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Association of Skipping Breakfast With Cardiovascular and All-Cause Mortality

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Background: Skipping breakfast is common among U.S. adults. Limited evidence suggests that skipping breakfast is associated with atherosclerosis and cardiovascular disease. Objectives: The authors sought to examine the association of skipping breakfast with cardiovascular and all-cause mortality. Methods: This is a prospective cohort study of a nationally representative sample of 6,550 adults 40 to 75 years of age who participated in the National Health and Nutrition Examination Survey III 1988 to 1994. Frequency of breakfast eating was reported during an in-house interview. Death and underlying causes of death were ascertained by linkage to death records through December 31, 2011. The associations between breakfast consumption frequency and cardiovascular and all-cause mortality were investigated by using weighted Cox proportional hazards regression models. Results: Among the 6,550 participants (mean age 53.2 years; 48.0% male) in this study, 5.1% never consumed breakfast, 10.9% rarely consumed breakfast, 25.0% consumed breakfast some days, and 59.0% consumed breakfast every day. During 112,148 person-years of follow-up, 2,318 deaths occurred including 619 deaths from cardiovascular disease. After adjustment for age, sex, race/ethnicity, socioeconomic status, dietary and lifestyle factors, body mass index, and cardiovascular risk factors, participants who never consumed breakfast compared with those consuming breakfast everyday had hazard ratios of 1.87 (95% confidence interval: 1.14 to 3.04) for cardiovascular mortality and 1.19 (95% confidence interval: 0.99 to 1.42) for all-cause mortality. Conclusions: In a nationally representative cohort with 17 to 23 years of follow-up, skipping breakfast was associated with a significantly increased risk of mortality from cardiovascular disease. Our study supports the benefits of eating breakfast in promoting cardiovascular health.
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SPECIAL FOCUS ISSUE: CARDIOVASCULAR HEALTH PROMOTION
Association of Skipping Breakfast With
Cardiovascular and All-Cause Mortality
Shuang Rong, MD, PHD,
a,b
Linda G. Snetselaar, PHD,
b
Guifeng Xu, MD,
b
Yangbo Sun, MD, PHD,
b
Buyun Liu, MD, PHD,
b
Robert B. Wallace, MD,
b
Wei Bao, MD, PHD
b,c,d
ABSTRACT
BACKGROUND Skipping breakfast is common among U.S. adults. Limited evidence suggests that skipping breakfast is
associated with atherosclerosis and cardiovascular disease.
OBJECTIVES The authors sought to examine the association of skipping breakfast with cardiovascular and all-cause mortality.
METHODS This is a prospective cohort study of a nationally representative sample of 6,550 adults 40 to 75 years of age
who participated in the National Health and Nutrition Examination Survey III 1988 to 1994. Frequency of breakfast
eating was reported during an in-house interview. Death and underlying causes of death were ascertained by linkage
to death records through December 31, 2011. The associations between breakfast consumption frequency and
cardiovascular and all-cause mortality were investigated by using weighted Cox proportional hazards regression models.
RESULTS Among the 6,550 participants (mean age 53.2 years; 48.0% male) in this study, 5.1% never consumed
breakfast, 10.9% rarely consumed breakfast, 25.0% consumed breakfast some days, and 59.0% consumed breakfast
every day. During 112,148 person-years of follow-up, 2,318 deaths occurred including 619 deaths from cardiovascular
disease. After adjustment for age, sex, race/ethnicity, socioeconomic status, dietary and lifestyle factors, body mass
index, and cardiovascular risk factors, participants who never consumed breakfast compared with those consuming
breakfast everyday had hazard ratios of 1.87 (95% condence interval: 1.14 to 3.04) for cardiovascular mortality
and 1.19 (95% condence interval: 0.99 to 1.42) for all-cause mortality.
CONCLUSIONS In a nationally representative cohort with 17 to 23 years of follow-up, skipping breakfast was
associated with a signicantly increased risk of mortality from cardiovascular disease. Our study supports the
benets of eating breakfast in promoting cardiovascular health. (J Am Coll Cardiol 2019;73:202532)
© 2019 by the American College of Cardiology Foundation.
Cardiovascular disease (CVD) remains the
leading cause of death in the United States
and worldwide. Over the past decades,
numerous dietary and lifestyle risk factors have
been identied for CVD morbidity and mortality,
forming the basis of the American Heart Associations
Diet and Lifestyle Recommendations for Americans.
However, previous dietary studies have focused
mainly on dietary compositions and their
combinations, such as dietary fats, seafood, and Med-
iterranean diet pattern, and so on. Less is known
about the impact of common eating behaviors on
CVD outcomes.
Breakfast is believed to be an important meal of
the day, whereas there has been an increasing prev-
alence of skipping breakfast over the past 50 years in
the United States, with as many as 23.8% of young
people skipping breakfast every day (13). However,
ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2019.01.065
From the
a
Department of Nutrition and Food Hygiene, School of Public Health, Medical College, Wuhan University of Science and
Technology, Wuhan, China;
b
Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa;
c
Obesity
Research and Education Initiative, University of Iowa, Iowa City, Iowa; and the
d
Fraternal Order of Eagles Diabetes Research
Center, University of Iowa, Iowa City, Iowa. The authors have reported that they have no relationships relevant to the contents of
this paper to disclose.
Manuscript received September 3, 2018; revised manuscript received December 8, 2018, accepted January 8, 2019.
Listen to this manuscripts
audio summary by
Editor-in-Chief
Dr. Valentin Fuster on
JACC.org.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.73,NO.16,2019
ª2019 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER
studies on the health effects of skipping
breakfast are sparse. Accumulating evidence,
although still limited, suggests that skipping
breakfast is associated with increased risk of
overweight/obesity (2,4), dyslipidemia (5,6),
hypertension (7,8), type 2 diabetes (9,10),
metabolic syndrome (11),coronaryheartdis-
ease (12), and cerebrovascular disease (13).It
is imperative to understand the long-term
health impact of skipping breakfast on cardio-
vascular mortality in the general population.
The aim of our study was to examine the
association of skipping breakfast with cardio-
vascular and all-cause mortality in a nationally
representative cohort in the United States.
METHODS
STUDY POPULATION. The National Health and Nutri-
tion Examination Survey (NHANES), conducted by
the National Center for Health Statistics (NCHS) at the
Centers for Disease Control and Prevention (CDC), is a
large-scale, multistage, ongoing, nationally repre-
sentative health survey of the civilian noninstitu-
tionalized population in the United States (1416).
Each survey participant completed a household
interview followed by a physical examination in a
mobile examination center. NHANES has been
approved by the NCHS Ethics Review Board. Written
informed consent was obtained from all participants.
In this study, we used data from NHANES III
(1988 to 1994), because information on breakfast
eating was available during that period. NHANES III
was conducted in two 3-year phases (1988 to 1991
and 1991 to 1994). Of the 39,695 participants in the
NHANES III, 33,994 (86%) were interviewed in their
homes by trained staff. Seventy-eight percent
(30,818) of the selected persons were examined in the
mobile examination center, and an additional 493
persons were given a special, limited examination in
their homes. Detailed descriptions of NHANES III
procedures, interviewing, questionnaires and data
collection, quality control techniques, survey design,
nonresponse, and sample weighting have been
described extensively (17,18).
We included participants 40 to 75 years of age who
were free of a history CVD or cancer disease at base-
line and had mortality follow-up information
including underlying cause of death. Considering in-
dividuals at exceptionally high risk of death may
change their dietary intake, and therefore, their diet
information may no longer represent their habitual
consumption, we excluded those who died within
12 months of their NHANES III health examination.
After further exclusion of participants who were
pregnant, who had missing information on frequency
of breakfast consumption, and who had daily total
energy intake <500 kcal or >5,000 kcal, 6,550 sub-
jectswereincludedastheanalyticalsample.
OUTCOME ASCERTAINMENT. We used the NHANES
III Public-Use Linked Mortality File through
December 31, 2011, which was linked by the NCHS to
the National Death Index with a probabilistic match-
ing algorithm to determine the mortality status (19).
National Death Index is an NCHS centralized database
of all deaths in the United States. Data about under-
lying cause of death were used for case denition
according to the 9th Revision International Statistical
Classication of Diseases (ICD-9) through 1998, and
the remainder for case denition according to the
10th Revision (ICD-10). In order to adjust for changes
between the 2 coding systems, nal causes of deaths
occurring before 1999 were recorded into comparable
ICD-10based underlying-cause-of-death groups (19).
The NCHS classied mortality from heart diseases,
including acute rheumatic fever and chronic rheu-
matic heart diseases (codes I00I09), hypertensive
heart disease (codes I11), hypertensive heart and renal
disease (codes I13), ischemic heart diseases (codes
I20I25) and other heart diseases (codes I26I51), and
mortality from cerebrovascular disease (i.e., stroke)
(codes I60I69) according to ICD-10 (20).Wedened
deaths from CVD as death from either heart disease or
cerebrovascular disease. Follow-up of participants
continued until death, with censoring at the time of
death for those who died of causes other than CVD, or
on December 31, 2011, for those who survived.
Follow-up time for each person was calculated as the
difference between the NHANES III examination date
and the last known date alive or censored from the
NHANES III mortality le.
EXPOSURE MEASUREMENT. All participants were
asked How often do you eat breakfast?during the
household interview, and the possible answers
included every day,”“some days,”“rarely,”“never,
and weekends only.We merged the answer week-
ends onlyinto the category some daysfor analysis.
Finally, the frequency of breakfast eating was classi-
ed as never,”“rarely,”“some days,and every day.
COVARIATE ASSESSMENT. Information on age, sex,
race/ethnicity, family income, smoking status, alco-
holic intake, and physical activity was collected using
standardized questionnaires during interviews. Race/
ethnicity was classied as non-Hispanic white, non-
Hispanic black, Mexican American, or other. Marital
status was categorized as married (married and living
SEE PAGE 2033
ABBREVIATIONS
AND ACRONYMS
BMI =body mass index
CDC =Centers for Disease
Control and Prevention
CI =condence interval
CVD =cardiovascular disease
HEI2010 =Healthy Eating
Index2010
HR =hazard ratio
ICD =International Statistical
Classication of Diseases
NCHS =National Center for
Health Statistics
NDI =National Death Index
NHANES =National Health and
Nutrition Examination Survey
Rong et al.JACC VOL. 73, NO. 16, 2019
Skipping Breakfast and Mortality APRIL 30, 2019:202532
2026
as married), widowed, divorced, and single (never
married and separated). Family income-to-poverty
ratios were categorized as #1.30, 1.31 to 3.50, and
>3.50. A higher income-to-poverty ratio represents a
higher family income status. Participants were cate-
gorized as nonsmoker, past smoker, and current
smokers based on their responses to questions about
smoking at least 100 cigarettes during their lifetime
and whether they were currently smoking. The
amount of alcohol consumed was determined based
on the responses to 2 survey queries that questioned
thenumberofdaysofdrinkingoverthepast
12 months and the number of drinks per day on a
given drinking day (21). Current alcohol intake was
categorizedasnone(0g/day),moderatedrinking(0.1
to 27.9 g/day for men and 0.1 to 13.9 g/day for
women), and heavy drinking ($28 g/day for men
and $14 g/d for women) (22). For physical activity,
theinactivegroupwasdened as those with no re-
ported leisure time physical activity, the active group
was dened as those who had recommended levels of
physical activity (23) (i.e., self-reported leisure time
moderate activity [metabolic equivalents ranging
from 3 to 6] of 5 or more times per week or leisure
time vigorous activity [metabolic equivalents >6] 3 or
more times per week), and the insufciently active
group was dened as those who were not inactive and
did not meet the criteria for recommended levels of
physical activity. Dietary information was collected
through 24-h dietary recall interviews. Total energy
intake was calculated using the U.S. Department of
Agriculture Automated Multiple-Pass Method. We
used the Healthy Eating Index2010 (HEI2010) to
indicate the overall quality of diet (HEI2010 score
from 0 to 100, with 100 being the best-quality diet)
(24).
Measurements of height, weight, and blood pres-
sure were performed following a standardized pro-
tocol. Body mass index (BMI) was calculated as
weight in kilograms divided by height in meters
squared (kg/m
2
,<25, 25 to 29.9, $30) (18).Hyper-
tension was dened as currently taking antihyper-
tensive medication, or if not, having systolic blood
pressure level $130 mm Hg and/or diastolic blood
pressure level $80 mm Hg, according to the 2017
American College of Cardiology/American Heart As-
sociation hypertension guidelines (25).Diabeteswas
dened as having been diagnosed with diabetes or
currently taking insulin or were taking diabetes pills,
or having a hemoglobin A
1c
level $6.5% or a fasting
plasma glucose level $126 mg/dl (26). Dyslipidemia
was dened as having a physicians diagnosis or
currently taking cholesterol-lowering medications, or
having a triglyceride level $150 mg/dl or high-density
lipoprotein cholesterol level <40 mg/dl based on
recommendations by the National Cholesterol Edu-
cation Program Adult Treatment Panel III (27).
STATISTICAL ANALYSIS. All statistical analyses
accounted for the complex, multistage, stratied, and
cluster-sampling design (including oversampling of
certain subpopulations) of NHANES by using sample
weights, strata, and primary sampling units
embedded in the NHANES data. Means and pro-
portions of baseline characteristics were compared by
using linear regression for continuous variables and
logistic regression for categorical variables. The as-
sociations between breakfast consumption frequency
and cardiovascular and all-cause mortality were
investigated by using Cox proportional hazards
regression models with the following covariates: age,
sex, and race/ethnicity (model 1); model 1 plus marital
status,familyincomelevel,smokingstatus,alcohol
intake, and physical activity (model 2); model 2 plus
total energy intake and overall diet quality indicated
by HEI2010 (model 3). We further adjusted for BMI,
hypertension (yes/no), diabetes (yes/no), and dysli-
pidemia (yes/no) in a separate model (model 4). We
have checked model assumptions for all the analyses.
All statistical analyses were conducted using survey
modules of SAS software version 9.4 (SAS Institute,
Cary, North Carolina). Two-sided p values <0.05 was
considered statistically signicant.
RESULTS
Among the 6,550 participants 40 to 75 years of age
(mean age 53.2 years, SE 0.3; 48.0% male) in this
study, 5.1% (n ¼336) never consumed breakfast,
10.9% (n ¼713) rarely consumed breakfast, 25.0%
(n ¼1,639) consumed breakfast some days, and 59.0%
(n ¼3,862) consumed breakfast every day. During
112,148 person-years of follow-up (median follow-up
18.8 years; maximum follow-up 23 years), 2,318
deaths occurred including 619 deaths from CVD. As
shown in Table 1, participants who never consumed
breakfast were more likely to be non-Hispanic black,
former smokers, heavy drinkers, unmarried, physi-
cally inactive, and with less family income, lower
total energy intake, and poorer dietary quality, when
compared with those who regularly ate breakfast. As
shown in Table 2, participants who never consumed
breakfast were more likely to have obesity, and
higher total blood cholesterol level than those who
consumed breakfast regularly.
Participants who never consumed breakfast were
at higher risk for death from CVD. After adjustment
forage,sex,andrace/ethnicity,participantswho
never consumed breakfast had a 75% higher risk of
JACC VOL. 73, NO. 16, 2019 Rong et al.
APRIL 30, 2019:202532 Skipping Breakfast and Mortality
2027
all-cause mortality (hazard ratio [HR]: 1.75; 95% con-
dence interval [CI]: 1.46 to 2.10) and 2.58-fold higher
risk of cardiovascular mortality(HR:2.58;95%CI:
1.64 to 4.06) compared with those who consumed
breakfast every day. In the fully adjusted model, the
multivariable-adjusted HRs for all-cause mortality
and cardiovascular mortality for participants who
never consumed breakfast were 1.19 (95% CI: 0.99 to
1.42) and 1.87 (95% CI: 1.14 to 3.04), respectively
(Table 3, Central Illustration). Sensitivity analysis
excluding participants with diabetes yielded similar
results for both all-cause mortality and CVD mortality
(data not shown).
We further examined the associations of
breakfast eating with heart diseasespecicand
stroke-specic mortality separately (Table 4).
Comparedwiththosewhoconsumedbreakfast
every day, participants who never consumed
breakfast had a higher risk of heart diseasespecic
mortality (HR: 2.34; 95% CI: 1.44 to 3.80) and
stroke-specic mortality (HR: 3.53; 95% CI: 1.40 to
8.95) in models adjusted for age, sex, race/ethnicity
(Table 4). In the fully-adjusted model, the associa-
tion between skipping breakfast and heart disease-
specic mortality was moderately attenuated and
became non-signicant(HR:1.59;95%CI:0.90to
TABLE 1 Baseline Demographic and Lifestyle Characteristics of the Study Population, Accordin g to the Frequency of
Breakfast Consumption
Frequency of Breakfast Consumption
pValue
Every Day
(n ¼3,862)
Some Days
(n ¼1,639)
Rarely
(n ¼713)
Never
(n ¼336)
Mean age, yrs 55.62 0.31 49.47 0.40 49.54 0.40 52.82 0.85 0.005
Sex, %
Male 45.81 1.05 52.59 1.53 49.49 3.06 46.40 4.22 0.030
Female 54.19 1.05 47.41 1.53 50.51 3.06 53.60 4.22
Race/ethnicity, %
Non-Hispanic white 79.77 1.43 75.69 1.75 79.18 1.82 68.62 4.14 <0.001
Non-Hispanic black 7.98 0.52 14.73 1.09 11.56 1.14 13.20 1.67
Hispanic 4.16 0.39 4.34 0.35 3.57 0.36 4.13 0.75
Other 8.09 1.24 5.24 1.12 5.69 1.32 14.05 4.11
Marital status, %
Married 73.92 1.01 73.93 1.58 73.24 2.46 68.60 4.08 0.593
Widowed 7.80 0.57 6.42 0.81 6.94 1.19 9.99 2.10
Divorced 10.30 0.90 11.43 1.15 13.43 1.88 12.43 2.24
Single 7.89 0.64 8.06 0.91 6.31 1.35 8.65 3.49
Ratio of family income to poverty, %
#1.30 7.71 0.73 8.80 1.32 9.26 1.62 12.30 2.92 0.193
1.313.50 34.59 1.40 35.22 1.90 33.87 2.54 41.76 3.96
>3.50 50.45 1.88 50.39 2.36 50.56 3.43 38.71 3.56
Missing 7.25 0.55 5.59 0.84 6.32 1.56 7.23 2.25
Smoking status, %
Nonsmoker 47.63 1.40 36.00 1.36 29.75 2.95 24.84 3.32 <0.001
Current smoking 34.82 1.09 30.27 1.52 33.70 3.21 26.86 4.03
Former smokers 17.56 1.01 33.73 1.57 36.55 3.59 48.30 4.32
Alcohol drinking status, %*
Nondrinker 76.42 1.24 72.11 2.29 66.24 3.41 70.12 3.61 <0.001
Moderate drinking 7.96 0.78 8.03 1.09 7.98 1.93 5.07 1.27
Heavy drinking 11.17 1.01 15.92 1.68 21.44 2.52 17.22 2.53
Missing 4.44 0.64 3.95 0.84 4.34 1.19 7.59 2.69
Physical activity, %
Inactive 13.84 0.96 14.76 1.30 15.56 1.58 28.34 2.55 <0.001
Insufcient 41.39 1.59 50.95 1.66 50.00 2.49 34.93 2.94
Recommended level 44.77 1.77 34.29 1.63 34.44 2.57 36.74 4.19
Mean total energy intake, kcal/day 2,010.85 24.99 2,097.99 32.81 2,022.21 43.43 1,733.58 54.70 <0.001
Mean HEI2010 68.08 0.40 61.30 0.58 60.40 0.67 57.53 1.17 <0.001
Values are weighted mean SE for continuous variables or weighted % SE for categorical variables. *Nondrinker: 0 g/day; moderate drinking: 0.1 to 27.9 g/day for men and
0.1 to 13.9 g/day for women; heavy drinking: $28 g/day for men and $14 g/day for women.
HEI2010 ¼Healthy Eating Index2010.
Rong et al.JACC VOL. 73, NO. 16, 2019
Skipping Breakfast and Mortality APRIL 30, 2019:202532
2028
2.80). However, the association between skipping
breakfast and stroke-specic mortality remained
signicant (HR: 3.39; 95% CI: 1.40 to 8.24).
DISCUSSION
In this large prospective study of a nationally repre-
sentative cohort with 17 to 23 years of follow-up,
we found that skipping breakfast was signicantly
associated with an increased risk of cardiovascular
mortality, especially stroke-specic mortality. The
association was independent of demographic, socio-
economic, dietary, and lifestyle factors; BMI; and
cardiovascular risk factors.
To the best of our knowledge, this is the rst pro-
spective analysis of skipping breakfast and risk of
cardiovascular mortality. Our ndings are generally
in line with previous studies on the relationship
between breakfast eating and CVD incidence. A
cohort of male U.S. health professionals showed that
men who skipped breakfast had a 27% higher risk of
coronary heart disease compared with men who ate
breakfast (12). Another prospective cohort study of a
Japanese general population indicated 14%, 18%,
and 36% greater risks for incident total CVD, total
stroke, and hemorrhage stroke, respectively, among
those skipping breakfast (13). A cross-sectional anal-
ysis performed within the Progression of Early Sub-
clinical Atherosclerosis study indicated that skipping
breakfast was associated with increased odds for
prevalent noncoronary and generalized atheroscle-
rosis independently of the presence of conventional
cardiovascular risk factors (28). Recently, habitual
breakfast skippers were found at increased risk for
development of coronary artery disease and hyper-
tension in Western India (29). In addition, longitudi-
nal studies also showed that skipping breakfast
may have detrimental effects on cardiometabolic risk
factors, including general obesity, abdominal obesity,
metabolic syndrome, hypertension, and higher fast-
ing insulin, total cholesterol, and low-density lipo-
protein cholesterol concentrations (6,11).Taken
together,thesestudiesaswellasourndings
TABLE 2 Distribution of CVD Risk Factors of the Study Population, According to the Frequency of Breakfast Consumption
CVD Risk Factors
Frequency of Breakfast Consumption
Every Day
(n ¼3,862)
Some Days
(n ¼1,639)
Rarely
(n ¼713)
Never
(n ¼336) p Value
BMI categories, %
<25.0 37.45 1.44 33.88 1.70 38.34 3.13 35.09 3.75 0.001
25.029.9 37.21 1.23 37.43 2.07 33.98 2.50 29.53 3.41
$30.0 25.23 1.16 28.65 1.74 27.65 2.50 34.21 4.16
Hypertension, % 54.97 1.16 51.48 1.76 53.21 3.13 53.15 4.04 0.050
DBP, mm Hg 76.46 0.23 77.45 0.41 77.78 0.50 77.14 0.68 0.269
SBP, mm Hg 127.79 0.48 125.10 0.74 125.49 0.86 127.50 1.43 0.919
Diabetes, % 15.14 0.99 10.75 1.12 8.91 1.58 17.13 3.00 <0.001
Fasting glucose, mg/dl 104.24 0.90 100.84 1.20 100.55 2.02 107.56 3.31 0.338
Dyslipidemia, % 46.70 1.85 46.90 1.85 41.39 2.60 47.75 4.02 0.199
TC, mg/dl 216.09 1.41 214.05 1.53 220.59 2.02 225.72 3.51 0.005
LDL-c, mg/dl 135.39 1.61 135.72 1.86 140.54 2.58 141.19 6.55 0.304
HDL-c, mg/dl 50.81 0.51 49.74 0.63 52.35 0.98 50.98 1.50 0.478
TG, mg/dl 161.54 4.77 153.61 3.59 148.03 6.87 167.40 7.41 0.690
Values are weighted % SE for categorical variables or weighted mean SE for continuous variables.
BMI ¼body mass index; CVD ¼cardiovascular disease; DBP ¼diastolic blood pressure; HDL-c ¼high-density lipoprotein cholesterol; LDL-c ¼low-density lipoprotein
cholesterol; SBP ¼systolic blood pressure; TC ¼total cholesterol; TG ¼triglycerides.
TABLE 3 Associations of Breakfast Consumption Frequency With Cardiovascular and
All-Cause Mortality in U.S. Adults 40 to 75 Years of Age
Frequency of Breakfast Consumption
Every Day Some Days Rarely Never
CVD mortality
Deaths/person-yrs 415/64,594 114/29,290 49/12,655 41/5,609
Unadjusted 1 (ref) 0.55 (0.390.77) 0.63 (0.391.01) 1.79 (1.023.15)
Model 1 1 (ref) 1.09 (0.801.49) 1.29 (0.802.08) 2.58 (1.644.06)
Model 2 1 (ref) 0.96 (0.701.32) 1.10 (0.671.81) 1.93 (1.163.19)
Model 3 1 (ref) 0.94 (0.671.31) 1.10 (0.671.80) 1.84 (1.123.03)
Model 4 1 (ref) 0.95 (0.671.33) 1.13 (0.681.86) 1.87 (1.143.04)
All-cause mortality
Deaths/person-yrs 1,533/64,594 462/29,290 198/12,655 125/5,609
Unadjusted 1 (ref) 0.67 (0.560.80) 0.67 (0.530.84) 1.27 (0.991.64)
Model 1 1 (ref) 1.18 (1.011.38) 1.22 (0.951.55) 1.75 (1.462.10)
Model 2 1 (ref) 1.01 (0.861.19) 1.01 (0.771.30) 1.23 (1.021.49)
Model 3 1 (ref) 1.00 (0.841.18) 0.98 (0.751.27) 1.17 (0.961.42)
Model 4 1 (ref) 1.00 (0.851.18) 0.99 (0.761.28) 1.19 (0.991.42)
Values are n or weighted hazard ratio (95% condence interval). Model 1: adjusted for age, sex, and race/
ethnicity. Model 2: model 1 þmarital status, family income level, smoking status, alcohol intake, physical activity.
Model 3: model 2 þtotal energy intake and overall diet quality indicated by Healthy Eating Index-2010. Model 4:
model 3 þbody mass index, hypertension, diabetes mellitus, and dyslipidemia.
CVD ¼cardiovascular disease.
JACC VOL. 73, NO. 16, 2019 Rong et al.
APRIL 30, 2019:202532 Skipping Breakfast and Mortality
2029
underscore the importance of eating breakfast as a
simple way to promote cardiovascular health and
prevent cardiovascular morbidity and mortality.
Skipping breakfast is related to less daily total en-
ergy intake. In this study, participants who never
consumed breakfast had 14% less daily total energy
intake,comparedwiththosewhoconsumedbreakfast
every day. However, the reduced calorie intake may
not explain the observed association between skip-
ping breakfast and higher risk of cardiovascular
mortality, because animal studies and some previous
epidemiological studies have reported protective
effects of caloric restriction on reducing the risk of
chronic diseases and mortality (30,31). Several
mechanisms may explain how skipping breakfast may
induce cardiometabolic abnormalities and ultimately
lead to cardiovascular mortality. First, skipping
breakfast, which is related to changes in appetite and
decreased satiety, might lead to overeating later and
impairment in insulin sensitivity (3234). By contrast,
eating breakfast has a benecial effect on appetite
regulation and also improves the glycemic response
at the next eating occasion with increased sensitivity
to insulin (35,36). Second, skipping breakfast was
CENTRAL ILLUSTRATION Hazard Ratios for Mortality From All Causes, Cardiovascular Disease, Heart Disease,
and Stroke Based on Frequency of Breakfast Consumption
Cause of Death
Cardiovascular disease
Every day
Some days
Rarely
Never
All-cause
Every day
Some days
Rarely
Never
Heart disease
Every day
Some days
Rarely
Never
Stroke
Every day
Some days
Rarely
Never
1 (ref)
0.95 (0.67 to 1.33)
1.87 (1.14 to 3.04)
1.13 (0.68 to 1.86)
1 (ref)
1.00 (0.85 to 1.18)
1.19 (0.99 to 1.42)
0.99 (0.76 to 1.28)
1 (ref)
0.90 (0.61 to 1.34)
1.59 (0.90 to 2.80)
1.22 (0.72 to 2.08)
1 (ref)
1.11 (0.53 to 2.32)
3.39 (1.40 to 8.24)
0.66 (0.26 to 1.66)
Hazard Ratios (95% CI)
9.08.07.06.05.0
Hazard Ratios and 95% Confidence Interval
4.03.02.01.00.0 10.0–1.0
Rong, S. et al. J Am Coll Cardiol. 2019;73(16):202532.
Hazard ratios were adjusted for age, sex, race/ethnicity, marital status, family income level, smoking status, alcohol intake, physical activity, total energy intake, overall
diet quality indicated by Healthy Eating Index2010, body mass index, hypertension, diabetes mellitus, and dyslipidemia. Horizontal lines represent 95% condence
intervals. CI ¼condence interval.
Rong et al.JACC VOL. 73, NO. 16, 2019
Skipping Breakfast and Mortality APRIL 30, 2019:202532
2030
associated with stress-independent overactivity in
the hypothalamic-pituitary-adrenal axis because of a
longer period of fasting, leading to elevated blood
pressure in the morning (7). Eating breakfast has also
been shown to help lower blood pressure (37,38),
which in turn may prevent blood vessel clogging,
hemorrhage, and cardiovascular events. Third, skip-
ping breakfast might also induce deleterious changes
in lipid levels, such as higher total cholesterol and
atherogenic low-density lipoprotein cholesterol con-
centrations, which are independent risk factors of
atherosclerosis (6,28).Fourth,skippingbreakfastmay
be a behavioral marker for unhealthy dietary and
lifestyle habits (39). However, in this study, we have
adjusted for a variety of dietary and lifestyle factors
including smoking, alcohol drinking, physical activ-
ity, total energy intake, and overall diet quality, and
the association between skipping breakfast and car-
diovascular mortality remained signicant.
STUDY STRENGTHS. The major strengths of this
population-based study are the use of a nationally
representative sample, which facilitates generaliza-
tion of the ndings to the general population in the
United States, the long-term follow-up period of up to
23 years, and the low rates of unmatched records in
the NHANES III Linked Mortality File. In addition,
with the comprehensive data collected in NHANES III,
we were able to control potential confounding effects
from a variety of demographic, socioeconomic, life-
style, and dietary factors.
STUDY LIMITATIONS. First, we did not have infor-
mation about what foods and beverages NHANES III
participants consumed for breakfast. Beyond the
health benets of eating breakfast compared with
skipping breakfast, it is interesting to understand
how different choices of foods and beverages for
breakfast will affect mortality risk. Second, we were
not able to assess the effects of changes in breakfast
eating habits during the follow-up on cardiovascular
and all-cause mortality, because information on
breakfast eating in NHANES III was collected only at
baseline. Third, the NHANES III Linked Mortality File
identied causes of death through linkage to the
NationalDeathIndex,whichisbasedondeathcer-
ticates. Although this approach has been previously
validated by the CDC and used in many CDC reports
or relevant published reports, we could not rule out
the possibility of errors in classication of the cause
of death. Finally, although we have adjusted for many
potential confounders, we could not completely rule
out the possibility of residual confounding by un-
measured factors.
CONCLUSIONS
In this large prospective study of U.S. adults 40 to 75
years of age, we found that skipping breakfast was
signicantly associated with an increased risk of
death from CVD. Our study supports the benets of
eating breakfast in promoting cardiovascular health.
ACKNOWLEDGMENTS The authors thank the partic-
ipants and staff of the National Health and Nutrition
Examination Survey III 1988 to 1994 for their valuable
contributions.
ADDRESS FOR CORRESPONDENCE: Dr. Wei Bao,
Department of Epidemiology, College of Public
Health, University of Iowa, 145 North Riverside Drive,
Room S431 CPHB, Iowa City, Iowa 52242. E-mail:
wei-bao@uiowa.edu. Twitter: @UIowaCPH.
TABLE 4 Associations of Breakfast Consumption Frequency With Heart Disease and
Stroke Mortality in U.S. Adults 40 to 75 Years of Age
Frequency of Breakfast Consumption
Every Day Some Days Rarely Never
Heart disease mortality
Deaths/person-yrs 312/64,594 88/29,290 39/12,655 33/5,609
Unadjusted 1 (ref) 0.55 (0.370.81) 0.71 (0.421.21) 1.61 (0.902.87)
Model 1 1 (ref) 1.09 (0.761.56) 1.45 (0.862.45) 2.34 (1.443.80)
Model 2 1 (ref) 0.94 (0.651.36) 1.22 (0.712.09) 1.71 (0.992.98)
Model 3 1 (ref) 0.90 (0.621.33) 1.19 (0.692.03) 1.58 (0.902.78)
Model 4 1 (ref) 0.90 (0.611.34) 1.22 (0.722.08) 1.59 (0.902.80)
Stroke mortality
Deaths/person-yrs 103/64,594 26/29,290 10/12,655 8/5,609
Unadjusted 1 (ref) 0.55 (0.291.05) 0.32 (0.140.73) 2.57 (0.907.35)
Model 1 1 (ref) 1.09 (0.552.12) 0.66 (0.281.55) 3.53 (1.408.95)
Model 2 1 (ref) 1.01 (0.512.00) 0.59 (0.241.46) 2.99 (1.217.40)
Model 3 1 (ref) 1.07 (0.532.15) 0.64 (0.261.59) 3.25 (1.347.90)
Model 4 1 (ref) 1.11 (0.532.32) 0.66 (0.261.66) 3.39 (1.408.24)
Values are n or weighted hazard ratio (95% condence interval). Model 1: adjusted for age, sex, and race/
ethnicity. Model 2: model 1 þmarital status, family income level, smoking status, alcohol intake, and physical
activity. Model 3: model 2 þtotal energy intake and overall diet quality indicated by Healthy Eating Index-2010.
Model 4: model 3 þbody mass index, hypertension, diabetes mellitus, and dyslipidemia.
PERSPECTIVES
COMPETENCY IN MEDICAL KNOWLEDGE: Regularly skip-
ping breakfast in a middle-aged and older population without
known CVD is associated with an increased risk of death from
CVD.
TRANSLATIONAL OUTLOOK: Further studies are needed to
elucidate the biological mechanisms underlying this association
to optimize the impact of a targeted intervention that might
improve cardiovascular health.
JACC VOL. 73, NO. 16, 2019 Rong et al.
APRIL 30, 2019:202532 Skipping Breakfast and Mortality
2031
REFERENCES
1. Haines PS, Guilkey DK, Popkin BM. Trends in
breakfast consumption of US adults between 1965
and 1991. J Am Diet Assoc 1996;96:46470.
2. Deshmukh-Taskar P, Nicklas TA, Radcliffe JD,
ONeil CE, Liu Y. 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 2013;16:207382.
3. Kant AK, Graubard BI. 40-year trends in meal
and snack eating behaviors of American adults.
J Acad Nutr Diet 2015;115:5063.
4. van der Heijden AA, Hu FB, Rimm EB, van
Dam RM. A prospective study of breakfast con-
sumption and weight gain among U.S. men.
Obesity (Silver Spring) 2007;15:24639.
5. Farshchi HR, Taylor MA, Macdonald IA. Delete-
rious effects of omitting breakfast on insulin
sensitivity and fasting lipid proles in healthy lean
women. Am J Clin Nutr 2005;81:38896.
6. Smith KJ, Gall SL, McNaughton SA, Blizzard L,
Dwyer T, Venn AJ. Skipping breakfast: longitudinal
associations with cardiometabolic risk factors in
the Childhood Determinants of Adult Health
Study. Am J Clin Nutr 2010;92:131625.
7. Witbracht M, Keim NL, Forester S, Widaman A,
Laugero K. Female breakfast skippers display a
disrupted cortisol rhythm and elevated blood
pressure. Physiol Behav 2015;140:21521.
8. Lee TS, Kim JS, Hwang YJ, Park YC. Habit of
eating breakfast is associated with a lower risk of
hypertension. J Lifestyle Med 2016;6:647.
9. Ballon A, Neuenschwander M, Schlesinger S.
Breakfast skipping is associated with increased risk
of type 2 diabetes among adults: a systematic
review and meta-analysis of prospective cohort
studies. J Nutr 2019;149:10613.
10. Bi H, Gan Y, Yang C, Chen Y, Tong X, Lu Z.
Breakfast skipping and the risk of type 2 diabetes:
a meta-analysis of observational studies. Public
Health Nutr 2015;18:30139.
11. Odegaard AO, Jacobs DR Jr., Steffen LM, Van
Horn L, Ludwig DS, Pereira MA. Breakfast fre-
quency and development of metabolic risk. Dia-
betes Care 2013;36:31006.
12. Cahill LE, Chiuve SE, Mekary RA, et al. Pro-
spective study of breakfast eating and incident
coronary heart disease in a cohort of male US
health professionals. Circulation 2013;128:33743.
13. Kubota Y, Iso H, Sawada N, Tsugane S,
Group JS. Association of breakfast intake with
incident stroke and coronary heart disease: the
Japan Public Health Center-Based Study. Stroke
2016;47:47781.
14. National Center for Health Statistics. Plan and
Operation of the Third National Health and
Nutrition Examination Survey (NHANES III, 1988-
94): Reference Manuals and Reports: Weighting
and Estimation Methodology Report. Hyattsville,
MD: Centers for Disease Control and Prevention,
1998.
15. National Center for Health Statistics. National
Health and Nutrition Examination Survey: NHANES
Questionnaires, Datasets, and Related Documen-
tation. Available at: https://wwwn.cdc.gov/nchs/
nhanes/Default.aspx. Accessed January 28, 2012.
16. Ahluwalia N, Dwyer J, Terry A, Moshfegh A,
Johnson C. Update on NHANES dietary data: focus
on collection, release, analytical considerations,
and uses to inform public policy. Adv Nutr 2016;7:
12134.
17. National Center for Health Statistics, U.S.
Department of Health and Human Services.
NHANES III Reference Manuals and Reports (CD-
ROM). Hyattsville, MD: Centers for Disease Con-
trol and Prevention, 1996.
18. Plan and operation of the Third National
Health and Nutrition Examination Survey, 1988-
94. Series 1: programs and collection procedures.
Vital Health Stat 1 1994:1407.
19. National Center for Health Statistics. NCHS
2011 Linked Mortality Files Matching Methodol-
ogy. Hyattsville, MD: Ofce of Analysis and
Epidemiology, 2013.
20. World Health Organization. International Sta-
tistical Classication of Diseases and Related
Health Problems: Tenth Revision. 2nd edition.
Geneva, Switzerland: World Health Organization,
2004.
21. Liangpunsakul S. Relationship between alcohol
intake and dietary pattern: ndings from NHANES
III. World J Gastroenterol 2010;16:405560.
22. U.S. Department of Agriculture and U.S.
Department of Health and Human Services. 2015
2020 Dietary Guidelines for Americans. 8 edition.
Washington, DC: U.S. Government Printing Ofce,
2015.
23. Pate RR, Pratt M, Blair SN, et al. Physical ac-
tivity and public health. A recommendation from
the Centers for Disease Control and Prevention
and the American College of Sports Medicine.
JAMA 1995;273:4027.
24. Retnakaran R, Qi Y, Connelly PW, Sermer M,
Hanley AJ, Zinman B. Low adiponectin concen-
tration during pregnancy predicts postpartum in-
sulin resistance, beta cell dysfunction and fasting
glycaemia. Diabetologia 2010;53:26876.
25. Whelton PK, Carey RM, Aronow WS, et al. 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/
NMA/PCNA guidelinefor the prevention, detection,
evaluation,and management of high bloodpressure
in adults: executive summary: a report of the
American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guide-
lines. J Am Coll Cardiol 2018;71:2199269.
26. Menke A, Casagrande S, Geiss L, Cowie CC.
Prevalence of and trends in diabetes among adults
in the United States, 1988-2012. JAMA 2015;314:
10219.
27. National Cholesterol Education Program
(NCEP). Expert Panel on Detection Evaluation, and
Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III). Third Report of the
National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III) nal report. Circulation
2002;106:3143421.
28. Uzhova I, Fuster V, Fernandez-Ortiz A, et al.
The importance of breakfast in atherosclerosis
disease: insights from the PESA study. J Am Coll
Cardiol 2017;70:183342.
29. Sharma K, Shah K, Brahmbhatt P, Kandre Y.
Skipping breakfast and the risk of coronary artery
disease. QJM 2018;111:7159.
30. Most J, Tosti V, Redman LM, Fontana L. Cal-
orie restriction in humans: an update. Ageing Res
Rev 2017;39:3645.
31. Ahmet I, Tae HJ, de Cabo R, Lakatta EG,
Talan MI. Effects of calorie restriction on car-
dioprotection and cardiovascular health. J Mol Cell
Cardiol 2011;51:26371.
32. Alwattar AY, Thyf ault JP, Leidy HJ. T he effect
of breakfast typ e and frequency o f consumption
on glycemic response in overweight/obese l ate
adolescent girl s. Eur J Clin Nutr 2 015;69:
88590.
33. Astbury NM, Taylor MA, Macdonald IA.
Breakfast consumption affects appetite, energy
intake, and the metabolic and endocrine re-
sponses to foods consumed later in the day in
male habitual breakfast eaters. J Nutr 2011;141:
13819.
34. Reutrakul S, Hood MM, Crowley SJ,
Morgan MK, Teodori M, Knutson KL. The rela-
tionship between breakfast skipping, chronotype,
and glycemic control in type 2 diabetes. Chrono-
biol Int 2014;31:6471.
35. Jovanovic A, Gerrard J, Taylor R. The second-
meal phenomenon in type 2 diabetes. Diabetes
Care 2009;32:1199201.
36. Gwin JA, Leidy HJ. A review of the evidence
surrounding the effects of breakfast consumption
on mechanisms of weight management. Adv Nutr
2018;9:71725.
37. Ahuja KD, Robertson IK, Ball MJ. Acute effects
of food on postprandial blood pressure and mea-
sures of arterial stiffness in healthy humans. Am J
Clin Nutr 2009;90:298303.
38. Peitzman SJ, Berger SR. Postprandial blood
pressure decrease in well elderly persons. Arch
Intern Med 1989;149:2868.
39. Park S, Rim SJ, Lee JH. Associations between
dietary behaviours and perceived physical and
mental health status among Korean adolescents.
Nutr Diet 2018;75:48893.
KEY WORDS all-cause mortality,
cardiovascular mortality, skipping breakfast
Rong et al.JACC VOL. 73, NO. 16, 2019
Skipping Breakfast and Mortality APRIL 30, 2019:202532
2032
... 29 Of note, long-term human intervention studies of eating plans that involve fasting are rare, because of ethical and feasibility reasons. The few prospective cohort studies of eating timing and frequency and risk of incident CAD events (such as a myocardial infarction) reported inconclusive results, [30][31][32] although the topic has not yet been researched among solely the most extreme cases causing hospitalization and mortality, or in a Canadian population. Definitions of eating timing and frequency patterns (breakfast, eating occasions, snacks, and meals) and CAD varied across these studies, making comparison among them difficult. ...
... This method of examining potential mediation was used in previous studies of eating timing and frequency. 30,32,41,42 In models in which eating frequency was the main exposure, we also adjusted for breakfast (yes, no). Values were coded as "missing" if they were unavailable at baseline (< 1% for most covariates; < 10%-14% for household income and BMI). ...
... 49 However, unlike in the present study, stroke was included in the definition of cardiovascular disease in 3 of the 4 included studies, which has a modestly different etiologic pathway than CAD. Three of the 4 studies included in the same meta-analysis examined the association between skipping breakfast and CAD separately and found that skipping breakfast was not significantly associated with risk of CAD after adjustment for various potential confounders and/or mediators, [30][31][32] which is in line with our findings. For example, a recent prospective cohort study of a nationally representative sample of adults in the US indicated that people who never consumed breakfast, compared with those consuming breakfast every day, had a 3.39-fold higher risk of stroke-specific mortality (95% CI: 1.40-8.24), ...
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... However, in our study, we did not find a relationship between the frequency of eating breakfast and hypertension. Thus, our findings are quite similar to Rong et al. (2019), who also found no correlation between eating breakfast and hypertension. The ratio of hypertensive versus normotensive participants and the mean age of our sample could explain the results obtained [36]. ...
... Thus, our findings are quite similar to Rong et al. (2019), who also found no correlation between eating breakfast and hypertension. The ratio of hypertensive versus normotensive participants and the mean age of our sample could explain the results obtained [36]. ...
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... Skipping breakfast is one cause of later meal timing; adults who skipped breakfast consumed a greater amount of food at lunch and dinner [48] and breakfast consumption is associated with higher socioeconomic status [49]. The benefits of consuming breakfast have been well-documented [52,53], however, many adults skip breakfast worldwide [49,[54][55][56]. Non-Hispanic Whites and Non-Hispanic Blacks have been reported as the groups that are most likely and least likely to consume breakfast, respectively [49]. ...
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To investigate the potential role of apple polyphenol extract (APE) in the prevention and alleviation of circadian rhythm disturbances, eighty male C57BL/6 mice fed a high-fat diet (HFD) were randomized into four groups: 24 h ad libitum feeding (AL), 12 h restricted nighttime feeding (NF) or daytime feeding (DF), and daytime feeding with APE intragastric administration (DF-APE). Five weeks later, the mice were sacrificed at 6 h intervals over 24 h. Disrupted fluctuations in serum lipid profiles and hormones, along with desynchronization of circadian clock genes and metabolic genes were observed after daytime HFD feeding. However, APE treatment improved hepatic steatosis and recovered circadian rhythms of Cry1/2, and genes Acc and Hsl related to lipid synthesis and hydrolysis of cholesteryl esters, and Cyp7a1 in bile acid synthesis. In conclusion, the present study provides new evidence revealing that the circadian clock might be a novel target for APE to regulate metabolic homeostasis.
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Atrial fibrillation is the most common form of arrhythmia and can result in significant morbidity and mortality. While there are many potential causes of atrial fibrillation that have been well studied, this work considers the potential effect of chronically skipping meals on the development of atrial fibrillation. The authors discuss the various processes that skipping meals initiates in the body that may ultimately result in atrial fibrillation. Through a better understanding of the various disease pathophysiologies that can contribute to the development of atrial fibrillation, this narrative review may help lead to more advanced therapeutic and preventive approaches.
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The recommendation to eat breakfast has received scrutiny due to insufficient causal evidence for improvements in weight management. Despite the limited number of randomized controlled trials examining the effects of breakfast consumption compared with skipping breakfast on weight loss, an increasing number of studies target the hormonal and behavioral mechanisms underlying weight management. This review provides a comprehensive examination of the intervention-based clinical trials that test whether breakfast consumption improves appetite control and satiety as well as energy expenditure compared with skipping breakfast. Several factors were considered when interpreting the body of evidence. These include, but were not limited to, the following: the composition of breakfast, with a specific focus on dietary protein; meal size and form; and habitual breakfast behaviors. The evidence within this review shows positive to neutral support for the inclusion of breakfast for improvements in appetite control, satiety, and postprandial energy expenditure. The protein content, energy content, and form of the meal (i.e., beverages compared with foods) are key modulating factors for ingestive behavior and energy expenditure mechanisms. Specifically, breakfast meals containing a larger amount of protein (≥30 g protein/meal) and energy (≥350 kcal/meal) and provided as solid foods increased the magnitude of the appetite and satiety response compared with breakfast skipping. Longer-term randomized controlled trials including the measurement of ingestive behavior and weight management are needed to identify the role of breakfast for health promotion.
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Background/introduction: Nutritional studies have indicated a critical role of dietary habits in development of cardiovascular diseases (CVD). Aim: We aimed to compare the risk of coronary artery disease (CAD) in habitual "breakfast skippers" with those of "habitual breakfast eaters" in Western part of India. We also planned to compare the cardiometabolic profile of both the groups. Design: In this prospective, case-control study of 1607 individuals; 980 were patients of CAD (cases) undergoing various cardiac interventions for revascularization and other 627 were healthy individuals (controls) who were free from CVD. Methods: Details of demographics and classical risk factors were collected for all the participants. Subjects were categorized as "breakfast eater" or "breakfast skippers" according to their response to the questionnaire. Logistic regression and correlation analysis were performed to assess the independent risk of all the factors and their inter-variable association. Results: Significantly (p < 0.05) high prevalence of classical risk factors and breakfast skipping habit were found in cases as compared to controls. Diabetes showed the highest odds ratio (7.296; 95% CI - 4.825 - 11.030; p < 0.0001) for CAD, followed by hypertension (3.756; 95% CI - 2.891 - 4.881; p < 0.0001) and habits of smoking/tobacco/alcohol consumption (1.914; 95% CI - 1.528 - 2.398; p < 0.0001) and breakfast skipping 1.348 (95% CI - 1.076 - 1.689; p < 0.0001). Breakfast skipping emerged as stronger risk factor than obesity and sedentary life style in Indians and showed close association with hypertension. Discussion/conclusion: Habitual breakfast skippers are at increased risk for development of CAD and hypertension in Western India.
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Background The association between skipping breakfast and cardio-metabolic syndrome is well known. However, there are very few Korean studies about the habit of eating breakfast and hypertension. The present study aimed to investigate the relationship between the habit of eating breakfast and hypertension in a healthy Korean population. Methods Participants in the 2014 Korea National Health and Nutrition Examination Surveys (KNHANES) were enrolled for this study. Medical history, including hypertension, was measured using a 24-hour recall method. The habit of eating breakfast was estimated from self-reported questionnaires and was classified into two groups: the eating breakfast group, defined as those who ate breakfast more than 5 times per week, and the not eating breakfast group, defined as those who did not eat any breakfast for a week. Results The crude odds ratio of skipping breakfast for the prevalence of hypertension was 0.366. However, after adjusting for all considerable confounding factors (age, sex, regular exercise, current smoking, systolic blood pressure, diastolic blood pressure, body mass index, waist circumference, and red blood cell counts), not eating breakfast was associated with a higher risk of HTN (OR = 1.065; 95% CI = 1.057–1.073; p-value < 0.001) Conclusion The habit of eating breakfast was associated with a lower risk of hypertension among healthy Korean adults.
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NHANES is the cornerstone for national nutrition monitoring to inform nutrition and health policy. Nutritional assessment in NHANES is described with a focus on dietary data collection, analysis, and uses in nutrition monitoring. NHANES has been collecting thorough data on diet, nutritional status, and chronic disease in cross-sectional surveys with nationally representative samples since the early 1970s. Continuous data collection began in 1999 with public data release in 2-y cycles on ∼10,000 participants. In 2002, the Continuing Survey of Food Intakes by Individuals and the NHANES dietary component were merged, forming a consolidated dietary data collection known as What We Eat in America; since then, 24-h recalls have been collected on 2 d using the USDA's Automated Multiple-Pass Method. Detailed and targeted food-frequency questionnaires have been collected in some NHANES cycles. Dietary supplement use data have been collected (in detail since 2007) so that total nutrient intakes can be described for the population. The continuous NHANES can adapt its content to address emerging public health needs and reflect federal priorities. Changes in data collection methods are made after expert input and validation/crossover studies. NHANES dietary data are used to describe intake of foods, nutrients, food groups, and dietary patterns by the US population and large sociodemographic groups to plan and evaluate nutrition programs and policies. Usual dietary intake distributions can be estimated after adjusting for day-to-day variation. NHANES remains open and flexible to incorporate improvements while maintaining data quality and providing timely data to track the nation's nutrition and health status. In summary, NHANES collects dietary data in the context of its broad, multipurpose goals; the strengths and limitations of these data are also discussed in this review.
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Background: Epidemiologic studies have indicated that breakfast skipping is associated with risk of type 2 diabetes. However, the shape of the dose-response relation and the influence of adiposity on this association have not been reported. Objective: We investigated the association between breakfast skipping and risk of type 2 diabetes by considering the influence of the body mass index (BMI). Methods: In this systematic review and meta-analysis, PubMed and Web of Science were searched up to August 2017. Prospective cohort studies on breakfast skipping and risk of type 2 diabetes in adults were included. Summary RRs and 95% CIs, without and with adjustment for BMI, were estimated with the use of a random-effects model in pairwise and dose-response meta-analyses. Results: In total 6 studies, based on 96,175 participants and 4935 cases, were included. The summary RR for type 2 diabetes comparing ever with never skipping breakfast was 1.33 (95% CI: 1.22, 1.46, n = 6 studies) without adjustment for BMI, and 1.22 (95% CI: 1.12, 1.34, n = 4 studies) after adjustment for BMI. Nonlinear dose-response meta-analysis indicated that risk of type 2 diabetes increased with every additional day of breakfast skipping, but the curve reached a plateau at 4-5 d/wk, showing an increased risk of 55% (summary RR: 1.55; 95% CI: 1.41, 1.71). No further increase in risk of type 2 diabetes was observed after 5 d of breakfast skipping/wk (P for nonlinearity = 0.08). Conclusions: This meta-analysis provides evidence that breakfast skipping is associated with an increased risk of type 2 diabetes, and the association is partly mediated by BMI.
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Aim To investigate the associations between a wide range of dietary behaviours and self‐reported physical and mental health status in a representative sample of Korean adolescents. Methods Data from the 2016 Korea Youth Risk Behaviour Web‐based Survey were used. Participants were middle‐ and high‐school students (n = 65 528) in grades 7–12. Participants’ dietary behaviours were assessed using questionnaires on three encouraged dietary behaviours (consumption of fruits, vegetables, and milk) and three discouraged behaviours (skipping breakfast and consumption of fast food and soft drinks). Participants were also asked to rate their perceived general and oral health, happiness, sleep satisfaction, stress, depressed mood, and suicidal ideation. Results After adjusting for sex, school grade, residential area, socioeconomic status, and other dietary behaviours, a high intake of fast food and soft drink and frequent skipping of breakfast were all associated with worse physical and mental health status. Moreover, a high intake of fruits, vegetables, and milk were associated with better perceived general health, oral health, happiness, and sleep satisfaction. Conclusions Our data suggest that existing encouraged dietary habits mostly have beneficial effects on perceived physical and mental health in Korean adolescents. However, the cross‐sectional study design prevents our ability to assess causal relationships.
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Background: Daily habits, including the number and quality of eating occasions, are potential targets for primary prevention strategies with large health impacts. Skipping breakfast is considered a frequent and unhealthy habit associated with an increased cardiovascular (CV) risk. Objectives: The study sought to explore the association between different breakfast patterns and CV risk factors and the presence, distribution, and extension of subclinical atherosclerosis. Methods: Cross-sectional analysis was performed within the PESA (Progression of Early Subclinical Atherosclerosis) study, a prospective cohort of asymptomatic (free of CV events at baseline) adults 40 to 54 years of age. Lifestyle and multivascular imaging data along with clinical covariates were collected from 4,052 participants. Multivariate logistic regression models were used in the analysis. Results: Three patterns of breakfast consumption were studied: high-energy breakfast, when contributing to >20% of total daily energy intake (27% of the population); low-energy breakfast, when contributing between 5% and 20% of total daily energy intake (70% of the population); and skipping breakfast, when consuming <5% of total daily energy (3% of the population). Independent of the presence of traditional and dietary CV risk factors, and compared with high-energy breakfast, habitual skipping breakfast was associated with a higher prevalence of noncoronary (odds ratio: 1.55; 95% confidence interval: 0.97 to 2.46) and generalized (odds ratio: 2.57; 95% confidence interval: 1.54 to 4.31) atherosclerosis. Conclusion: Skipping breakfast is associated with an increased odds of prevalent noncoronary and generalized atherosclerosis independently of the presence of conventional CV risk factors. (Progression of Early Subclinical Atherosclerosis [PESA]; NCT01410318).
Article
Calorie restriction (CR), a nutritional intervention of reduced energy intake but with adequate nutrition, has been shown to extend healthspan and lifespan in rodent and primate models. Accumulating data from observational and randomized clinical trials indicate that CR in humans results in some of the same metabolic and molecular adaptations that have been shown to improve health and retard the accumulation of molecular damage in animal models of longevity. In particular, moderate CR in humans ameliorates multiple metabolic and hormonal factors that are implicated in the pathogenesis of type 2 diabetes, cardiovascular diseases, and cancer, the leading causes of morbidity, disability and mortality. In this paper, we will discuss the effects of CR in non-obese humans on these physiological parameters. Special emphasis is committed to recent clinical intervention trials that have investigated the feasibility and effects of CR in young and middle-aged men and women on parameters of energy metabolism and metabolic risk factors of age-associated disease in great detail. Additionally, data from individuals who are either naturally exposed to CR or those who are self-practicing this dietary intervention allows us to speculate on longer-term effects of more severe CR in humans.
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Background and purpose: The association between breakfast intake and the risk of cardiovascular disease, including stroke, among Asian people remains unknown. We sought to prospectively investigate whether the omission of breakfast is related to increased risks of stroke and coronary heart disease in general Japanese populations. Methods: A total of 82 772 participants (38 676 men and 44 096 women) aged 45 to 74 years without histories of cardiovascular disease or cancer were followed up from 1995 to 2010. Participants were classified as having breakfast 0 to 2, 3 to 4, 5 to 6, or 7 times/wk. The hazard ratios of cardiovascular disease were estimated using Cox proportional hazards models. Results: During the 1 050 030 person-years of follow-up, we documented a total of 4642 incident cases, 3772 strokes (1051 cerebral hemorrhages, 417 subarachnoid hemorrhages, and 2286 cerebral infarctions), and 870 coronary heart disease. Multivariable analysis showed that those consuming no breakfast per week compared with those consuming breakfast everyday had hazard ratios (95% confidence interval; P for trend) of 1.14 (1.01-1.27; 0.013) for total cardiovascular disease, 1.18 (1.04-1.34; 0.007) for total stroke, and 1.36 (1.10-1.70; 0.004) for cerebral hemorrhage. Similar results were observed even after exclusion of early cardiovascular events. No significant association between the frequency of breakfast intake and the risk of coronary heart disease was observed. Conclusions: The frequency of breakfast intake was inversely associated with the risk of stroke, especially cerebral hemorrhage in Japanese, suggesting that eating breakfast everyday may be beneficial for the prevention of stroke.
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Objective: To encourage increased participation in physical activity among Americans of all ages by issuing a public health recommendation on the types and amounts of physical activity needed for health promotion and disease prevention. Participants: A planning committee of five scientists was established by the Centers for Disease Control and Prevention and the American College of Sports Medicine to organize a workshop. This committee selected 15 other workshop discussants on the basis of their research expertise in issues related to the health implications of physical activity. Several relevant professional or scientific organizations and federal agencies also were represented. Evidence: The panel of experts reviewed the pertinent physiological, epidemiologic, and clinical evidence, including primary research articles and recent review articles. Consensus process: Major issues related to physical activity and health were outlined, and selected members of the expert panel drafted sections of the paper from this outline. A draft manuscript was prepared by the planning committee and circulated to the full panel in advance of the 2-day workshop. During the workshop, each section of the manuscript was reviewed by the expert panel. Primary attention was given to achieving group consensus concerning the recommended types and amounts of physical activity. A concise "public health message" was developed to express the recommendations of the panel. During the ensuing months, the consensus statement was further reviewed and revised and was formally endorsed by both the Centers for Disease Control and Prevention and the American College of Sports Medicine. Conclusion: Every US adult should accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week.