For those that skipped breakfast, higher mean intakes of energy, carbohydrates, saturated fat, refined grains and added sugar from snacks were observed.

For people with diabetes, skipping breakfast was associated with poorer total daily dietary intakes, especially the percent of energy from added sugars. Breakfast skippers consumed snacks with more energy, carbohydrate and sugar.

These data suggest skipping breakfast has a negative relation to overall dietary intakes for people with diabetes. Kelly: Employee; Self; Abbott. Fanelli: None. Krok-Schoen: None. Taylor: Consultant; Self; Abbott Laboratories. Research Support; Self; Abbott Laboratories.

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Home Browse Communities and Collections Author Title Subject Date About About uO Research Policies FAQ Login. Breakfast skipping is associated with differences in meal patterns, macronutrient intakes and overweight among pre-school children Description Title: Breakfast skipping is associated with differences in meal patterns, macronutrient intakes and overweight among pre-school children Authors: Dubois, Lise Girard, Manon Potvin Kent, Monique Farmer, Anna Tatone-Tokuda, Fabiola Date: Abstract: Objectives: To examine the association between skipping breakfast, daily energy, macronutrients and food intakes, and BMI in pre-school children.

Setting: Data obtained from a representative sample n of children born in Quebec Canada in Subjects: One thousand five hundred and forty-nine children, with a mean age of 49 SD 3·12 months. Results: Ten per cent of children ate breakfast on fewer than 7 days per week.

This behaviour was associated with a lower diet quality and concentrated energy intakes through higher protein intakes at lunch and the consumption of snacks higher in energy and carbohydrate in the afternoon and evening; yet total daily energy intakes were not significantly different from those of pre-school children who ate breakfast every day.

Conclusions: Eating breakfast every day is associated with having a healthy body weight, likely due to a more even distribution of energy intake across meals throughout the day. Breakfast skipping is associated with differences in meal patterns, macronutrient intakes and overweight among pre-school children.

Estimated mean intakes of macronutrients among skippers and non-skippers were calculated using the generalized linear models and using the margins command, adjusting for covariates which were found to be significantly associated with breakfast skipping.

The high number of adolescents with zero intake for specific food groups, meant that these variables were highly skewed and estimated mean intakes were not calculated as a result. Crude intakes are reported for these variables.

Regression models were adjusted for demographic variables region, age, maternal education, FAS, and family structure and lifestyle factors, including physical activity and diet quality DQI.

The analysis was adjusted for clustering by school using the svy command. Additionally, a separate analysis was conducted stratified by each of 8 HELENA centres Greece, Germany, Belgium, France, Italy, Sweden, Austria, and Spain , adjusting for region, age, sex, maternal education, FAS, and family structure.

respondents did not reporting having breakfast on one or both 24 HDR days. Overall Across the eight countries the proportion of breakfast skippers ranged from Among males, breakfast skipping ranged from When two different classification approaches were compared using Preferences questionnaire or HDR , Using the alternative classification, only 6.

Table 2 shows the profile of male and female skippers and non-skippers. Median IQR DQI was significantly higher among skippers than non-skippers; this was true of both males [ Table 2 shows macronutrients and food group intake among male and female breakfast skippers and non-skippers.

Nutrient intakes among skippers and non-skippers were described as estimated means Table 3. Energy intake from nutrients was also examined among skippers and non-skippers according to meal Supplementary Table 1. Food groups. This association remained in the full model after including region, age, maternal education, FAS, family structure, physical activity, diet quality and energy intake as covariates [Adjusted Odds Ratio AOR , 2.

This was also true of female adolescents AOR, 0. However, none of these associations were significant. A different relationship was found when the regression analysis was performed using the alternative HDR classification of breakfast skipping Supplementary Table 3 males [AOR, 0.

The aim of this study was to describe the demographic and dietary patterns associated with breakfast skipping among European adolescents, and to explore the association between habitual breakfast skipping and being overweight or obese.

There were a number of key findings. Firstly, a high proportion of adolescents Secondly, in terms of demographics, among males, there were higher proportions of skippers among older age groups, and those living in Southern Europe.

Among females, there were greater proportions of skippers among those with lower family affluence, with mothers of lower education.

Thirdly, both male and female adolescents who skipped breakfast had significantly lower diet quality overall, and lower intake of fibre and fruit. While the range in terms of the prevalence of breakfast skipping across the eight countries was not as great as that reported among children of the ENERGY study 31 , this could reflect the different age group, the selection of countries sampled, and the approach used to determine skippers i.

However, the variation between countries in the current study does suggest that some cultural differences in patterns of breakfast skipping, or in the interpretation of the breakfast meal, may exist. This variation may reflect an on-going issue with research in this area 43 , namely, the different approaches used to classify breakfast skippers across studies, which makes cross-study comparisons difficult.

The current study findings suggest that different approaches to classify skippers, even within the same study, do not classify adolescents consistently, and indicate a different relationship between skipping and BMI may exist depending on the approach used.

However, as highlighted by Rampersaud et al. preceding school Unless definitions are made explicit, it is important to allow for differences in the interpretation of breakfast among study participants. Variation in the types of food groups consumed in morning may have also influenced whether adolescents would report themselves as skipper or non-skipper.

The high proportion of skippers among females fits with existing evidence suggesting sex differences in dietary behaviours 44 , including meal and breakfast skipping 20 , 22 , 24 , 26 , However, some studies have found skipping is higher among males 8 , 20 , with another pan-European study finding no significant different in prevalence between girls and boys The current findings on socio-demographics and breakfast skipping are also consistent with previous work from the US 26 and Netherlands 27 , indicating breakfast skipping is more common among older children, and with research from other pan-European studies, which show an association of skipping with lower family affluence 24 , living with a single-parent family 24 , and lower parental education Previous work also shows breakfast skipping appears to cluster with other unhealthy dietary behaviours 5 , 21 and that skippers may have lower intake of several important nutrients The lower diet quality, and lower intake of fruit and fibre identified among male and female skippers in the current study may suggest that adolescents who habitually skip breakfast are missing key nutritional elements through skipping the breakfast meal, or, alternatively, that the breakfast skipping behaviour may be a marker of irregular dietary behaviours.

In spite of the different approaches used to classify skippers across studies including the use of questionnaires to assess frequency of intake per week the current findings are consistent with existing work which show an association between breakfast skipping and higher BMI 3 , 8 , 14 , 22 , including a systematic review of studies across Europe 6.

However, the current study differs to others in examining the relationship by sex, and finding this association is significant among males only. Even if we cannot assert that breakfast skipping itself leads to an adolescent becoming overweight or obese, the behaviour may be a marker, both for higher BMI, and a poorer diet.

Examining differences in nutrient and food intakes between skippers and non-skippers can provide some insight into how the behaviour may contribute to a higher BMI. Previous work suggests that daily energy intake may be compensated among skippers by greater consumption of more energy-dense foods, for example those high in carbohydrates, over the rest of the day, or from higher consumption during a morning snack 31 ; a pattern observed in the current study.

The fact this behaviour is associated with a poorer diet and higher BMI should be a cause for concern, given the risk of these habits tracking into adulthood There is scope to raise awareness about adolescents who may be particularly vulnerable, most likely to engage in this behaviour, and to target interventions appropriately.

The sex-specific association reported in the current study could in some way be indicative of different motivations for engaging in breakfast skipping between male and females.

Male and female adolescents may have different reasons for engaging in breakfast skipping, and the role of gender in breakfast skipping needs to be better understood. A recent systematic review of factors which influence meal skipping among young adults, cited a perceived lack of time, weight control, money, and habit among the main correlates of skipping Interventions to address the behaviour may benefit if they are designed as appropriate to male and female adolescents.

To inform intervention development, qualitative work would be needed to fully understand any sex differences, the specific motivations for breakfast skipping, and other contextual factors which could impact on the behaviours in these groups.

One of the strengths of this study is the use of a large pan-European dataset representing adolescents across ten European Cities, and eight countries. This is also the first study to examine adjusted differences in nutrient intakes among skippers and non-skippers.

Furthermore, food and nutrient intake was collected using a validated instrument, the computerised HDR, HELENA-DIAT Although data collected from the preferences questionnaire and I-PAQ were self-reported, FAS and I-PAQ have been validated in other studies 41 , The study is strengthened by the use of the self-report preferences questionnaire to classify breakfast skippers, which was felt to better represent habitual dietary behaviours.

However, the study has some limitations. It should be noted that the data were collected during the academic year — and are now 10 years old. It is possible that dietary patterns among adolescents may have changed since the original study was conducted.

For example, does slight agreement also imply slight disagreement with the statement? This discrepancy further suggests the need for a more standardised approach to defining breakfast skipping which would allow for more comparable results across studies. The current study is limited by its cross-sectional design, and the findings reported here would ideally be confirmed through a longitudinal study.

Overweight or obese adolescents may be likely to skip breakfast rather than becoming overweight through skipping and poor dietary intake. A longitudinal study among year olds by Berkey et al. in the US 14 found that breakfast skipping appears to have a different effect according to baseline weight status.

Over a year of follow-up, children who were overweight and who skipped breakfast lost weight whereas normal weight children who skipped breakfast gained weight relative to normal weight children who ate breakfast regularly.

Interventions to target breakfast skipping should potentially be sex-specific and account for different motivations for the behaviour among male and female adolescents. Identification of meal patterns, and developing a better understanding their determinants, has the potential to inform the development of targeted interventions to address this important public health issue.

The HELENA dataset is available to access subject to submission and approval of a study proposal by Professor Luis Moreno lmoreno unizar. es at the University of Zaragoza.

No competing interests were disclosed. The preparation of this paper was supported by the DEterminants of DIet and Physical ACtivity DEDIPAC knowledge hub. The HELENA Study took place with the financial support of the European Community Sitxth RTD Framework Programme Contract FOOD-CT This analysis was conducted as a part of the Determinants of Diet and Physical Activity DEDIPAC study, of subtask 1.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Click here to access the data. Is the work clearly and accurately presented and does it cite the current literature?

Is the study design appropriate and is the work technically sound? Are sufficient details of methods and analysis provided to allow replication by others? If applicable, is the statistical analysis and its interpretation appropriate?

Are all the source data underlying the results available to ensure full reproducibility? Competing Interests: No competing interests were disclosed. Alongside their report, reviewers assign a status to the article:.

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Close Copy Citation Details. PUBLISHED 05 Jun Luis A. Alba M. Jonatan R. Mathilde Kersting Roles: Data Curation. Janas M. OPEN PEER REVIEW DETAILS REVIEWER STATUS.

As Hour Recall data was not available from Pecs Hungary this city was excluded. Using responses from the Food Choices and Preferences Questionnaire adolescents were classified as breakfast skippers or non-breakfast skippers. All analyses were stratified by sex.

Differences in the intake of macronutrients, both overall and when breakfast was excluded, and key foods were compared between skippers and non-skippers using Wilcoxen Rank Sum test. Among both male and female estimated mean fibre intake and median fruit intake were significantly lower among skippers compared to non-skippers.

Conclusions: Different patterns of daily macronutrient intake were observed among adolescents who skip and do not skip breakfast. Gender may play a key part in breakfast skipping behaviours.

READ ALL READ LESS. Keywords Breakfast skipping, meal patterns, adolescents, overweight, obese, DEDIPAC. Corresponding Author s.

Fiona Riordan fiona. riordan ucc. Introduction Breakfast consumption has been associated with a better nutrition profile and diet quality 1 — 3 , improved cognitive function 3 , 4 , and a lower body mass index BMI 2 , 3 , 5 , 6.

Methods Study design and sampling The Healthy Lifestyle in Europe by Nutrition in Adolescence HELENA study is a cross sectional, school-based study of European adolescents aged Breakfast skipping Several studies 2 , 3 , 17 , 27 have highlighted that some variation exists in terms of how breakfast consumers or skippers are defined.

Socio-demographic variables The association of breakfast skipping with the following socio-demographic variables was examined: region, age, family affluence scale FAS , maternal education and family structure. Diet and physical activity Diet Quality Index A Diet Quality Index DQI was developed based on information from the two non-consecutive HDRs.

Study tools Questionnaires and study tools will progressively be made publically available via the HELENA study website. Statistical analysis Analysis was conducted using Stata SE version Table 1. Breakfast skipping across eight HELENA centres. HELENA - Healthy Lifestyle in Europe by Nutrition in Adolescence.

Energy, macronutrient and food intakes among skippers and non-skippers Median IQR DQI was significantly higher among skippers than non-skippers; this was true of both males [ Table 2.

Demographic profile of breakfast skippers and non-skippers stratified by sex. Table 3. Table 4. Discussion Key findings The aim of this study was to describe the demographic and dietary patterns associated with breakfast skipping among European adolescents, and to explore the association between habitual breakfast skipping and being overweight or obese.

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Resources ADA Professional Membership ADA Member Directory Diabetes. X Twitter Facebook LinkedIn. This Feature Is Available To Subscribers Only Sign In or Create an Account. Close Modal. Results: During follow-up, we documented 3. In Chinese adults, more breakfast carbohydrates or less proteins intake was associated with the reduced risk of cardiovascular diseases.

Especially for women, higher intake of breakfast carbohydrates was associated with a lower risk of major cardiovascular events quintile 5 vs. quintile 1, HR 0. Higher intake of breakfast proteins was associated with a higher risk of major cardiovascular events quintile 5 vs. quintile 1, HR 1.

quintile 1, HR 2. There was a significant association between breakfast fat intake and cardiovascular diseases in the adult population, but less significant correlation was found in Chinese men or women.

Breakfast fat intake was positively associated with the risk of major cardiovascular events quintile 5 vs. There was a significant reduction in major cardiovascular events and stroke when breakfast energy intake was moderated, even if the independence of skipping breakfast.

Conclusion: High carbohydrate intake and low protein and fat intake at breakfast may contribute to cardiovascular health while maintaining a moderate energy intake. In , cardiovascular disease CVD mortality in China remained at the top of the disease spectrum 1 , accounting for an average of two out of every five deaths.

Stroke, as one of the major CVD, has become the leading cause of death among adults in China 2. CVD has rapidly transformed from a disease in developed countries to a global disease with increasing prevalence and incidence in low-income countries.

The prevailing risk factors for cardiovascular disease, namely hypertension, and diabetes mellitus, along with the unhealthy poor-quality diet, would contribute to this complex transition 3. The presence of poor eating habits or dietary factors has been validated to be associated with a range of chronic diseases 4.

Equally, meal timing as well as daily nutrient intake regulates cardiovascular risk. There was evidence that the timing of food consumption may alter the circadian rhythm of metabolism, which in turn affects the biological clock 6 , 7.

According to studies, late-lunch eating 8 and late-night eating 9 , 10 were related to a higher risk of cardiometabolic health. Similarly, breakfast skipping or irregular breakfast eating habits were associated with a greater risk of CVD 11 — 13 , though a recent review on the association of breakfast skipping with cardiovascular disease has drawn a controversial conclusion However, with the accelerated pace of life and the deep-rooted concept of weight control and weight loss, breakfast skipping, as a part of the strategies proposed for reducing energy intake, is becoming more prevalent 15 , Noticeably, it cannot be assumed that people who eat breakfast are necessarily healthier.

The basic principle of a healthy breakfast is to try to ensure that the variety of food is as diverse as possible and nutrient intake at breakfast is reasonable.

Studies have investigated the beneficial effects of regular eating breakfast on risk factors of cardiovascular disease 11 , 17 , but subsequent results remain inconsistent, possibly because of different breakfast compositions.

A series of studies have supported that total energy consumption at breakfast reduced weight gain and CVD risk factors, such as elevated serum low-density lipoprotein cholesterol 18 , An animal study also has made a similar conclusion that high energy intake at breakfast has a favorable regulation of blood lipids There was evidence, both from a randomized controlled trial 21 and a prospective observational study 22 , showing that a reduction in dietary saturated fatty acids SFA reduces the risk of CVD.

While few studies have been conducted that assess whether fat intake at breakfast has any effect on CVD, researchers found a reduction in the risk of intracerebral hemorrhage associated with higher saturated or monounsaturated fat consumption at breakfast in Japanese men Correspondingly, greater protein intake at breakfast could reduce body weight 18 , 24 , and was inversely associated with systolic and diastolic pressure and positively associated with high-density lipoprotein cholesterol 25 , which may have beneficial effects on cardiovascular health.

Protein intake from plant sources was associated with a lower risk of cardiovascular disease mortality 26 , whereas protein intake from animal sources with a higher risk of cardiovascular health Given to different animal sources, many studies have provided much evidence that red meats, such as poultry and beef, were associated with a range of adverse cardiovascular health 28 — Furthermore, processed meat that contain high amounts of sodium have been linked with a higher risk of CVD incidence In most nutritional guidelines, there is a lack of recommendations regarding eating habits timing, quantity, energy content, and frequency in adults 31 , During the past two decades, the overall energy intake in Chinese adults has shown a decreasing trend, and the dietary structure significantly changed However, a longitudinal study has not been conducted to date to examine the relationship between macronutrient intake at breakfast and the risk of cardiovascular disease.

In this study, our primary aim was to assess the association of energy and macronutrient carbohydrate, protein, and fat intake at breakfast with cardiovascular disease events among Chinses adults. The secondary aim was to investigate the effect of energy and macronutrient intake at breakfast on cardiovascular diseases in participants with the presence of hypertension.

In this study, data were derived from a stratified, multistage prospective survey of the China Health and Nutrition Survey CHNS , a cohort study.

More details of the sampling process and design used in CHNS have previously been published elsewhere The food codes used before in CHNS did not match the published China Food Composition tables 35 , and the dietary survey data have not yet been published.

In brief, data on 22, participants were collected in nine provinces from , , , , , and , including Liaoning, Heilongjiang, Jiangsu, Shandong, Henan, Hubei, Hunan, Guangxi and Guizhou. A total of 12, individuals were involved in this analysis Figure 1.

Dietary intake was evaluated at the household and individual level using the household food stock method combined with three consecutive h recalls 36 , 37 , which means selected for 3 consecutive days from Monday to Sunday according to the randomization principle.

Investigators were required to receive standardized training on dietary survey techniques and proper food estimation methods before conducting the household dietary survey. The classification of food categories is based on the food codes recorded in the CHNS database.

The food codes in the CHNS database have used two different systems of food coding. In particular, food codes from the Chinese Food Composition Table were used in and to calculate individual daily intake of select nutrients for each food item.

From to , surveys were based on the edition of the Chinese Food Composition Table with a supplement of the edition. Noteworthy, different food sources under the same category cannot be directly summed up. The differences in energy and nutrients provided by different food sources should be noted when estimating food consumption, to ensure the accuracy of meal data.

A double labeled water method has been validated in this survey to determine total energy intake from combined dietary intake The follow-up period was calculated as the time from their initial year of survey participation to either an expected outcome event or lost to follow-up or the censoring date.

Here we summarized the formula as the following:. The six rounds of survey were conducted in , , , , and In this formula, n indicates the number of times participated in the survey, Y n indicates the survey year of n wave, Y n-1 indicates the survey year of n-1 wave, Y 1 indicates the year of the first participation in the survey.

This study was conducted to determine the presence of hypertension according to hypertension control guidelines Physical activity level was assessed based on time spent per week in different occupational, domestic, transportation and leisure activities using a validated questionnaire that calculates the Metabolic Equivalent of Task MET for each activity according to the Physical Activity Compendium 41 , Smoking status was categorized as a non-smoker, ex-smoker, and current smoker.

Continuous variables are summarized as means and stand deviations SDs and categorical variables as percentages. We evaluated the proportional hazards assumption using the Schoenfeld residual method combined with visual inspection of log—log plots, which were consistent with proportional hazards.

Hazard ratios HRs of three cardiovascular outcomes major cardiovascular events, MI, and stroke attributed to energy intake including breakfast energy, the proportion of energy from macronutrients at breakfast were calculated using a multivariable Cox frailty model with random intercepts to account for household clustering.

For the overall analysis, participants were categorized into quintiles of energy intake at breakfast and nutrient intake carbohydrate, fat, and protein at breakfast based on the percentage of energy provided by nutrients. The lowest quintile category was used as the reference group.

Minimally adjusted models were adjusted for age, sex, and household clustering as a random effect. Maximally adjusted models were further adjusted for an urban or rural location, education level, income, physical activity, smoking status, alcohol intake, BMI, history of hypertension, diabetes, total energy intake, saturated fatty acid SFA , grains, vegetables, and dietary fiber.

In addition, we used restricted cubic splines with four knots at the 5th, 35th, 65th, and 95th to investigate the shape of the association between breakfast nutrient intakes and outcomes.

Interactions were explored between energy and macronutrient intake at breakfast and the presence of hypertension. We introduced a cross-product interaction term in the multivariable model to assess the significance of the interaction and to examine whether the effect of energy and macronutrient intake at breakfast on events differed in participants with or without hypertension.

The fully adjusted model was subjected to sensitivity analysis by the addition of skipping breakfast. All statistical analyses were performed with R software, version 4.

Demographic characteristics of participants and data on dietary intake at baseline according to quintiles of energy intake at breakfast are presented in Table 1. Compared with those in quintiles 1—4, participants in the fifth quintile who consumed more energy at breakfast were more likely to be men, poorly educated, those with high physical activity levels, and those who lived in rural areas and were from regions of central China.

Participants who were to be no smokers or alcohol drinkers at baseline were more likely to appear in the fifth quintile. Breakfast energy intake was associated with higher intakes of total energy and carbohydrate and lower intakes of protein and fat at baseline.

Table 1. Baseline characteristics according to quintiles of energy intake at breakfast: CHNS, — Higher percentage energy from carbohydrate intake at breakfast was associated with a lower risk of major cardiovascular events quintile 5 vs. In comparisons between quintile 5 and quintile 1, percentage energy from protein intake at breakfast was associated with a higher risk of major cardiovascular events quintile 5 vs.

Similarly, percentage energy from the fat intake at breakfast was positively associated with risks of major cardiovascular events quintile 5 vs. Table 2. Association between energy and percentage energy from macronutrients at breakfast and health outcomes.

For breakfast energy intake, we observed a possible non-linear relationship between breakfast energy intake and cardiovascular outcomes. In Figure 2 , we used a restricted cubic spline to visualize the relationship between the risk of CVD and energy intake at breakfast on a continuous scale.

Multivariable-adjusted restricted cubic spline further showed a significant L-shaped association of breakfast energy intake with stroke Figure 2C.

The L-shaped curve indicated that energy intake at breakfast was inversely associated with the risk of stroke at lower intake levels, but higher intakes increased the risk when exceeding a certain threshold.

That is to say, breakfast energy intake that is too low or too high might increase the risk of stroke. Correspondingly, the relationship between energy intake at breakfast and major cardiovascular events was mainly U-shaped Figure 2A , given that the first half of the curve was relatively flat.

The U-shaped curve indicated that energy intake at breakfast that is too low or too high might also increase the risk of major cardiovascular events. Figure 2. Multivariable-adjusted hazard ratios of association between breakfast energy intake and cardiovascular events [ A major cardiovascular events; B myocardial infarction; C new-onset stroke].

A knot is located at the 5th, 35th, 65th, and 95 th percentiles for energy intake at breakfast. The model was fully adjusted for age, gender, urban or rural location, education level, income, physical activity, smoking status, alcohol intake, BMI, history of hypertension, diabetes, total intake of energy, SFA, grains, vegetables, and dietary fiber, with household identification as random intercepts.

In the analysis for energy and major nutrients from breakfast, we evaluated the associations of intakes of energy, carbohydrates, protein, and fat at breakfast with risks of major cardiovascular events, MI, and stroke by sex Supplementary Table 1. For male participants, adequate intake of energy at breakfast may reduce the risk of stroke quintile 5 vs.

For female participants, higher percentage energy from carbohydrate intake at breakfast was associated with lower risk of major cardiovascular events quintile 5 vs.

Percentage energy from protein intake at breakfast was associated with higher risk of myocardial infarction quintile 5 vs. In addition, breakfast proteins were divided into animal and plant proteins and then compared separately by sex with regard to health outcomes, but no association was found Supplementary Table 2.

No significant associations with the risk of major cardiovascular disease, MI, and stroke were found for the replacement of carbohydrates at breakfast with protein or fat at breakfast Figure 3. Figure 3. Adjustments included age, gender, urban or rural location, education level, income, physical activity, smoking status, alcohol intake, BMI, history of hypertension, diabetes, energy intake at breakfast, SFA, grains, vegetables, and dietary fiber.

We further examined associations with energy and macronutrient intake and health outcomes according to the presence of hypertension at baseline. There were no significant interactions between breakfast energy intake and cardiovascular events Figure 4.

However, significant interactions were tested between macronutrient intake and a history of hypertension. We conducted stratification analyses to investigate the effect of percentage energy from carbohydrate, protein, and fat intake at breakfast on health outcomes.

The higher percentage of energy from carbohydrate intake was associated with a lower risk of major cardiovascular events and new-onset stroke in participants without the presence of hypertension at baseline Supplementary Figure 1.

On the contrary, a percentage of energy from protein or fat intake was positively associated with risks of major cardiovascular events and new-onset stroke in participants without hypertension Supplementary Figures 2 , 3.

Figure 4. Stratified analyses by the history of hypertension at baseline of the association between breakfast energy intake and health outcomes. Adjustments included age, gender, urban or rural location, education level, income, physical activity, smoking status, alcohol intake, BMI, history of diabetes, total intake of energy, SFA, grains, vegetables, and dietary fiber, if not stratified.

After additional adjustment for skipped breakfast, sensitivity analyses showed that the relationship among major cardiovascular events, myocardial infarction, new-onset stroke, and macronutrient intake remained consistent with the previous results, with a more significant p trend Supplementary Table 3.

Our study demonstrated that, based on this nationally representative sample of Chinese adults, adequate energy intake at breakfast might be associated with major cardiovascular events and stroke. Second, we also found that a relatively higher intake of carbohydrates at breakfast was associated with a lower risk of cardiovascular disease.

By contrast, a higher intake of protein and fat at breakfast was positively associated with the risk of cardiovascular disease. The link between the proportion of breakfast carbohydrates, protein, and fat intake and reduced cardiovascular events was stronger in participants without hypertension.

Previous studies have focused on the relationship between breakfast consumption and cardiovascular and metabolic disorders. The higher the breakfast energy intake, the lower the risk of CVD, as demonstrated in Western countries 10 , We also found that more energy intakes at breakfast may reduce the risk of stroke in men, which was consistent with the CIRCS study in the Japanese population An animal experiment showed that high energy intake at breakfast reversed the expression of disrupted clock genes and had beneficial effects on lipid control

However, significant interactions were tested between macronutrient intake and a history of hypertension. We conducted stratification analyses to investigate the effect of percentage energy from carbohydrate, protein, and fat intake at breakfast on health outcomes.

The higher percentage of energy from carbohydrate intake was associated with a lower risk of major cardiovascular events and new-onset stroke in participants without the presence of hypertension at baseline Supplementary Figure 1.

On the contrary, a percentage of energy from protein or fat intake was positively associated with risks of major cardiovascular events and new-onset stroke in participants without hypertension Supplementary Figures 2 , 3.

Figure 4. Stratified analyses by the history of hypertension at baseline of the association between breakfast energy intake and health outcomes. Adjustments included age, gender, urban or rural location, education level, income, physical activity, smoking status, alcohol intake, BMI, history of diabetes, total intake of energy, SFA, grains, vegetables, and dietary fiber, if not stratified.

After additional adjustment for skipped breakfast, sensitivity analyses showed that the relationship among major cardiovascular events, myocardial infarction, new-onset stroke, and macronutrient intake remained consistent with the previous results, with a more significant p trend Supplementary Table 3.

Our study demonstrated that, based on this nationally representative sample of Chinese adults, adequate energy intake at breakfast might be associated with major cardiovascular events and stroke.

Second, we also found that a relatively higher intake of carbohydrates at breakfast was associated with a lower risk of cardiovascular disease.

By contrast, a higher intake of protein and fat at breakfast was positively associated with the risk of cardiovascular disease. The link between the proportion of breakfast carbohydrates, protein, and fat intake and reduced cardiovascular events was stronger in participants without hypertension.

Previous studies have focused on the relationship between breakfast consumption and cardiovascular and metabolic disorders. The higher the breakfast energy intake, the lower the risk of CVD, as demonstrated in Western countries 10 , We also found that more energy intakes at breakfast may reduce the risk of stroke in men, which was consistent with the CIRCS study in the Japanese population An animal experiment showed that high energy intake at breakfast reversed the expression of disrupted clock genes and had beneficial effects on lipid control In the current study, an important finding was that appropriate intake of energy at breakfast was positively associated with the risk of major CVD and stroke, and the associations were independent of skipping breakfast.

But there was no significant relationship of breakfast energy intake with MI. In conducting independent analyses of breakfast energy intake and MI, the effect of stroke as a factor may have been overlooked as to a few samples that experienced a stroke before MI. This may be due to changes in lifestyle and eating habits following a stroke, which in turn affects the relationship between breakfast energy intake and MI.

As a source of carbohydrates in the body, carbohydrates are one of the essential energy-yielding nutrients for the human body to sustain life activities. In this study, we concluded that energy from carbohydrates at breakfast accounted for Although high intake of carbohydrates was linked to cardiovascular risk factors, it was unknown whether carbohydrate intake at breakfast affects the body.

Our research revealed a very interesting conclusion that a higher intake of breakfast carbohydrates was associated with a reduced risk of CVD, especially in female population, which was contrary to other studies 48 — One reason is possibly that the energy provided by breakfast carbohydrate intake is derived from the calculation of breakfast energy intake in our study rather than total daily energy intake in other studies.

This suggests that a higher intake of carbohydrates, compared to protein and fat at breakfast, was beneficial for preventing cardiovascular events. Interestingly, a systematic review has indicated that carbohydrate quality may be more important than quantity when assessing the relationship between carbohydrate intake and cardiometabolic outcomes Therefore, future studies should further evaluate the association between food sources of breakfast carbohydrates and CVD.

In the current study, there were no associations between source-specific protein intake e. Breakfast protein intake was positively associated with CVD incidence, which was inconsistent with many previous studies 52 , By the comparison of two systematic reviews 26 , 54 , we found differences in the associations between the exposure variables of meat as a food group and protein as a nutrient and CVD.

In addition, to the best of our knowledge, dietary patterns have been undergoing rapid transitions in China over the past two decades. The amount of consuming meat continued to increase dramatically, with livestock and poultry intake far above the recommendations Moreover, adults eating away-from-home meals are more likely to consume processed meat, which may contribute to the burden of CVD.

Considering this may be the reason for the inconsistent results of our study and other studies based on the non-Chinese population. For breakfast fat intake, we found a positive correlation between energy intake from fat and the risk of major cardiovascular events, myocardial infarction, and stroke.

Previous studies have demonstrated the effect of breakfast fat intake on cardiovascular health. Granulocyte colony-stimulating factor G-CSF and granulocyte-monocyte colony-stimulating factor GM-CSF were elevated after a high-fat breakfast, which has implications for adipose tissue inflammation and the risk of developing atherosclerosis Additionally, a crossover clinical trial has suggested that dietary intake of unsaturated fatty acids at breakfast may induce an anti-inflammatory response, in turn affecting cardiometabolic risk Inconsistent with our findings, the replacement of saturated fatty acids with unsaturated fatty acids may reduce cardiovascular risk 21 , However, a recent systematic review showed a lack of rigorous evidence for limiting the consumption of saturated fatty acids or replacing saturated fatty acids with polyunsaturated fatty acids There is much evidence that eating a high-fat breakfast has adverse effects on cardiovascular health, but further well-conducted cohort studies are needed to identify the relationship between types of fatty acids and cardiovascular health.

To our knowledge, this is the first longitudinal study to use a health and nutrition survey database in a large sample population from nine provinces in China.

It is noteworthy that our study yielded somewhat different results from previous studies by a risk assessment of the association between breakfast energy and macronutrient intake and cardiovascular disease. However, our study had some limitations. First, self-reported disease diagnosis was subjective and potentially associated with recall bias.

Second, although the adjustment for socioeconomic and lifestyle factors and intakes of main food groups, unknown confounding factors that we did not account for are possible.

Third, the h meal recall method generally cannot accurately assess daily dietary intake. Breakfast is part of the daily diet, and eating breakfast every day is also a healthy lifestyle advocated by the World Health Organization. Chinese dietary nutritional guidelines also point out that a reasonable diet, part of which is eating breakfast regularly, can reduce the risk of cardiovascular disease.

As the first meal of the day, breakfast is very important for dietary nutrition intake. In conclusion, a higher intake of carbohydrates, and a relatively lower intake of protein and fat at breakfast may contribute to cardiovascular health on the basis of maintaining a moderate energy intake.

This information is of importance in providing nutritional recommendations, especially a reasonable combination of breakfast nutrition for the public. Therefore, in the perspective of the future, we need to further explore the impact of macronutrient quality on cardiovascular disease in addition to macronutrient quantity.

The datasets presented in this study can be found in online repositories. The studies involving human participants were reviewed and approved by the Institutional Review Committees of the University of North Carolina at Chapel Hill and the National Institute of Nutrition and Food Safety, Chinese Center for Disease Control and Prevention.

XD and RY made substantial contributions to the conception and design of the study. XD was a major contributor in writing the first draft of the manuscript.

Data collection and statistical analysis were performed by MM and SK with assistance from XD. RY, JZ, and XT reviewed and commented on the first draft. All authors contributed to the article and approved the submitted version.

This research uses data from China Health and Nutrition Survey CHNS. We are grateful to thank the National Institute for Nutrition and Health, the China Center for Disease Control and Prevention, the Carolina Population Center P2C HD and T32 HD , the University of North Carolina at Chapel Hill, the National Institute for Health NIH; RHD, DK, R24 HD, and RHD , and the NIH Fogarty International Center D43 TW and D43 TW for financial support for the collection and analysis of the CHNS data from to and the future surveys.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.

Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. CVD, cardiovascular disease; MI, myocardial infarction; SFA, saturated fatty acid; SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index; MET, metabolic equivalent of task; CHNS, China health and nutrition survey; SD, stand deviations; CI, confidence interval; HR, hazard ratios.

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Am J Clin Nutr 69 5 — Download references. is a Postdoctoral Fellow Universidad de Castilla-La Mancha—ID UNIVERS , and M. T-S is supported by the Junta de Extremadura PD and European Social Fund FSE.

In addition, this research has been funded by the FEDER, the FSE and the Junta de Extremadura, with grant numbers GR Departamento de Expresión Plástica, Musical y Dinámica, Facultad de Educación, Universidad de Murcia UM , Murcia, Región of Murcia, Spain. Health and Social Research Center, Universidad de Castilla-La Mancha UCLM , , Cuenca, Spain.

Departamento de Didáctica de la Expresión Musical, Plástica y Corporal, Grupo Análisis Comportamental de la Actividad Física y el Deporte ACAFYDE , Facultad de Formación del Profesorado, Universidad de Extremadura, Av.

de la Universidad, , Cáceres, Spain. Navarrabiomed, Hospital Universitario de Navarra HUN , Universidad Pública de Navarra UPNA , IdiSNA, , Pamplona, Navarra, Spain.

You can also search for this author in PubMed Google Scholar. JFL-G and AG-H were involved in the conception and design of the study.

JFL-G, AG-H, PAS-M, and MATS were responsible for the acquisition and collation of data. JFL-G performed the analyses and wrote the initial manuscript. AG-H, PAS-M, and MATS critically revised the manuscript for important intellectual content.

All authors have read and approved the final manuscript. Correspondence to Pedro Antonio Sánchez-Miguel. The Bioethics Committee of the University of Murcia ID Nº.

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Reprints and permissions. López-Gil, J. et al. Skipping breakfast and excess weight among young people: the moderator role of moderate-to-vigorous physical activity. Eur J Pediatr , — Download citation. Received : 09 February Revised : 09 May Accepted : 10 May Published : 01 June Issue Date : August Anyone you share the following link with will be able to read this content:.

Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Download PDF. Abstract The present study aimed to test whether the daily minutes of moderate-to-vigorous physical activity MVPA engaged moderate the relationship between breakfast status and excess weight i.

Association between breakfast frequency and physical activity and sedentary time: a cross-sectional study in children from 12 countries Article Open access 21 February Use our pre-submission checklist Avoid common mistakes on your manuscript. Introduction Excess weight understood as the sum of overweight and obesity in young people is one of the most relevant concerns in global public health, although it arose as a serious matter some decades ago [ 1 ].

Methods Population and study design All primary and secondary schools in the Valle de Ricote Region of Murcia, Spain were asked to take part in this research. Anthropometric measures To measure the body height of participants, a portable height rod precision: 0.

Moderate-to-vigorous physical activity Participants fulfilled the Physical Activity Questionnaire for Adolescents PAQ-A or the Physical Activity Questionnaire for Older Children PAQ-C to provide an estimation of the time spent in MVPA during the last seven days [ 29 , 30 ].

Full size image. Table 2 Association between daily minutes of moderate-to-vigorous physical activity and breakfast status and excess weight status Full size table. Discussion The present study suggested that the relationship between skipping breakfast and excess weight was moderated by daily minutes of MVPA in two Spanish regions.

Availability of data and materials The data generated and analyzed for the current study are available at reasonable request to the corresponding author. Code availability Not applicable.

Abbreviations BMI: Body mass index KIDMED: Mediterranean Diet Quality Index for children and teenagers MVPA: Moderate-to-vigorous physical activity MVPA PA: Physical activity PAQ-A: Physical Activity Questionnaire for Adolescents PAQ-C: Physical Activity Questionnaire for Older Children OR: Odds ratio SES: Socioeconomic status WHO: World Health Organization.

References Lobstein T, Jackson-Leach R, Moodie ML et al Child and adolescent obesity: part of a bigger picture. Guilford Press Serra-Majem L, Ribas L, Ngo J et al Food, youth and the Mediterranean diet in Spain.

WHO Press Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J Development of a WHO growth reference for school-aged children and adolescents. Rev Esp Salud Publica 83 3 — Article Google Scholar Bervoets L, Van Noten C, Van Roosbroeck S et al Reliability and validity of the Dutch Physical Activity Questionnaires for Children PAQ-C and Adolescents PAQ-A.

Dekker Monteagudo C, Palacín-Arce A, Bibiloni M del M et al Proposal for a Breakfast Quality Index BQI for children and adolescents. l42 Betts JA, Chowdhury EA, Gonzalez JT, Richardson JD, Tsintzas K, Thompson D Is breakfast the most important meal of the day? Funding Open Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature.

Author information Authors and Affiliations Departamento de Expresión Plástica, Musical y Dinámica, Facultad de Educación, Universidad de Murcia UM , Murcia, Región of Murcia, Spain José Francisco López-Gil Health and Social Research Center, Universidad de Castilla-La Mancha UCLM , , Cuenca, Spain José Francisco López-Gil Departamento de Didáctica de la Expresión Musical, Plástica y Corporal, Grupo Análisis Comportamental de la Actividad Física y el Deporte ACAFYDE , Facultad de Formación del Profesorado, Universidad de Extremadura, Av.

View author publications. Ethics declarations Ethics approval The Bioethics Committee of the University of Murcia ID Nº. Consent to participate Informed consent was obtained from all subjects involved in the study.

Consent for publication Written informed consent has been obtained from the patients to publish this paper. Conflict of interest The authors declare no competing interests.

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