Breakfast and Child Obesity:



Breakfast and Child Obesity:

What’s the Link?

The US Department of Agriculture’s School Breakfast Program (SBP) was initially conceived as a means to address food insecurity among children from low income households (1). Not surprisingly, analyses over time suggest that the SBP has achieved that goal. Children at SBP schools are more likely to eat breakfast, and more likely to meet nutritional standards for a number of micronutrients, fiber intake and servings of fruits and vegetables (2).

There are also some data to suggest that children who participate in the SBP have greater cognitive achievements (3-6), fewer disciplinary problems and reduced tardiness or absenteeism (7, 8).

Now, the Injury Free Coalition for Kids of Seattle is proposing an obesity-prevention initiative that seeks to enhance participation in a school breakfast program while making changes in the variety, type and quality of breakfast foods offered.

It is reasonable to wonder about the evidence to suggest that encouraging participation in a school breakfast program may reduce the risk of obesity.

A Look at the Evidence: Technical Considerations

A number of studies have examined the association between breakfast consumption and overweight or obesity in adults and in children. Fewer studies have looked specifically at participation in the SBP. And very few studies have made the effort to establish the type and content of breakfast (cereals, eggs, etc.) and its association with weight outcomes [while a number of studies have looked specifically at ready-to-eat cereal consumption, many of these have been conducted or funded by cereal manufacturers]. In addition, many non-experimental studies fail to adjust for other important determinants of obesity, such as socioeconomic status, parental education, and physical activity.

There are no identifiable standard definitions of “breakfast consumption.” In some cases, breakfast must be eaten a certain number of days a week in order to qualify as breakfast consumer. Other studies use single day recall methods. In some cases any intake was accepted as breakfast, while others required a minimum proportion of daily energy for morning intake to qualify as a meal.

Most studies in this area are cross-sectional: they examine the prevalence of obesity or overweight as a function of (usually self-reported) breakfast consumption. A few studies track weight change and breakfast intake longitudinally. Only one study seems to have randomly assigned (obese adult) participants to breakfast vs. no breakfast to test effects on weight change.

A Look at the Evidence: Cross Sectional Studies

In most cross-sectional studies of adults, breakfast skipping is associated with a increased risk of obesity (9). In particular, ready to eat or cooked cereal consumption was associated with lower BMI (10), although other investigators suggest that this association is seen only in women (11)

Breakfast skipping is not uncommon among children and teens (11-37%), with higher rates reported among older age groups, girls, low-income children, and among some Black and Hispanic adolescents (4). Children and adolescents who are breakfast eaters (whether school breakfast or breakfast elsewhere) are less likely to be overweight (12-22). And, as in adults, ready to eat cereals have been specifically studied and shown to be negatively associated with BMI and blood glucose levels and positively associated with physical fitness (23).

The effect of school breakfast participation on obesity has also been studied. Participation in the SBP reduces breakfast skipping. Participation has never been shown to increase the risk of obesity. And, at least among food-insecure girls, participation in SBP and other food assistance programs is associated with a 68% reduction in the risk of overweight (24) In addition, the availability of the SBP affects the quality of the diets of other members of the family. The SBP is associated with better scores on the Healthy Eating Index and fewer calories from fat among preschool children and adults in the families of school-age children. (25)

A Look at the Evidence: Longitudinal Studies

Berkey’s 3-year study of 14,586 Caucasian children 9-17 y/o showed a decrease in BMI among overweight subjects who reported skipping breakfast. However, among initially normal weight subjects who skipped breakfast, BMI tended to increase over time (26).

Two publications from the 9-year NHLBI Growth & Health Study tracked the effect of breakfast skipping and cereal consumption on BMI over time. For both white and African American girls, days eat breakfast was negatively associated with BMI. This association disappeared however, when analysts added physical activity and energy intake into their models, suggesting that the effect of breakfast skipping might be mediated by changes in total daily energy intake or energy expenditure(27). In analysis that included breakfast type, days eating cereal was independently associated with lower BMI (28).

A Look at the Evidence: Experimental Studies

Only one randomized trial of breakfast consumption and weight control was found in our review (29). In this trial, 52 obese adult women were randomly assigned a weight-loss program. The no-breakfast group ate two meals per day and the breakfast group ate three meals per day. The energy content of the two weight-loss programs was identical. Among baseline breakfast-skippers, weight loss was greater in the breakfast vs. no breakfast group. Behavioral data suggested that eating breakfast helped reduce dietary fat and minimize impulsive snacking.

Energy, Physical Activity and Meal Quality,

The paradoxical relationship between breakfast eating and lower risk of obesity may be driven by the effect of breakfast on total energy intake. Studies attempting to quantify this relationship have not, however, consistently shown a lower daily energy intake among breakfast eaters. However, breakfast eating has been associated with greater total physical activity (17, 30, 31)and decreased time spent watching television (32, 33), either of which may contribute to a desirable energy balance.

Others have shown that an experimentally-assigned low glycemic index breakfast can reduce energy intake at lunch time (34), suggesting that breakfast habits may influence daily eating patterns, And, finally, the diurnal distribution of food intake may contribute to the risk of childhood obesity, with a the percentage of the intake of energy at dinner time associated with an increased risk of overweight (35). Moving energy consumption to the breakfast meal, without a change in total energy intake might, therefore, reduce the risk of obesity.

Summary

Although there is a strong relationship between breakfast intake and nutritional adequacy, the link between breakfast and body weight is less clearly drawn. The literature to date suggests that:

▪ There is no evidence to suggest that promoting breakfast consumption contributes to overweight

▪ In fact, children who skip breakfast are more likely to be overweight

▪ Food insecure children who eat school breakfasts are less likely to be overweight

▪ The type of breakfast eaten is probably important: complex carbohydrates and low fat, low sugar cereal meals are associated with reduced BMI

▪ The link between breakfast intake and weight control might be mediated through effects on physical activity

▪ Breakfast intake at school can positively influence family eating behaviors

▪ More longitudinal or experimental studies are needed to gauge the impact of school breakfast promotion on body weight outcomes.

References

1. Kennedy E, Davis C. US Department of Agriculture School Breakfast Program. Am J Clin Nutr 1998;67(4):798S-803S.

2. Gleason P, Suitor C. Children’s Diets in the Mid-1990s: Dietary Intake and Its Relationship with School Meal Participation. Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation; 2001. Report No.: CN-01-CD1.

3. Taras H. Nutrition and student performance at school. J Sch Health 2005;75(6):199-213.

4. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc 2005;105(5):743-60; quiz 761-2.

5. Pollitt E, Mathews R. Breakfast and cognition: an integrative summary. Am J Clin Nutr 1998;67(4):804S-813S.

6. Pollitt E. Does breakfast make a difference in school? J Am Diet Assoc 1995;95(10):1134-9.

7. Kleinman RE, Hall S, Green H, Korzec-Ramirez D, Patton K, Pagano ME, et al. Diet, breakfast, and academic performance in children. Ann Nutr Metab 2002;46 Suppl 1:24-30.

8. Murphy JM, Pagano ME, Nachmani J, Sperling P, Kane S, Kleinman RE. The relationship of school breakfast to psychosocial and academic functioning: cross-sectional and longitudinal observations in an inner-city school sample. Arch Pediatr Adolesc Med 1998;152(9):899-907.

9. Ma Y, Bertone ER, Stanek EJ, 3rd, Reed GW, Hebert JR, Cohen NL, et al. Association between eating patterns and obesity in a free-living US adult population. Am J Epidemiol 2003;158(1):85-92.

10. Cho S, Dietrich M, Brown CJ, Clark CA, Block G. 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). J Am Coll Nutr 2003;22(4):296-302.

11. Song WO, Chun OK, Obayashi S, Cho S, Chung CE. Is consumption of breakfast associated with body mass index in US adults? J Am Diet Assoc 2005;105(9):1373-82.

12. Boutelle K, Neumark-Sztainer D, Story M, Resnick M. Weight control behaviors among obese, overweight, and nonoverweight adolescents. J Pediatr Psychol 2002;27(6):531-40.

13. Dwyer JT, Evans M, Stone EJ, Feldman HA, Lytle L, Hoelscher D, et al. Adolescents' eating patterns influence their nutrient intakes. J Am Diet Assoc 2001;101(7):798-802.

14. O'Dea JA, Caputi P. Association between socioeconomic status, weight, age and gender, and the body image and weight control practices of 6- to 19-year-old children and adolescents. Health Educ Res 2001;16(5):521-32.

15. Ortega RM, Requejo AM, Lopez-Sobaler AM, Quintas ME, Andres P, Redondo MR, et al. Difference in the breakfast habits of overweight/obese and normal weight schoolchildren. Int J Vitam Nutr Res 1998;68(2):125-32.

16. Sjoberg A, Hallberg L, Hoglund D, Hulthen L. Meal pattern, food choice, nutrient intake and lifestyle factors in The Goteborg Adolescence Study. Eur J Clin Nutr 2003;57(12):1569-78.

17. Keski-Rahkonen A, Kaprio J, Rissanen A, Virkkunen M, Rose RJ. Breakfast skipping and health-compromising behaviors in adolescents and adults. Eur J Clin Nutr 2003;57(7):842-53.

18. Resnicow K. The relationship between breakfast habits and plasma cholesterol levels in schoolchildren. J Sch Health 1991;61(2):81-5.

19. Wolfe WS, Campbell CC, Frongillo EA, Jr., Haas JD, Melnik TA. Overweight schoolchildren in New York State: prevalence and characteristics. Am J Public Health 1994;84(5):807-13.

20. Sampson AE, Dixit S, Meyers AF, Houser R, Jr. The nutritional impact of breakfast consumption on the diets of inner-city African-American elementary school children. J Natl Med Assoc 1995;87(3):195-202.

21. Pastore DR, Fisher M, Friedman SB. Abnormalities in weight status, eating attitudes, and eating behaviors among urban high school students: correlations with self-esteem and anxiety. J Adolesc Health 1996;18(5):312-9.

22. Siega-Riz AM, Popkin BM, Carson T. Trends in breakfast consumption for children in the United States from 1965-1991. Am J Clin Nutr 1998;67(4):748S-756S.

23. Kafatos A, Linardakis M, Bertsias G, Mammas I, Fletcher R, Bervanaki F. Consumption of ready-to-eat cereals in relation to health and diet indicators among school adolescents in Crete, Greece. Ann Nutr Metab 2005;49(3):165-72.

24. Jones SJ, Jahns L, Laraia BA, Haughton B. Lower risk of overweight in school-aged food insecure girls who participate in food assistance: results from the panel study of income dynamics child development supplement. Arch Pediatr Adolesc Med 2003;157(8):780-4.

25. Bhattacharya J. Breakfast of Champions? The School Breakfast Program and the Nutrition of Children and Families. Cambridge, MA: National Bureau of Economic Research; 2004. Report No.: Working Paper 10608.

26. Berkey CS, Rockett HR, Gillman MW, Field AE, Colditz GA. Longitudinal study of skipping breakfast and weight change in adolescents. Int J Obes Relat Metab Disord 2003;27(10):1258-66.

27. Affenito SG, Thompson DR, Barton BA, Franko DL, Daniels SR, Obarzanek E, et al. Breakfast consumption by African-American and white adolescent girls correlates positively with calcium and fiber intake and negatively with body mass index. J Am Diet Assoc 2005;105(6):938-45.

28. Barton BA, Eldridge AL, Thompson D, Affenito SG, Striegel-Moore RH, Franko DL, et al. The relationship of breakfast and cereal consumption to nutrient intake and body mass index: the National Heart, Lung, and Blood Institute Growth and Health Study. J Am Diet Assoc 2005;105(9):1383-9.

29. Schlundt DG, Hill JO, Sbrocco T, Pope-Cordle J, Sharp T. The role of breakfast in the treatment of obesity: a randomized clinical trial. Am J Clin Nutr 1992;55(3):645-51.

30. Aarnio M, Winter T, Kujala U, Kaprio J. Associations of health related behaviour, social relationships, and health status with persistent physical activity and inactivity: a study of Finnish adolescent twins. Br J Sports Med 2002;36(5):360-4.

31. Cohen B, Evers S, Manske S, Bercovitz K, Edward HG. Smoking, physical activity and breakfast consumption among secondary school students in a southwestern Ontario community. Can J Public Health 2003;94(1):41-4.

32. Magnusson MB, Hulthen L, Kjellgren KI. Obesity, dietary pattern and physical activity among children in a suburb with a high proportion of immigrants. J Hum Nutr Diet 2005;18(3):187-94.

33. Casey PH, Szeto K, Lensing S, Bogle M, Weber J. Children in food-insufficient, low-income families: prevalence, health, and nutrition status. Arch Pediatr Adolesc Med 2001;155(4):508-14.

34. Warren JM, Henry CJ, Simonite V. Low glycemic index breakfasts and reduced food intake in preadolescent children. Pediatrics 2003;112(5):e414.

35. Maffeis C, Provera S, Filippi L, Sidoti G, Schena S, Pinelli L, et al. Distribution of food intake as a risk factor for childhood obesity. Int J Obes Relat Metab Disord 2000;24(1):75-80.

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