Carrie Ruxton PhD, RD, Freelance Dietitian, Nutrition Communications
Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. Her specialist areas are child nutrition, obesity and functional foods. www.nutrition-communications.com
Breakfast is often viewed as the best meal of the day. However, skipping breakfast is becoming a common aspect of modern lifestyles. In particular, the proportion of children, teens and young adults skipping breakfast is on the rise which is likely to have implications for their later health. This article will consider how skipping breakfast may have broader implications in relation to diet quality and health. The latest evidence, including recent observational studies, will be reviewed.
While genetic and lifestyle factors are the main influencers of nutritional intakes and health status, the type and frequency of breakfast consumed can also play a role (1). As Table 1 shows, adolescents and young adults are most likely to skip breakfast; a trend that has grown in recent years. This is reinforced by data from a German longitudinal study where the number of food records reporting regular breakfast consumption decreased significantly between 1986 and 2007 in both younger and older children, although the proportion of children eating ready-to-eat cereals increased (2).
Another survey of adolescents from England and Australia identified that breakfast skipping was more common in England (18 versus 8 per cent) and, for those missing breakfast, reasons included: not having time or being too busy (42.9%), not being hungry in the morning (24.3%), not enjoying breakfast (15.7%), and weight management reasons (4.3%) (7). In the Netherlands, a large cross-sectional study of young people aged 10 to 19 years (n=2404) reported that older age, being female and attending vocational or senior education were common factors associated with2 breakfast skipping (8) while other research has shown that leisure time activity is higher among breakfast consumers (9).
Nutritional and Health Consequences
Nutritional Intake The nutritional and health implications of skipping breakfast may be far reaching and are summarised in Table 2. Several studies have investigated how missing breakfast may impact on diet quality. Amongst pre-school children (mean age 4 years), eating breakfast on a daily basis has been positively associated with a healthier body weight, possibly due to a more even distribution of energy intake across meals throughout the day (10). An analysis of 24-hour dietary recall data from the US National Health and Nutrition Examination Survey has found that children and teens (9-18 years) eating ready-to-eat cereals have significantly lower intakes of total fat and cholesterol, and higher intakes of total carbohydrate, dietary fibre and several micronutrients compared with those skipping breakfast (4). Using data from the same survey, young adults (20 to 39 years) eating ready-to-eat cereals had higher intakes of several micronutrients and a better diet quality than breakfast skippers (11). Equally, amongst Korean adults (aged 30-50 years) ‘rare breakfast eaters’ were found to consume significantly less energy, fat, dietary fibre, calcium, and potassium, leading to a reduction in overall diet quality (6). In addition, eating breakfast cereals on a daily basis in the periconceptual period (when trying for a baby or in the early stages of pregnancy) may help to improve nutritional intakes. In a US study, around 31% of women ate cereals regularly which was associated with significantly higher intakes of folate, iron, zinc, calcium, fibre and vitamins A, C, D and E, while the risk of nutritional inadequacies was reduced by 65-90% (12).
A relatively large body of evidence has investigated links between breakfast skipping and body weight. One meta-analysis of 19 cross-sectional studies focusing on Asian and Pacific regions found that breakfast skippers were more likely to be overweight or obese, emphasising that this is a global problem and not specific to certain cultures (13).
Again, in childhood and teenage populations, breakfast skipping may further contribute to the growing obesity epidemic. The ENERGY1 survey; a cross-sectional study collecting data from parents (n=6512) of 10-12 year-olds across eight European countries, found that those skipping breakfast were significantly more likely to be overweight, or obese (14). Equally, a Greek observational survey conducted on 14,278 teenagers aged 13-19 years found that both male and females eating breakfast on a regular basis had a significantly lower body mass index than breakfast skippers (9). Similarly, a Dutch cross-sectional electronic health survey (E-MOVO), comprised of 25,176 teens aged 13-16 years, identified breakfast skipping as the most important risk factor for overweight and obesity (15).
1 EuropeaN Energy balance Research to prevent excessive weight Gain among Youth3
Finally, a study comprised of 9,919 participants which considered dietary habits in the transition from adolescence to adulthood, found that increased weight in adulthood was linked with fewer days of eating breakfast and a general decline in eating breakfast over time (16)>.
Metabolic parameters Skipping breakfast can affect metabolic and blood biochemical profile, an aspect considered by several studies. Amongst children and teenagers, an observational study of 174 sedentary 6-16 year olds found that the prevalence of eating breakfast daily was 48% in boys and 45% in girls. In addition, eating breakfast more frequently was inversely associated with blood levels of glucose, triglyceride and very low density lipoprotein (LDL) cholesterol (17). It has been claimed that skipping breakfast boosts appetite later in the day but, in a small study of pre-pubertal obese children (n=10), a fasted state (mimicking breakfast skipping) appeared to have no impact on appetite hormones such as peptide YY and glucagon-like peptide-1, although larger studies are needed to test this (18). Amongst adult populations, a large prospective study following Australian children from 9-15 years into adulthood (n=2,184) at age 26-36 years found that breakfast skipping led to adverse changes in waist circumference, fasting insulin levels, total and LDL cholesterol levels during their childhood and teenage years (19). In contrast, research on Korean adults, aged 30-50 years, found that breakfast skipping was associated with a reduced risk of elevated serum triglyceride levels (6). This was unexpected as those who rarely consumed breakfast tended to have higher fat intakes and lower carbohydrate intakes as a proportion of energy.
Other health benefits
There is emerging evidence linking breakfast skipping to other aspects of health. In terms of cognitive function, among pre-pubertal obese children, the absence of breakfast was found to increase levels of inattention which, in turn, was associated with a reduction in the amount of carbohydrate used as fuel (18). In addition, amongst a sample of 40 adolescents (mean age 14 years), eating a 35g portion of breakfast cereal with a low glycaemic index was found to improve cognitive function, while teenagers also reported that they felt more alert, satiated and content (20).
There are some reported links between breakfast skipping and altered reproductive function. A survey of college students aged 18 to 20 years found that the severity of dysmenorrhea (the failure to menstruate) and incidence of irregular menstrual cycles were significantly higher amongst girls who regularly skipped breakfast. Interestingly, those girls skipping breakfast also tended to suffer from constipation more frequently (21,22). Further to this, skipping breakfast has been associated with bone loss, with 20% of students losing body mineral density in the lumbar spine (38% in the femoral neck) when studied over a period of 3 years (23).
Overall, a growing number of studies suggests that skipping breakfast can affect both diet quality and health (Table 2). As many of these rely on observational data, further controlled studies should be done to determine cause and effect, and to reveal likely mechanisms. Future studies should attempt to control for other diet and lifestyle factors, such as exercise and fibre intake, that may affect the health outcomes under investigation.
Equally, clearer definitions of ‘breakfast skipping’ are needed. Presently, there is great variability across studies in terms of what constitutes breakfast skipping indicating a need for uniformity. While many studies have been published looking at breakfast skipping in younger generations, the frequency of breakfast consumption amongst older populations, particularly in relation to markers of health appears to be understudied.
This report has identified that young people, especially teenagers, are most likely to skip breakfast. In terms of the reasons behind this, negative attitudes towards breakfast appear to be a strong determinant of breakfast skipping (25) as are perceived lack of time, being too busy, not being hungry, lacking enjoyment of breakfast, or trying to manage body weight (7).
Other work has shown that parenting and mentoring play key roles in preventing breakfast skipping. In one study, regular breakfast consumption amongst parents was correlated positively with the likelihood of their children eating breakfast (26). Similarly, when mothers, or a best friend skip meals, including breakfast, children have been found to follow suit (27). Most recently, depression in children, cyberbullying and school bullying have also been linked to breakfast skipping (28). Other factors and behaviours associated with breakfast skipping are suggested in Table 3.
Dietitians can play a key role in helping to communicate what an ideal breakfast entails. Whole grain cereals, which often contain several health-enhancing properties, such as dietary fibre, inulin, beta-glucan, resistant starch, carotenoids, phenolics, tocotrienols, and tocopherols (31), are a good breakfast option. Equally, as suggested by the evidence, eating fortified cereals is an easily modifiable dietary habit and could help to top up habitual micronutrient intakes.
In conclusion, breakfast has long been regarded as the best meal of the day. Skipping breakfast is associated with lower nutrient intakes and may impact broadly on health status. Health professionals can help by communicating the detrimental effects of breakfast skipping to the lay public, especially younger people. Breakfast education programmes could play a key role here, especially by suggesting examples of quick, healthy breakfast meals.
This work was supported by the Breakfast Cereal Information Service, an independent information body set up to provide balanced information on breakfast cereals. It is supported by a restricted educational grant from the Association of Cereal Food Manufacturers.
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