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ntroduction There is an increasing awareness regarding the effects of chrono-nutrition on glycemic control and weight regulation. Therefore, this study aimed to determine the relationship between breakfast skipping and late�night eating to body mass index and glycemic control among patients with type 2 diabetes. Subjects and methods This cross-sectional study was conducted among 310 patients with diabetes in Tabuk City, Saudi Arabia during the period from December 2020 to April 2021. A structured questionnaire was used to interview the participants, the following were reported: demographic data, breakfast skipping, late-night eating, smoking, level of exercise, family history of diabetes, and diabetes complications. Weight and height were measured to calculate the body mass index (BMI), and the last glycated hemoglobin was collected to estimate the degree of glycemic control. Statistical Package for Social Sciences (SPSS Statistics, IBM Corp., Armonk, USA) was used for data analysis. The ethical committee of the University of Tabuk approved the research. Results Out of 310 patients with diabetes (54.8% women), nearly half (45.2%) were breakfast-skippers and 20% eat late at night. Breakfast skipping was correlated with BMI (Wald, 5.481, 95% CI, 0.154-0.847, P-value, 0.019). A positive direct correlation was evident between late dinner intake, BMI, and HbA1c (Wald, 4.210, 95% CI, 0.743-0.993, P-value, 0.04 for HbA1c, and Wald, 6.777, 95% CI, 1.0221-1.165, P-value, 0.009 for BMI). Conclusion Breakfast skipping and late dinner intake were associated with obesity, while only late dinner consumption was associated with poor glycemic control. Further larger multi-center studies investigating the chronotype and glycemic index are recommended.
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The Effect of Breakfast Skipping and Late Night
Eating on Body Mass Index and Glycemic Control
Among Patients With Type 2 Diabetes Mellitus
Hyder Mirghani
1. Internal Medicine, University of Tabuk, Tabuk, SAU
Corresponding author: Hyder Mirghani, s.hyder63@hotmail.com
Abstract
Introduction
There is an increasing awareness regarding the effects of chrono-nutrition on glycemic control and weight
regulation. Therefore, this study aimed to determine the relationship between breakfast skipping and late-
night eating to body mass index and glycemic control among patients with type 2 diabetes.
Subjects and methods
This cross-sectional study was conducted among 310 patients with diabetes in Tabuk City, Saudi Arabia
during the period from December 2020 to April 2021. A structured questionnaire was used to interview the
participants, the following were reported: demographic data, breakfast skipping, late-night eating, smoking,
level of exercise, family history of diabetes, and diabetes complications. Weight and height were measured to
calculate the body mass index (BMI), and the last glycated hemoglobin was collected to estimate the degree
of glycemic control. Statistical Package for Social Sciences (SPSS Statistics, IBM Corp., Armonk, USA) was
used for data analysis. The ethical committee of the University of Tabuk approved the research.
Results
Out of 310 patients with diabetes (54.8% women), nearly half (45.2%) were breakfast-skippers and 20% eat
late at night. Breakfast skipping was correlated with BMI (Wald, 5.481, 95% CI, 0.154-0.847, P-value, 0.019).
A positive direct correlation was evident between late dinner intake, BMI, and HbA1c (Wald, 4.210, 95% CI,
0.743-0.993, P-value, 0.04 for HbA1c, and Wald, 6.777, 95% CI, 1.0221-1.165, P-value, 0.009 for BMI).
Conclusion
Breakfast skipping and late dinner intake were associated with obesity, while only late dinner consumption
was associated with poor glycemic control. Further larger multi-center studies investigating the chronotype
and glycemic index are recommended.
Categories: Endocrinology/Diabetes/Metabolism
Keywords: breakfast skipping, late-night eating, hba1c, obesity, saudi arabia
Introduction
Diabetes mellitus is a global health burden and the number is increasing at an alarming rate. Currently, 285
million are affected by this lifelong morbid metabolic disorder. The number is projected to reach 438 million
by the year 2030 and the Kingdom of Saudi Arabia is among the countries with the highest prevalence,
according to International Diabetes Federation [1, 2].
Lifestyle management is a fundamental aspect of diabetes care from the initial evaluation through regular
follow-up, assessment for complications, and subsequent management. Nutrition therapy plays an integral
role for every patient with diabetes mellitus, and every diabetic patient should receive individualized
nutritional therapy. The American Diabetes Association recommends the glycated hemoglobin (HbA1c) be
targeted to <7 to prevent or delay the microvascular complications. For patients with type 2 diabetes
mellitus, medical nutrition therapy is associated with 0.5-2% glycated hemoglobin reduction [3,4].
Breakfast skipping among adults is associated with insulin resistance, hypertension, elevated lipids
concentration, and increasing body weight. Eating late at night (late dinner) regardless of meal composition
had been linked to higher cardiovascular disease risk [5]. On the other hand, a recent review indicated that
the consumption of whole grains and cereal fiber in breakfast and limiting rapidly available carbohydrates
lowers insulinemia and glycemia [6].
Many factors have been suggested to link type 2 diabetes mellitus and breakfast skipping including
1
Open Access Original
Article DOI: 10.7759/cureus.15853
How to cite this article
Mirghani H (June 23, 2021) The Effect of Breakfast Skipping and Late Night Eating on Body Mass Index and Glycemic Control Among Patients With
Type 2 Diabetes Mellitus. Cureus 13(6): e15853. DOI 10.7759/cureus.15853
nocturnal activity, decreased appetite, smoking, and lack of exercise, but the mechanisms are poorly
understood. Furthermore, the habit of breakfast skipping could be associated with late dinner owing to
various factors including fatigue, poor appetite, and lack of time [7].
The meal timing and the daily rhythm of feeding-fasting are emerging as important health determinants.
Previous literature observed that decreased length of overnight fasting or increased late-night eating
enhances the risk of metabolic diseases like diabetes and obesity. The daily eating pattern is a possible
significant modifiable aspect of lifestyle to contain metabolic disorders [8].
To the best of our knowledge, no researchers have assessed breakfast skipping and dinner timing effects on
BMI and HbA1c. Given the above and the fact that glycemic control is an essential element in the prevention
of microvascular complications, we conducted this research. In the present study, we aimed to assess
breakfast skipping and late dinner intake among patients with type 2 diabetes and their relation to glycemic
control.
Materials And Methods
Study type and participants
This cross-sectional study was conducted among 310 diabetic patients in Tabuk City, the Kingdom of Saudi
Arabia. A stratified random sampling technique was used to select the participants. The patients were
already diagnosed with the diseases according to the American Diabetes Association guidelines.
Inclusion and exclusion criteria
All adults with type 2 diabetes mellitus were included, those with type 1 diabetes and pregnant ladies were
excluded from the study. The study was conducted during the period from December 2020 to April 2021.
Sample size
The sample size was calculated using the following formula: n=Z2 P-Q/d2 where Z=95% confidence (1.96),
P=rate of diabetes mellitus in Saudi Arabia [9].
Measures
A structured questionnaire was used to collect the following: age, sex, level of education, the diabetes
medications, the diabetes complications, family history of diabetes mellitus, the frequency of breakfast
intake, and dinner consumption within the last two hours before sleeping, the level of exercise, and smoking
status. The most recent glycated hemoglobin was reported to assess the degree of glycemic control.
The weight and height of all the participants were measured, and the body mass index was calculated using
the formula: BMI = Weight in Kg/(Height in meters)2
For this research, the following definitions were adopted:
· Normal weight = BMI 18.5-24.9
· Overweight = 25-29.5
· Obese = 30-40
· Morbid obesity >40
· Breakfast was defined as any food or beverages consumed between 5:00 a.m. and 10:00 a.m. [7]
· Late dinner: eating dinner within two hours before bedtime at least three times per week [10]
· Breakfast skipping: Skipping the breakfast at least three times per week [10]
Participants signed a written informed consent and the ethical committees of the University of Tabuk
approved the research (ref. number, UT-155-118-2021).
Statistical analysis
The Statistical Package for Social Sciences (SPSS Statistics version 20, IBM Corp., Armonk, USA) was used for
data analysis. Binary logistic regression analysis was used to compare breakfast-skippers and late dinner
eaters with non-skippers and early dinner eaters. The data were presented as percentages or mean± SD
unless otherwise specified and a P-value of <0.05 was considered significant.
2021 Mirghani et al. Cureus 13(6): e15853. DOI 10.7759/cureus.15853 2 of 6
Results
Among the participants (54.8% women), 77.7% were either obese (50.7%) or overweight (27%), the majority
(74.8%) were not reaching glycemic targets, and nearly a half (45.2%) were breakfast-skippers and 20% eat
late at night. Regarding diabetes complications, retinopathy was reported in 17.4% while 3.2% and 5.2% had
nephropathy and a history of coronary artery disease, respectively. In the current study, 60% reported a
family history of diabetes mellitus, 18.8% were cigarette smokers, and 20% were practicing exercise five
times/week and for 30 minutes (Table 1).
Character No %
Sex Women Men 170 (54.8%) 140 (45.2%)
BMI Obese Overweight Normal 154 (50.7%) 82 (27%) 68 (22.4%)
Glycemic control Poor (≤7) Good (>7) 332 (74.8%) 78 (25.2%)
Skipping breakfast 140 (45.2%)
Eating late in the night 62 (20%)
Retinopathy 54 (17.4%)
Nephropathy 10 (3.2%)
History of coronary artery disease 16 (5.2)
Family history of diabetes 186 (60%)
On regular exercise 62 (20%)
Smoking 58 (18.8%)
TABLE 1: Basic Characters of the Study Group
The current data showed that the mean age was 55.05±9.90 years, the glycated hemoglobin was 8.96±2.47,
and the body mass index was 31.01±7.57s. Table 2.
Character Mean± SD
Age 55.05±9.90
BMI 31.01±7.57
HbA1c8.96±2.47
TABLE 2: Age, BMI, and the Glycated Hemoglobin Among the Study Group
In the current study, breakfast skipping was correlated with BMI (Wald, 5.481, 95% CI, 0.154-0.847, P-value,
0.019); no correlation was evident between skipping breakfast and late dinner consumption (Wald, 0.009,
95% CI, 0.436-2.488, P-value, 0.927), age (Wald, 0.143, 95% CI, 0. 0.960-1.028, P-value, 0.705), sex (Wald,
0.103, 95% CI, 0.571-2.180, P-value, 0.748), and HbA1c (Wald, 0.518, 95% CI, 0.916-1.209, P-value, 0.472)
(Table 3).
2021 Mirghani et al. Cureus 13(6): e15853. DOI 10.7759/cureus.15853 3 of 6
Character Wald df Exp. 95% CI P-value
Age 0.143 1 0.993 0.960-1.028 0.705
Sex 0.103 1 1.116 0.571-2.180 0.748
BMI 5.481 1 0.361 0.154-0.847 0.019
Eating late in the night 0.009 1 1.042 0.436-2.488 0.927
HbA1c 0.518 1 1.052 0.916-1.209 0.472
Constant 0.436 1 2.215 0.509
TABLE 3: The Relationship Between Breakfasts Skipping, Ages, Sex, Eating Late in the Night,
Body Mass Index, HbA1c
HbA1c: glycated hemoglobin; df: degrees of freedom
Regarding the association of late dinner intake, BMI, and HbA1c, positive direct correlations were observed
with a significant statistical difference (Wald, 4.210, 95% CI, 0.743-0.993, P-value, 0.04 for HbA1c, and Wald,
6.777, 95% CI, 1.0221-1.165, P-value, 0.009 for BMI) (Table 4).
Character Wald df Exp. 95% CI P-value
HbA1c4.210 1 0.859 0.743-0.993 0.040
BMI 6.777 1 1.091 1.0221-1.165 0.009
constant 5.481 1 1.273 0.845
TABLE 4: The Relationship Between Eating Late in the Night, Body Mass Index, and HbA1c
HbA1c: glycated hemoglobin; df: degrees of freedom
Discussion
In the present study, nearly half of patients with diabetes skipped breakfast and one in five ate late in the
night. Breakfast skipping and late dinner consumption were associated with obesity. However, a direct
significant relationship was found between poor glycemic control and late dinner but not breakfast skipping.
The current study reported a breakfast-skipping rate of 45.2% in line with a previous study published in
Japan and reported a prevalence of 39.2% [11]. The current findings are in line with a recent study published
in the USA [12]. The association between breakfast skipping and BMI was discussed controversially (some
found an association [13] while others found no relationship [14]). In the present survey, breakfast skipping
was associated with a high BMI, in agreement with Gouda et al. [15].
The current study showed no significant differences between breakfast skipping and glycated hemoglobin.
Similarly, a study published in Japan [7] reported no association between hyperglycemia and breakfast
skipping, and the present data were in contradiction to previous studies [7] that concluded an association
between breakfast skipping and high glycated hemoglobin. The association between breakfast skipping and
diabetes is thought to be mediated by low-grade inflammation and BMI [16]. It is interesting to note that
eating late in the night in our study was associated with both higher BMI and glycated hemoglobin in
agreement with Nakajima and colleagues who reported similar results [7]. The association of breakfast
skipping with obesity and diabetes was observed by previous studies [17, 18]. However, few researchers have
assessed both breakfast skipping and late dinner consumption with obesity and poor glycemic control [7, 11].
The effects of late dinner intake on glycemic control are mediated by prolonging the postprandial glucose
spike. In addition, insulin sensitivity and glucose tolerance decrease during the night [19]. The high
prevalence of poor glycemic control (74.8%) is alarming and supporting previous observations [20]. The
current results imply that meal timing is a cheap applicable preventive and therapeutic intervention for
weight management and improving glycemic target among patients with diabetes mellitus [21].
The limitations of this study are the small size of the study sample and the fact that the study was conducted
2021 Mirghani et al. Cureus 13(6): e15853. DOI 10.7759/cureus.15853 4 of 6
at a single diabetes center, so generalization cannot be derived.
Conclusions
In the current study, a significant direct relationship was found between breakfast skipping, late dinner
intake, and body mass index. Late dinner consumption but not breakfast skipping was associated with poor
glycemic control. Further, larger multi-center studies focusing on meal amount, chronotype, and glycemic
index are highly recommended.
Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Ethical Committee,
University of Tabuk, Saudi Arabia issued approval UT-118-2021. Participants signed a written informed
consent and the ethical committees of the University of Tabuk approved the research (ref. number, UT-118-
2021). Animal subjects: All authors have confirmed that this study did not involve animal subjects or
tissue. Conf licts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.
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Objective This study aimed to report on the trends in incidence and prevalence rates of diabetes mellitus in Saudi Arabia over the last 25 years (1990–2015). Design A descriptive review. Methods A systematic search was conducted for English-language, peer reviewed publications of any research design via Medline, EBSCO, PubMed and Scopus from 1990 to 2015. Of 106 articles retrieved, after removal of duplicates and quality appraisal, 8 studies were included in the review and synthesised based on study characteristics, design and findings. Findings Studies originated from Saudi Arabia and applied a variety of research designs and tools to diagnosis diabetes. Of the 8 included studies; three reported type 1 diabetes and five on type 2 diabetes. Overall, findings indicated that the incidence and prevalence rate of diabetes is rising particularly among females, older children/adolescent and in urban areas. Conclusion Further development are required to assess the health intervention, polices, guidelines, self-management programs in Saudi Arabia.
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Objectives: The association between skipping breakfast and glycemic parameters, including glycemic variability, in patients with type 2 diabetes is not well understood. Therefore, the aim of this study was to investigate the effects of skipping breakfast on glycemic parameters, including glycemic variability, in patients with type 2 diabetes. Methods: In this cross-sectional study, we assessed lifestyle factors, including skipping breakfast, using a questionnaire method. We calculated the average, SD, and coefficient of variation (CV) of hemoglobin (Hb)A1c levels. The CV of HbA1c was defined as follows: CV = (SD / average HbA1c) × 100 (%). Results: Among 317 patients, 22 (6.9%) skipped breakfast. Patients who did not eat breakfast were younger (58 [14.5] versus 67.4 [10.1] y, P < 0.001) than those who did. The proportion of current smokers among patients skipping breakfast was higher than the proportion of smokers among patients who did not (40.9 versus 11.5%, P < 0.001). Average (7.7 [1.3] versus 7.1 [0.8]%, P = 0.003), SD (0.32 [0.17-0.85] versus 0.21 [0.14-0.35], P = 0.024) and CV (0.04 [0.03-0.10] versus 0.03 [0.02-0.05], P = 0.028) of HbA1c level were higher among patients who skipped breakfast than among those who did not. Multiple regression analysis revealed that skipping breakfast was associated with average HbA1c (β = 0.527, P = 0.006) and CV of HbA1c (β = 0.026, P = 0.001) after adjusting for age, sex, body mass index, duration of diabetes, exercise, smoking, amount of alcohol consumption, total energy intake, carbohydrate intake, and medications for diabetes. Conclusions: Skipping breakfast is independently associated with poor glycemic control, including glycemic variability, in patients with type 2 diabetes.
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Aims: To provide global estimates of diabetes prevalence for 2019 and projections for 2030 and 2045. Methods: A total of 255 high-quality data sources, published between 1990 and 2018 and representing 138 countries were identified. For countries without high quality in-country data, estimates were extrapolated from similar countries matched by economy, ethnicity, geography and language. Logistic regression was used to generate smoothed age-specific diabetes prevalence estimates (including previously undiagnosed diabetes) in adults aged 20-79 years. Results: The global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. The prevalence is higher in urban (10.8%) than rural (7.2%) areas, and in high-income (10.4%) than low-income countries (4.0%). One in two (50.1%) people living with diabetes do not know that they have diabetes. The global prevalence of impaired glucose tolerance is estimated to be 7.5% (374 million) in 2019 and projected to reach 8.0% (454 million) by 2030 and 8.6% (548 million) by 2045. Conclusions: Just under half a billion people are living with diabetes worldwide and the number is projected to increase by 25% in 2030 and 51% in 2045.
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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.