CHS Ruxton, PhD, RD, Freelance Dietitian, Nutrition Communications
Correspondence to: *Dr Carrie Ruxton, Nutrition Communications, 26 East Road, Cupar, KY15 4HQ, UK. E-mail: Carrie@nutrition-communications.com
Breakfast is traditionally seen as the most important meal of the day and is viewed nowadays as a marker of a healthy diet. However, as many as one in five adults and over half of 15 year old girls in the UK skip breakfast on a regular basis. Research suggests that breakfast cereals are nutrient dense and can make a significant contribution to daily vitamin and mineral intakes, thus helping to bridge the gap where there are nutritional shortfalls. Regular breakfast cereal consumption, ideally on a daily basis, may also play a role in weight management. This article reviews current nutrient intake data, and evidence from key studies in this area.
It is well recognised that genetic and environmental factors are the main determinants of health status, but simple lifestyle strategies such as the type and frequency of breakfast consumed can also influence nutritional intakes and health1. Despite this knowledge, the latest research highlights that around one in five adults and children (around 20%) skip breakfast2,3,4.
Missing breakfast may have broader implications, affecting overall diet quality and public health. For example, evidence from the National Diet and Nutrition Survey (NDNS), indicates that the UK public still has some way to go in terms of meeting nutritional standards, particularly for certain micronutrients such as iron and vitamin D5. Also, meta-analytical evidence has shown that breakfast skipping is associated with an increased risk of weight management issues across adult, adolescent and childhood populations6,7. Equally, data analysis from the US National Health and Nutritional Examination Survey (NHANES) suggests that adults eating ready-to-eat2 breakfast cereals regularly were 39% less likely to have abdominal obesity and 28% less likely to have elevated serum total cholesterol levels4.
There are many possible reasons behind breakfast skipping, with findings from a recent survey of students suggesting that not having time or being too busy (reported by 43%), not being hungry in the morning (24%) or not enjoying breakfast (16%) were the main drivers. Interestingly, concerns about weight management were only reported by 4% as being a reason for skipping breakfast8.
This article sets out to explain how eating breakfast cereals may help to make an important contribution to daily vitamin and mineral intakes. Using latest evidence available, it then goes on to describe how eating breakfast cereals may be associated with better weight management. Possible explanations behind study findings are also provided.
Nutritional contribution of breakfast cereals
The average calorie, protein and fibre content of common types of breakfast cereal, along with the micronutrient profile, are shown in Table 1. A "source" or "high fibre" claim can be made where a product contains at least 3 grams of fibre, or 6 grams of fibre per 100 grams, respectively9. Given this criteria, certain cereals may be classified as "high fibre"9. In addition, Nutrition and Health Claims regulations10 permit "source" claims for vitamins and minerals on foodstuffs that meet at least 15% of the Recommended Daily Amount (RDA) per 100 grams as sold, while a ''rich in'' claim applies when nutrient levels exceed 30% RDA. To that end, we can see that breakfast cereals are a "source" of zinc and a "rich source" of iron, B vitamins, folate and magnesium.
Turning to nutritional intakes, evidence from the latest UK NDNS, combining data from years 1 to 4 highlights that around 46% of girls and 23% of women have low iron intakes5. Relating this to biological biomarkers, iron-deficiency anaemia was identified in 5% of older girls and adult women5. Similarly, low vitamin D status (determined by low plasma 25-hydroxy vitamin D levels) was found in 23% of adults aged 19 to 64 years, 22% of children aged 11 to 18 years and 14% of children aged3 4 to 10 years. Furthermore, between January and March 2014, this increased to 40% of adults aged 19 to 64 years and children aged 11 to 18 years5.
The earlier NDNS report (combining years 1 to 3) provides additional data on the proportion of adults and children failing to achieve the Lower Reference Nutrient Intake (LRNI; the level below which deficiencies are likely to occur) set for vitamins and minerals. As shown in Figure 2, it can be seen that a proportion of adults and children fall below this, particularly young people aged 11 to 18 years in the case of iron, magnesium, zinc and riboflavin11.
Similarly, data from the UK low income NDNS (n= 3,278 aged 2 years and over) shows that that breakfast cereal consumers have higher intakes of thiamin, riboflavin, niacin, biotin, folate, vitamin B6, vitamin B12, iron and zinc than those not eating breakfast. Furthermore, eating breakfast was also associated with higher intakes of calcium, attributable to higher milk consumption12. As shown in Figure 2, it can be seen that around 50% of women aged 19 to 49 years with low incomes have iron intakes below the LRNI13. Finally, data from the North/South Ireland Food Consumption Survey suggests that breakfast cereal consumption contributes to micronutrient dense diets and a reduced risk of dietary inadequacy for calcium, iron, riboflavin and folate14.
Taken together, it is clear that breakfast cereals are nutrient dense and can help to top up daily nutrient intakes. As we have seen, a proportion of young people and adults remain to fall below LRNIs. Consequently, eating a micronutrient dense breakfast, such as one that includes breakfast cereals, may help to ensure that the intake of these essential nutrients reaches recommended levels.
Body weight and BMI
The latest Health Survey for England report reveals that nearly one in four adults, and over one in ten children aged 2 to 10 years, are obese. The direct costs of this to the NHS are estimated to be £4.2billion a year and are forecast to double by 2050 if this situation remains unchanged15.
4Recently, there has been an accumulation of evidence indicating that regular consumption of breakfast cereals is associated with a lower body mass index (BMI) compared with groups who do not eat these foods. This was confirmed by two systematic reviews in child and adult populations7,16. Several reasons have been proposed to explain why regular breakfast cereal consumption may contribute to a lower BMI. These include associated healthy lifestyle factors, such as the fact that breakfast cereal consumers may tend to take more exercise and drink less alcohol than those who rarely eat breakfast cereals17,18. Eating cereal for breakfast could also displace more energy dense options, such as butter, baked products, traditional fried breakfasts, confectionery or sugary drinks which tend to be associated with a higher BMI19,20. Equally, some studies have identified links between eating breakfast cereals and reduced snacking later in the day7,16,21,22.
Breakfast cereals represent an important source of fibre and whole grains which are independently associated with a lower risk of obesity17,23. In addition, the low glycaemic index (GI) of many breakfast cereals when consumed with milk could be impacting favourably on appetite control, since there is some evidence linking low GI diets with reduced obesity24. However, few studies have provided evidence to confirm this theory25,26.
Overall, eating breakfast cereals regularly appears to be associated with better weight management. As described, there are several theories as to why this may be the case. Longer term experimental studies are needed to investigate the role of breakfast skipping in weight change, as most research has taken the form of observational studies which do not necessarily imply causality27.
Breakfast is often regarded as the best meal of the day, yet is regularly missed by a significant proportion of adults and children, mainly due to busy lifestyles. This could have broader health implications. While people in Britain are living longer, weight management health issues and non-communicable disease such as type 2 diabetes are rising, as are health inequalities. One of the simplest and least costly ways of improving health is to have a healthy breakfast every day.
5This review has described the shortfall of certain vitamins and minerals in UK diets. Given this, breakfast cereals can make an important contribution to intakes of micronutrients, such as B vitamins (thiamin, riboflavin, niacin, folate), iron, magnesium and zinc. Furthermore, milk consumed with the cereal provides additional calcium and riboflavin.
Regular breakfast cereal consumers are also likely to have a lower BMI than non-consumers. Given the high prevalence of obesity, and the poor micronutrient and fibre intakes in those managing their weight, a number of recommendations have been made in Table 3. Of these, reinforcing the need to make time for breakfast would be of particular benefit to young people and females of reproductive age, who are at particular risk of low iron intakes and iron deficiency.
In relation to weight management, there appears to be good evidence that both children and adults who regularly consume breakfast cereals tend to have a lower BMI and are less likely to be overweight than those who eat breakfast cereals infrequently. This suggests that encouraging regular consumption of breakfast cereals would contribute to UK Government policy15 and, as part of a multi platform strategy, help to achieve a downward trend in levels of excess weight in children and adults by 2020. While there is a risk that restricting calories in order to lower BMI tends may reduce micronutrient intakes, encouraging nutrient-dense foods, such as breakfast cereals, could be one way to support weight management while ensuring that vitamin and mineral recommendations are achieved.
Breakfast skipping is an increasingly common occurrence, in the UK. A review of dietary survey data and latest evidence highlights that regular breakfast cereal consumption may: 1) help the UK population achieve recommended nutrient intakes, 2) improve the overall nutrient density of UK diets and 3) play a key role in weight management. In turn, this may have broader benefits in terms of helping to support a downward trend in BMI, overweight and obesity.6
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.
Tables and Figures reference:
1. Giovannini M et al. (2010) Symposium overview: Do we all eat breakfast and is it important? Crit Rev Food Sci Nutr 50: 97-9.
2. Horikawa C et al. (2011) Skipping breakfast and prevalence of overweight and obesity in Asian and Pacific regions: a meta-analysis. Prev Med 53: 260-7
3. Deshmukh-Taskar PR et al. (2010) The relationship of breakfast skipping and type of breakfast consumption with nutrient intake and weight status in children and adolescents: the National Health and Nutrition Examination Survey 1999-2006. J Am Diet Assoc 110: 869-78. 4. Deshmukh-Taskar P et al. (2013) The relationship of breakfast skipping and type of breakfast consumed with overweight/obesity, abdominal obesity, other cardiometabolic risk factors and the metabolic syndrome in young adults. The National Health and Nutrition Examination Survey (NHANES): 1999-2006. Public Health Nutr 16: 2073-82.
5. NDNS (2014) Statistical Press Notice: National Diet and Nutrition Survey: results from years 1,2,3 and 4 combined (2008/09-2011/12). Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/310998/NDNS_Statistical_press_notice_14May2014.pdf (accessed May 18th 2014). 6. Horikawa C et al. (2011) Skipping breakfast and prevalence of overweight and obesity in Asian and Pacific regions: a meta-analysis. Prev Med 53): 260-7.
7. de la Hunty A et al. (2013) Does regular breakfast cereal consumption help children and adolescents stay slimmer? A systematic review andmeta-analysis. Obes Facts 6: 70-85. 8. Mullan B et al. (2014) An examination of the demographic predictors of adolescent breakfast consumption, content, and context. BMC Public Health 14: 264.
9. EC (2006) Regulation (EC) No 1924/2006 of the European Parliament and of the Council of 20 December 2006 on nutrition and health claims made on foods. Available at: http://eur-7lex.europa.eu/LexUriServ/LexUriServ.do?uri=CONSLEG:2006R1924:20080304:EN:PDF (accessed May17th 2014)
10. European Commission (2008) Amending Directive 90/496/EEC of the Council as regards recommended daily allowances, energy conversion factors and definitions. Draft. Available at: http://multimedia.food.gov.uk/multimedia/pdfs/consultation/cwd (accessed May 17th 2014).
11. Bates B et al. (2012) National Diet and Nutrition Survey: Headline Results from Years 1, 2 and 3 (combined) of the Rolling Programme 2008/09 – 2010/11. NDNS Tables and Appendices. Available at: https://www.gov.uk/government/publications/national-diet-and-nutrition-survey-headline-results-from-years-1-2-and-3-combined-of-the-rolling-programme-200809-201011 (accessed May 17th 2014).
12. Holmes BA et al. (2012) The contribution of BREAKFAST CEREALS to the nutritional intake of the materially deprived UK population. Eur J Clin Nutr 66: 10-7.
13. Nelson M, Erens B, Bates B et al. (2007) Low Income Diet and Nutrition Survey. Three Volume Survey, Executive Summary. The Stationery Office: London.
14. Galvin MA et al. (2003) Impact of ready-to-eat breakfast cereal (RTEBC) consumption on adequacy of micronutrient intakes and compliance with dietary recommendations in Irish adults. Public Health Nutr 6: 351-63.
15. Department of Health (2011) Obesity. Available at: http://www.dh.gov.uk/en/Publichealth/Obesity/index.htm (accessed 17th May 2014).
16. Kosti RI et al. (2010) Ready-to-eat cereals and the burden of obesity in the context of their nutritional contribution: are all ready-to-eat cereals equally healthy? A systematic review. Nutr Res Rev 23: 314-22.
17. O'Neil CE et al. (2010) Whole grain and fiber consumption are associated with lower body weight measures in US adults: National Health and Nutrition Examination Survey 1999-2004. Nutr Res 30: 815-22.
18. Brand-Miller JC et al. (2002) Glycemic index and obesity. Am J Clin Nutr 76: 281S-5S.
19. Cho S et al. (2003) The effect of breakfast type on total daily energy intake and body mass index: results from the Third National Health and Nutrition Examination Survey NHANES III. Journal of the American College of Nutrition 22: 296.
20. Albertson AM et al. (2008) Consumption of breakfast cereal is associated with positive health outcomes: evidence from the National Heart, Lung, and Blood Institute Growth and Health Study. Nutr Res 28(11):744-52.8
21. Mattes RD (2002) Ready-to-eat cereal used as a meal replacement promotes weight loss in humans. Journal of the American College of Nutrition 21: 570.
22. Wal JS et al. (2007) Ready-to-eat cereal products as meal replacements for weight loss. Int J Food Sci Nutr 58: 331-40.
23. Good CK et al. (2008) Whole grain consumption and body mass index in adult women: an analysis of NHANES 1999-2000 and the USDA pyramid servings database. J Am Coll Nutr 27: 80-7.
24. Sjoberg A et al. (2003) Meal pattern, food choice, nutrient intake and lifestyle factors in The Goteborg Adolescence Study. Eur J Clin Nutr 57: 1569-78.
25. Cheng G et al. (2009) Relation of dietary glycemic index, glycemic load, and fiber and whole-grain intakes during puberty to the concurrent development of percent body fat and body mass index. Am J Epidemiol 169: 667-77.
26. Aston LM et al. (2008) No effect of a diet with a reduced glycaemic index on satiety, energy intake and body weight in overweight and obese women. Int J Obes (Lond) 32: 16.
27. McCrory MA (2014) Meal skipping and variables related to energy balance in adults: A brief review, with emphasis on the breakfastmeal. Physiol Behav. [Epub ahead of print]