from the morning group for both meal time situations (Figure 3). A similar pattern was found for state anxiety, although no difference was found between evening individuals whose main meal was breakfast and morning individuals whose main meal was lunch/dinner. However, the evening group participants did not differ from each other in terms of trait or state anxiety, regardless of the reported time for the main meal. There was no statistical difference between the groups for sleep quality (Figure 3). 按主餐分組（午餐/晚餐與早餐）對特質焦慮的分析表明，在兩種用餐時間情況下，晚上組與早晨組不同（圖 3）。狀態焦慮也發現了類似的模式，儘管在主餐是早餐的晚上個體和主餐是午餐/晚餐的早晨個體之間沒有發現差異。然而，無論報告的正餐時間如何，晚間組參與者在特質或狀態焦慮方面彼此沒有差異。兩組之間的睡眠質量沒有統計學差異（圖 3）。
Figure 2. Anxiety and sleep quality according to chronotype and time of last meal. MEQ: HorneOstberg Morningness-Eveningness Questionnaire (chronotype). STAI: State-Trait Anxiety Inventory. PSQI: Pittsburgh Sleep Quality Index. EB20h: Evening types who eat before 20:00 h; EA20h: evening types who eat after 20:00 h; MB20h: morning types who eat before 20:00 h; MA20h: morning types who eat after 20:00 h. Significance level: p > 0.05;^(**):p <= 0.05;^(****):p < 0.01;^(******):p < 0.001p>0.05 ;{ }^{*}: p \leq 0.05 ;{ }^{* *}: p<0.01 ;{ }^{* * *}: p<0.001. ns: non-significant. 圖 2.根據時間類型和最後一餐的時間的焦慮和睡眠品質。MEQ：HorneOstberg 晨昏問卷（時間型）。STAI：狀態-特質焦慮量表。PSQI： 匹茲堡睡眠質量指數。EB20h：20：00 之前進食的晚間類型;EA20h：20：00 後進食的晚間類型;MB20h：在 20：00 之前進食的早晨類型;MA20h：20：00 後進食的早起型。顯著性水準： p > 0.05;^(**):p <= 0.05;^(****):p < 0.01;^(******):p < 0.001p>0.05 ;{ }^{*}: p \leq 0.05 ;{ }^{* *}: p<0.01 ;{ }^{* * *}: p<0.001 .NS：不顯著。
Figure 3. Anxiety and sleep quality according to chronotype and main meal time. MEQ: HorneOstberg Morningness-Eveningness Questionnaire (Chronotype). STAI: State-Trait Anxiety Inventory. PSQI: Pittsburgh Sleep Quality Index. EBF: Evening types who reported breakfast as main meal; ELD: evening types who reported lunch/dinner as main meal; MBF: morning types who reported breakfast as main meal; MLD: morning types who reported lunch/dinner as main meal. Significance level: p > 0.05;**:p <= 0.05;^(****):p < 0.01;^(******):p < 0.001p>0.05 ; *: p \leq 0.05 ;{ }^{* *}: p<0.01 ;^{* * *}: p<0.001. ns: non-significant. 圖 3.根據時間類型和主要用餐時間的焦慮和睡眠品質。MEQ：HorneOstberg 晨晚問卷（時間型）。STAI：狀態-特質焦慮量表。PSQI： 匹茲堡睡眠質量指數。EBF：報告早餐為主餐的晚間類型;ELD：報告午餐/晚餐為主餐的晚間類型;MBF：報告早餐為主餐的早晨類型;MLD：報告午餐/晚餐為主餐的早晨類型。顯著性水準： p > 0.05;**:p <= 0.05;^(****):p < 0.01;^(******):p < 0.001p>0.05 ; *: p \leq 0.05 ;{ }^{* *}: p<0.01 ;^{* * *}: p<0.001 .NS：不顯著。
3. Discussion 3. 討論
The results of the present study partially confirmed the study hypothesis, in as far as students identified as a morning type showed lower levels of anxiety (trait and state), regardless of the time of their last meal, compared to evening types who had their last meal after 20:00 h . A similar result was observed when analyzing anxiety in relation to the main meal, as morning types showed lower levels of anxiety regardless of whether breakfast or lunch/dinner was their main meal of the day. However, although these individuals had their meals earlier than evening types as predicted, no associations were found between sleep quality and meal timing, regardless of chronotype. Budkevich et al. [27] found similar results in students who consumed food after 22:00 h and showed higher anxiety and sleep 本研究的結果部分證實了研究假設，就被確定為早晨類型的學生而言，與在 20：00 之後吃最後一餐的晚上類型相比，無論他們最後一餐的時間如何，都表現出較低的焦慮水準（特質和狀態）。在分析與主餐相關的焦慮時，也觀察到了類似的結果，因為無論早餐還是午餐/晚餐是他們一天的主餐，早晨類型的焦慮水準都較低。然而，儘管這些人如預測的那樣早於晚上進餐，但無論時間類型如何，都沒有發現睡眠品質和進餐時間之間存在關聯。Budkevich 等[27]在 22：00 h 後進食的學生中發現了類似的結果，並表現出更高的焦慮和睡眠
disturbances than students who ate earlier. Irregular meal timings, such as insufficient latency between the last meal and the onset of sleep and an increase in snack consumption, were also identified as markers associated with subjective mental health problems [28]. Late eating may also be associated with cardiometabolic risk factors [29], but there are few studies demonstrating the relationship among meal timing, anxiety, and sleep quality in students. 比早點吃飯的學生感到不安。不規律的進餐時間，例如最後一餐和入睡之間的潛伏期不足以及零食消費增加，也被確定為與主觀心理健康問題相關的標誌物 [28]。晚食也可能與心臟代謝危險因素有關 [29]，但很少有研究證明學生進餐時間、焦慮和睡眠品質之間的關係。
Higher levels of trait anxiety were reported by students who slept later, especially after 2:00 h, and by students who had poor sleep quality. Students who reported not engaging in regular physical activity had higher levels of moderate/high trait anxiety. These results are supported by a previous study involving students that showed a relationship between sleep quality and anxiety, as well as a high prevalence of anxiety in physically inactive students [30]. Poor sleep quality was also associated with low academic performance [31]. 睡眠較晚的學生（尤其是 2：00 h 後）和睡眠品質差的學生報告了更高水準的特質焦慮。報告不定期進行體育活動的學生具有更高水準的中/高度特質焦慮。這些結果得到了先前一項涉及學生的研究的支援，該研究顯示睡眠品質與焦慮之間存在關係，並且身體不活躍的學生焦慮的患病率很高 [30]。睡眠品質差也與學習成績差有關 [31]。
Female students reported higher levels of trait anxiety than males and moderate/high trait anxiety was reported predominantly by students aged 17-20 years. Other studies have also shown that women experience more anxiety than men [32,33]. Regarding age, a study of medical students aged 18-22 year conducted in Egypt reported results that contradict the present findings, showing that higher anxiety scores were significantly associated with greater age in students. This increase in anxiety with advancing age could be explained by the fact that the study population comprised medical undergraduates, a course with an increasing study load as the years progress. The present study population consisted of students with a mean age of 22.2+-5.222.2 \pm 5.2 (range 17-55) years, differing from the age profile of the cited study, and did not comprise exclusively of medical students. However, the present results corroborate the Egyptian study’s findings, which identified female gender as an important factor associated with anxiety [34]. 女學生報告的特質焦慮水準高於男生，中/高度特質焦慮主要由 17-20 歲的學生報告。其他研究也表明，女性比男性經歷更多的焦慮 [32,33]。關於年齡，在埃及對 18-22 歲的醫學生進行的一項研究報告的結果與目前的發現相矛盾，表明較高的焦慮分數與學生年齡較大顯著相關。這種焦慮隨著年齡的增長而增加的原因是，研究人群包括醫學本科生，隨著時間的推移，這門課程的學習負擔越來越大。目前的研究人群由平均年齡為 22.2+-5.222.2 \pm 5.2 （範圍 17-55） 歲的學生組成，與引用研究的年齡分佈不同，並且不完全由醫學生組成。然而，目前的結果證實了埃及研究的結果，該研究發現女性性別是與焦慮相關的重要因素 [34]。
In the present study, female students had a slightly higher prevalence of sleep problems ( 23%23 \% ) than males ( 17%17 \% ). These findings were similar to the results of Lund et al. [35] who, in a study of university students aged 17-24 years, found that women were more likely to report stress-related sleep problems than men. Sleep quality was also associated with low academic performance at the end of the academic year in medical students [36]. A study by Silva et al. [9] of Brazilian students showed a prevalence of 72%72 \% poor sleep quality and 5.4%5.4 \% possible sleep disorders, while in the present study, the prevalence of sleep disorders was 12%12 \% and the prevalence of poor sleep quality was 71%71 \%. 在本研究中，女生的睡眠問題患病率 （ 23%23 \% ） 略高於男生 （ 17%17 \% ）。這些發現與 Lund 等人 [35] 的結果相似，他們在一項針對 17-24 歲大學生的研究中發現，女性比男性更有可能報告與壓力相關的睡眠問題。醫學生的睡眠品質也與學年結束時的低學習成績有關 [36]。Silva 等人 [9] 對巴西學生的一項研究表明，睡眠品質 72%72 \% 差和 5.4%5.4 \% 可能的睡眠障礙普遍存在，而在本研究中，睡眠障礙的患病率是 12%12 \% ，睡眠品質差的患病率是 71%71 \% 。
In this study, no association was evident between sleep quality and chronotype. However, sleep onset time was associated with sleep quality, where students who went to bed later had worse sleep quality. Nevertheless, other studies have shown a relationship between evening chronotype and poorer sleep quality in students [9,37]. The lack of association between sleep quality and chronotype in the present investigation might be explained by the delivery of pre-recorded remote classes during the pandemic. In addition, students could access classes at any time in an asynchronous fashion, which was favorable for evening types. Thus, these students could be better synchronized with their chronotype, where previous studies have attributed the poor sleep quality associated with evening types to long sleep latency, short total sleep time, and late sleep onset. These factors can be modified during remote classes since students do not need to wake up early to commute to campuses. Evening-type students who study in the morning normally have poor sleep quality due to social jet lag, which affects academic performance and quality of life [9,36]. 在這項研究中，睡眠質量和時間型之間沒有明顯的關聯。然而，入睡時間與睡眠質量相關，晚睡的學生睡眠品質較差。然而，其他研究表明，晚上的睡眠類型與學生睡眠品質差之間存在關係[9,37]。在目前的調查中，睡眠質量和時間型之間缺乏關聯，這可能是由於在大流行期間提供預先錄製的遠程課程。此外，學生可以隨時以異步方式上課，這有利於晚上的類型。因此，這些學生可以更好地與他們的時間類型同步，以前的研究將與晚間類型相關的睡眠品質差歸因於睡眠潛伏期長、總睡眠時間短和入睡晚。這些因素可以在遠端課程期間進行修改，因為學生不需要早起通勤到校園。由於社交時差，晨夜型學生的睡眠品質通常較差，這會影響學習成績和生活品質[9,36]。
Most of the students in the study had breakfast every day ( 68.5%68.5 \% ), a habit associated with several physiological benefits, such as a reduced risk of coronary heart disease [38]. Studies have shown that people who skip breakfast are more overweight or obese [39], among other negative factors. 研究中的大多數學生每天都吃早餐 （ 68.5%68.5 \% ），這種習慣與多種生理益處相關，例如降低患冠心病的風險 [38]。研究表明，不吃早餐的人更超重或肥胖 [39]，以及其他負面因素。
Anxiety levels of the students were predominantly moderate, with 64%64 \% and 55%55 \% reporting moderate/high trait and state anxiety, respectively, whereas 17%17 \% and 13%13 \% reported high trait and state anxiety, respectively. It is important to take into account that data collection for the present study was carried out between August and September 2021, and 88.3%88.3 \% of the students were engaged in remote learning due to the COVID-19 pandemic, 學生的焦慮水準主要是中等的，分別有 64%64 \% 和 55%55 \% 報告中/高特質和狀態焦慮，而 17%17 \% 和 13%13 \% 分別報告了高特質和狀態焦慮。重要的是要考慮到本研究的數據收集是在 2021 年 8 月至 9 月期間進行的，並且 88.3%88.3 \% 由於 COVID-19 大流行，學生正在進行遠端學習，
declared in March 2020. A study conducted in the United States of 556 psychology students sought to test the hypothesis that state anxiety levels increased during the pandemic, while trait anxiety levels remained stable [40]. However, the authors found that trait anxiety levels increased significantly during the pandemic. In addition to the fear of the pandemic, various reasons may have contributed to the development of anxiety in this population, such as concerns about their future careers, among others. Akin to the US study, students in the present sample also exhibited higher trait anxiety levels than state anxiety. 2020 年 3 月宣佈。在美國對556名心理學學生進行的一項研究試圖檢驗以下假設：狀態焦慮水準在大流行期間增加，而特質焦慮水準保持穩定[40]。然而，作者發現，在大流行期間，特質焦慮水平顯著增加。除了對大流行的恐懼之外，各種原因可能導致該人群焦慮的發展，例如對未來職業的擔憂等。與美國的研究類似，本樣本中的學生也表現出比狀態焦慮更高的特質焦慮水準。
The present study has a few limitations, such as the fact that data collection was performed through self-reporting, rendering the data more subjective. Additionally, the sample was convenience-based. 本研究有一些局限性，例如數據收集是通過自我報告進行的，這使得數據更加主觀。此外，該樣本是基於便利性的。
The data collection period, although not at the height of the pandemic, may have influenced the results. However, this scenario allowed analysis of meal timings for students who were “freer” due to remote classes. If the study had been conducted at another time, the meal timing of morning and evening types would likely have been more similar due to social responsibilities and commitments. Another limitation of the study was the failure to analyze the quantity and quality of meals. Future studies assessing diet composition in other populations during normal routines outside the pandemic period, for example, can add further to the literature. 數據收集期雖然不是在大流行最嚴重的時候，但可能影響了結果。然而，這種情況允許分析由於遠程課程而“更自由”的學生的用餐時間。如果這項研究在其他時間進行，由於社會責任和承諾，早上和晚上的進餐時間可能會更加相似。該研究的另一個局限性是未能分析膳食的數量和品質。例如，未來評估其他人群在大流行期以外的正常日常生活中的飲食成分的研究可以進一步增加文獻。
In summary, despite current knowledge on the involvement of the circadian timing system in food metabolism, especially peripheral oscillators (such as the liver and pancreas), little is known about the effects of meal timings on the mental health and sleep quality of students. Elucidating the role of factors such as meal timings, quantity and food composition can promote benefits for human health [41]. 總之，儘管目前瞭解晝夜節律計時系統參與食物代謝，尤其是外周振蕩器（如肝臟和胰腺），但對進餐時間對學生心理健康和睡眠質量的影響知之甚少。闡明進餐時間、數量和食物成分等因素的作用可以促進對人類健康的益處 [41]。
4. Materials and Methods 4. 材料和方法
4.1. Ethics and Data Collection 4.1. 道德和數據收集
The study was submitted to and approved by the Research Ethics Committee (CEP) of the School of Public Health of the University of São Paulo (permit number: 4.821.293). All participants remotely signed the Informed Consent Form. 該研究已提交給聖保羅大學公共衛生學院研究倫理委員會 （CEP） 並獲得批准（許可證號：4.821.293）。所有參與者都遠程簽署了知情同意書。
A quantitative cross-sectional study was conducted, with data collected from August to September 2021. Due to the COVID-19 pandemic, data collection was conducted remotely using Google Forms. The study was publicized on health-related courses with the assistance of student representatives and course coordinators, as well as by email. The form remained open and available for five weeks. 進行了一項定量橫斷面研究，收集了 2021 年 8 月至 2021 年 9 月的數據。由於 COVID-19 大流行，數據收集是使用 Google 表單遠端進行的。在學生代表和課程協調員的協助下，該研究通過電子郵件在健康相關課程中進行了宣傳。該表格保持開放狀態，並提供了五周。
4.2. Data Collection Instruments 4.2. 資料收集工具
The questionnaire collected sociodemographic data, activity/class schedules, health status, use of medications for sleep induction/deprivation, and included the following scales: Morningness-Eveningness Questionnaire (MEQ), Pittsburgh Sleep Quality Index (PSQI), and State-Trait Anxiety Inventory (STAI). Additionally, participants answered questions about the timing of their main meal and their last meal before bedtime. 問卷收集了社會人口統計數據、活動/課程時程表、健康情況、睡眠誘導/剝奪藥物的使用，並包括以下量表：晨晚問卷 （MEQ）、匹茲堡睡眠質量指數 （PSQI） 和狀態特質焦慮量表 （STAI）。此外，參與者還回答了有關主餐和睡前最後一餐時間的問題。
The Portuguese version of the Morningness-Eveningness Questionnaire (MEQ), developed by Horne and Östberg [42] and validated by Ceolim and Menna-Barreto [43], was used to identify the students’ chronotypes. The MEQ consists of 19 multiple-choice questions about sleep habits and time preferences for specific tasks during the day. Each option is assigned a score, where a lower score indicates evening types and a higher score morning types [42]. We employed terciles to better characterize our sample regarding both trait and anxiety states. Since the sample is composed of students, the majority lean towards extreme or moderate eveningness due to their study/work routine. If we take into account the traditional classification of the questionnaire, this would hinder the analysis of proportions regarding the outcome, as we would have categories with many cases and others with few cases. This compromises the calculation of the chi-square test. In addition, we divided the data into two categories according to the median for better visualization of the data in box-plot graphs. 由 Horne 和 Östberg [42] 開發並由 Ceolim 和 Menna-Barreto [43] 驗證的葡萄牙語版本的晨晚問卷 （MEQ） 用於識別學生的時間類型。MEQ 包括 19 道多項選擇題，內容涉及白天特定任務的睡眠習慣和時間偏好。每個選項都分配了一個分數，其中較低的分數表示晚上類型，較高的分數表示早晨類型 [42]。我們採用 terciles 來更好地描述我們的樣本的特質和焦慮狀態。由於樣本由學生組成，由於他們的學習/工作習慣，大多數人傾向於極端或中度的夜晚。如果我們考慮到問卷的傳統分類，這將阻礙對結果比例的分析，因為我們會有案例很多的類別，而其他的案例很少。這會影響卡方檢驗的計算。此外，我們根據中位數將數據分為兩類，以便更好地在箱形圖中可視化數據。
The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality and possible sleep disturbances in the month leading up to application. The PSQI questionnaire has been validated for the Brazilian population [44]. The results from this questionnaire are grouped under seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction. The total score on the index ranges from 0 to 21 points, classified as follows: 0-40-4 points indicate good sleep quality, 5-105-10 points indicate poor sleep quality, and a score above 10 points indicates sleep disorders. During application of the PSQI, 15 students were excluded from the analysis due to incorrect responses to some questions in this questionnaire, giving a study sample of 147 students. 匹茲堡睡眠質量指數 （PSQI） 用於評估申請前一個月的睡眠品質和可能的睡眠障礙。PSQI 問卷已在巴西人群中得到驗證 [44]。該問卷的結果分為七個部分：主觀睡眠品質、睡眠潛伏期、睡眠持續時間、習慣性睡眠效率、睡眠障礙、睡眠藥物的使用和白天功能障礙。該指數的總分範圍為 0 到 21 分，分類為： 0-40-4 分數表示睡眠品質好， 5-105-10 分數表示睡眠品質差，10 分以上表示睡眠障礙。在應用 PSQI 期間，由於對本問卷中某些問題的回答不正確，15 名學生被排除在分析之外，給出了 147 名學生的研究樣本。
Subjective components related to anxiety were measured using the State-Trait Anxiety Inventory (STAI) [45]. This instrument assesses anxiety using two scales: trait anxiety (STAI-T), related to an individual’s personality data, representing a more stable aspect related to an individual’s propensity to experience varying levels of anxiety throughout life, while state anxiety (STAI-S) reflects a transient reaction related to a specific adversity an individual experiences at a given moment. This inventory was translated into Brazilian Portuguese by Biaggio et al. [46]. 使用狀態-特質焦慮量表 （STAI） 測量與焦慮相關的主觀成分 [45]。該工具使用兩個量表評估焦慮：特質焦慮 （STAI-T），與個人的性格數據相關，代表與個人一生中經歷不同程度焦慮的傾向相關的更穩定的方面，而狀態焦慮 （STAI-S） 反映了與個人在特定時刻經歷的特定逆境相關的瞬態反應。該清單由 Biaggio 等[46]翻譯成巴西葡萄牙文。
The two sub-scales (state anxiety and trait anxiety) each consist of 20 multiple-choice questions, scored separately with a minimum score of 20 and maximum of 80 for each sub-scale [47]. On this inventory, score bands of 20-39, 40-59, and 60-80 points indicate low, moderate, and high levels of anxiety, respectively [48]. 兩個分量表（狀態焦慮和特質焦慮）各由 20 個多項選擇題組成，每個分量表分別評分，最低得分為 20 分，最高得分為 80 分 [47]。在該量表中，20-39、40-59 和 60-80 分的分數區間分別表示低、中和高水平的焦慮 [48]。
Students reported the times at which they usually had their main meal. Some respondents answered by giving breakfast times, while others reported lunch times. In other words, the students defined their main meal, with breakfast time defined as meals consumed before 11:00 h and lunch after 11:00 h for students who woke up early. For students who identified 11:00 h as their main meal but woke up later, this was considered breakfast. Additionally, students were asked to report the time they typically had their last meal before bedtime. 學生們報告了他們通常吃正餐的時間。一些受訪者回答說提供早餐時間，而另一些受訪者則報告午餐時間。換句話說，學生們定義了他們的主餐，早餐時間定義為早起的學生在 11：00 之前吃的飯，在 11：00 之後吃的午餐。對於將 11：00 確定為主餐但後來醒來的學生，這被視為早餐。此外，學生們被要求報告他們通常在睡前吃最後一餐的時間。
4.3. Statistical Analysis 4.3. 統計分析
The power of the statistical analysis was calculated to verify the appropriateness of the sample size. For this purpose, the value of 0.30 was chosen as the effect size, considering alpha as 0.05, in an independent sample comparison of one-way fixed effect ANOVA. Thus, the statistical power estimated was 0.90 . This approach ensured that the study was sufficiently powered to yield reliable results, providing a solid foundation for the statistical analyses conducted in the investigation. The GPower program was used to perform this calculation (V. 3.1.9.7). 計算統計分析的功效以驗證樣本量的適當性。為此，在單向固定效應方差分析的獨立樣本比較中，將 alpha 視為 0.05，選擇值 0.30 作為效應大小。因此，估計的統計功效為 0.90 。這種方法確保了研究有足夠的把握度來產生可靠的結果，為調查中進行的統計分析提供了堅實的基礎。使用 GPower 程式執行此計算 （V. 3.1.9.7）。
For statistical analysis, Jamovi Project software (2021) version 2.2 and R software (version 4.2.3) were used. First, descriptive analyses were conducted for continuous variables (mean and standard deviation) and rates (percentages) for categorical variables. Chi-square tests were used to check for differences between the levels of trait and state anxiety. Spearman’s linear correlation coefficient was used for some descriptive analyses. A significance level of p < 0.05p<0.05 was adopted in all tests. 為了進行統計分析，使用了 Jamovi Project 軟體 （2021） 2.2 版和 R 軟體 （4.2.3 版）。首先，對連續變數 （平均值和標準差） 和分類變數的比率 （百分比） 進行描述性分析。卡方檢驗用於檢查特質和狀態焦慮水準之間的差異。Spearman 線性相關係數用於一些描述性分析。所有測試均採用顯著性水準 。 p < 0.05p<0.05
The hypothesis that morning-type students have earlier meal times and better sleep quality with lower anxiety levels was tested using a non-parametric analysis of variance (Kruskal-Wallis test). The Wilcoxon multiple comparisons test was used for analyses of variance that reached statistical significance. 使用非參數方差分析（Kruskal-Wallis 檢驗）檢驗了早晨型學生進餐時間較早、睡眠品質較好、焦慮水準較低的假設。Wilcoxon 多重比較檢驗用於達到統計顯著性的方差分析。
The independent variables (chronotype, time of last meal and main meal) were grouped into the following categories: evening students who had dinner before 20:00 h (EB20h); evening students who had dinner after 20:00 h (EA20h); evening students who reported breakfast as their main meal (EBF); and evening students who reported lunch/dinner as their main meal (ELD). The same categories were adopted for the morning group (MB20h, MA20h, MBF, and MLD). Based on the median, chronotype data were divided into two categories: evening (P0-P50) and morning (P50-P100). This criterion was essential to avoid 自變數 （時間類型、最後一餐和主餐的時間） 分為以下幾類： 在 20：00 之前吃晚飯的學生 （EB20h）;在 20：00 （EA20h） 之後吃晚飯的學生;報告早餐是主餐 （EBF） 的晚間學生;以及報告午餐/晚餐是主餐 （ELD） 的晚間學生。上午組採用相同的類別 （MB20h 、 MA20h 、 MBF 和 MLD）。根據中位數，時間型數據分為兩類：晚上 （P0-P50） 和早晨 （P50-P100）。必須避免此標準
compromising the sample size in each category, which might have affected the analysis of variance. 影響每個類別的樣本量，這可能會影響方差分析。
Studies have considered 21:00 h as late-night eating [49,50]. Additionally, a recent study with the Brazilian population found a higher risk for obesity among those who have their last meal after 21:00 h [18]. Considering that the popular time for dinner in Brazil is 19:00 h , we decided to select a time between 19:00 h and 21:00 h for stratifying the food intake schedules between groups. Thus, we chose 20:00 h as the cut-off time, opting for a more conservative approach. 研究認為 21：00 h 為深夜進食 [49,50]。此外，最近一項針對巴西人群的研究發現，在 21：00 小時后吃最後一餐的人患肥胖的風險更高 [18]。考慮到巴西的晚餐熱門時間是 19：00 小時，我們決定在 19：00 到 21：00 之間選擇一個時間，以便對各組之間的食物攝入時程表進行分層。因此，我們選擇 20：00 作為截止時間，選擇了更保守的方法。
5. Conclusions 5. 結論
Morning-type students, regardless of the time of their last meal at night, exhibited lower levels of trait and state anxiety compared to evening-type students who dined later (after 20:00 h). Additionally, morning types had lower anxiety levels than evening types, regardless of their meal timing preferences (breakfast or lunch/dinner). No associations were found between meal time and sleep quality, irrespective of chronotype. However, poorer sleep quality and later bedtime were associated with trait anxiety, where the later the bedtime, the poorer the sleep quality. Further studies should be conducted investigating the relationship between anxiety and sleep in healthcare students, with a focus on meal timing. 與晚飯（20：00 后）的晚間學生相比，無論晚上最後一餐的時間如何，早晨型學生都表現出較低的特質和狀態焦慮水準。此外，無論他們的進餐時間偏好如何（早餐或午餐/晚餐），早晨類型的焦慮水準都低於晚上的類型。無論時間類型如何，均未發現進餐時間和睡眠質量之間存在關聯。然而，較差的睡眠品質和較晚的就寢時間與特質焦慮有關，即較晚的就寢時間，睡眠品質越差。應進行進一步的研究，調查醫護學生焦慮與睡眠之間的關係，重點是進餐時間。
Author Contributions: Conceptualization, C.S.d.S.L., J.F.A., L.L.D. and C.R.d.C.M.; data collection, A.E.T.P.d.F. and C.S.d.S.L.; methodology, C.S.d.S.L., J.S.S. and C.R.d.C.M.; formal analysis, J.S.S.; writing orginal draft preparation, C.S.d.S.L.; writing review and editing, A.E.T.P.d.F., J.S.S., J.F.A., L.L.D. and C.R.d.C.M.; supervision, C.R.d.C.M.; project administration, J.F.A.; funding acquisition, L.L.D. All authors have read and agreed to the published version of the manuscript. 作者貢獻：概念化、C.S.D.S.L.、J.F.A.、L.L.D. 和 C.R.D.C.M.;數據收集，A.E.T.P.d.F. 和 C.S.D.S.L.;方法論，C.S.D.S.L.、J.S.S. 和 C.R.D.C.M.;J.S.S. 的形式分析;撰寫原始草稿準備，C.S.D.S.L.;寫作審查和編輯，A.E.T.P.d.F.、J.S.S.、J.F.A.、L.L.D. 和 C.R.D.C.M.;監督，C.R.D.C.M.;J.F.A. 專案管理;資金收購，法學博士所有作者均已閱讀並同意手稿的已發表版本。
Funding: This research was funded by the Fundação de Amparo à Pesquisa do Estado de São Paulo -FAPESP (Processo 2021/05367-6). Claudia Roberta de Castro Moreno is a fellowship recipient of CNPq 307875/2022-9. 資金： 本研究由 Fundação de Amparo à Pesquisa do Estado de São Paulo -FAPESP （Processo 2021/05367-6） 資助。Claudia Roberta de Castro Moreno 是 CNPq 307875/2022-9 的獎學金獲得者。
Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of University of São Paulo (protocol code 4.821.293 and date of approval was 1 July 2021). 機構審查委員會聲明：該研究是根據赫爾辛基宣言進行的，並經聖保羅大學倫理委員會批准（協定代碼 4.821.293，批准日期為 2021 年 7 月 1 日）。
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. 知情同意書：已獲得參與研究的所有受試者的知情同意。
Data Availability Statement: Correspondence and requests for materials should be addressed to crmoreno@usp.br. 數據可用性聲明：通信和材料請求應發送至 crmoreno@usp.br。
Conflicts of Interest: The authors declare no conflicts of interest. 利益衝突：作者聲明沒有利益衝突。
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