RESEARCH Guest Editorial

Defining Nutritious Breakfasts and Their Benefits Johanna Dwyer, DSc, RD ARTICLE INFORMATION Article history: Accepted 3 October 2014

2212-2672/Copyright ª 2014 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2014.10.005

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REAKFAST HAS LONG BEEN CONSIDERED THE MOST important meal of the day, and recent research has reaffirmed its nutritional benefits, as well as other positive outcomes, including feelings of well-being immediately after consumption and longer-term improvements in overall diet quality. There is also intriguing, but less conclusive, evidence of improved weight management, reduced risk of cardiovascular disease and type 2 diabetes, and better cognitive performance.1 However, despite common belief in and scientific support for its importance, breakfast is frequently skipped, and the composition of a nutritious breakfast is poorly defined. The two articles in this supplement to the Journal of the Academy of Nutrition and Dietetics address the need for a clear definition of breakfast, including nutrient needs, timing, and optimal components in terms of foods and beverages. The first article, “The Role of Breakfast in Health: Definition and Criteria for a Quality Breakfast,” is a commentary that brings together the perspectives of nutrition researchers and communicators with expertise in community and public health, education, child and school nutrition, Hispanic nutrition, and pediatrics to provide a framework for determining what constitutes a nutritious breakfast. The authors echo the 2010 Dietary Guidelines Advisory Committee in noting that the definition of breakfast has not been consistent across research studies. They conclude that “the lack of a standard breakfast definition means that measurement of breakfast consumption in research is subject to either individual study participant interpretation of what constitutes breakfast or differing definitions provided by researchers, which may account for conflicting research results.”1 To address this problem, they propose this basic definition of breakfast for use in all breakfast research: Breakfast is the first meal of the day that breaks the fast after the longest period of sleep and is consumed within 2 to 3 hours of waking; it is comprised of food or beverage

Statement of Potential Conflict of Interest and Funding/Support: See page S7.

ª 2014 by the Academy of Nutrition and Dietetics.

from at least one food group, and may be consumed at any location.1 The authors also propose criteria for a “quality” breakfast that are suitable for consumer use. They reviewed current research on breakfast, including consumption frequency and energy and nutrient intake, consumer perceptions, and ideal outcomes, and then used that information to develop a more evidence-based definition of foods and beverages in a nutritious breakfast pattern. In doing this, the authors perform a real service for nutrition and dietetics practitioners that will simplify our counseling tasks by describing the pluses and minuses of each pattern in detail. It will come as no surprise to registered dietitian nutritionists to learn that there are many patterns for good breakfasts that contribute reasonable amounts of calories while decreasing the content of nutrients to limit, and contributing considerable amounts of nutrients for which intakes need to be increased because they are lacking in many American diets. The authors also stress the importance of translating and communicating breakfast guidance to consumers, industry, and policymakers. They provide specific approaches for doing so, including highlighting the tangible, personal benefits of eating breakfast, and providing specific strategies for overcoming barriers to daily breakfast eating. Also welcome is the authors’ call “for more clinical research examining the impact of breakfast consumed, using a standard definition, on nutrient intakes, diet quality, and health biomarkers in longitudinal studies or using multiple days of assessment.”1 In addition to these good suggestions, it would be helpful to carry out rigorous randomized experimental studies in actual classroom situations on the effects of breakfasts of various types on cognition and attention in the classroom. Although it is often assumed that breakfasts have positive effects, very few high-quality studies exist on their presence. A recent systematic review of existing evidence on the role of energy and nutrients provided by breakfast on the accomplishment of school-related tasks and cognition concluded that there was insufficient quantity and consistency among existing studies to draw firm conclusions, and that the hypothesis of better and more sustained performance with a breakfast providing more than 20% daily energy intake still needed substantiation.2 However, the review did find some mixed evidence that a lower postprandial glycemic response present with breakfast was beneficial to cognitive performance, and this is worth pursuing. The ability of school breakfast programs to encourage students to come to school needs much more study in the United States. There is conclusive evidence that this is true in developing countries, but very little work has been done in highly industrialized JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH countries. There is good reason to suspect academic performance will improve if school breakfasts attract students who otherwise might not come to school on time or at all.3 Perhaps it is also time to review the energy contributions of the National School Breakfast Program—the current criterion is that approximately 25% of a child’s energy needs are offered. Considering the prevalence of obesity in children, should the breakfast as served be less, with an option of getting freely available seconds for children who ask for more? The second article in the supplement, “Nutrient Intake, Diet Quality, and Weight/Adiposity Parameters in Breakfast Patterns Compared with No Breakfast in Adults: National Health and Nutrition Examination Survey 2001-2008,” is new research reviewing the literature that compares “nutrient intake, diet quality, and weight/adiposity measures of consumers assigned to different breakfast patterns with breakfast skippers.”4 The National Health and Nutrition Examination Survey (NHANES) data were used to categorize the most prevalent breakfast patterns of US adults into 12 groups, and then the impact of those patterns on nutrient intakes and diet quality was assessed. The authors used cluster analysis to identify breakfast consumption patterns based on the calorie intake from certain foods. Of the 12 patterns identified, the most popular was the Grain/100% Fruit Juice pattern consumed by nearly 25% of the sample. What is more surprising is that the second most common pattern was skipping breakfast entirely, at nearly 19%. There was no evidence that the skippers had lower or higher energy intakes throughout the day than the breakfast eaters. The contributions of calories to intakes varied from about 4% to 26% of total energy intakes. When the authors examined each pattern according to the energy and nutrients consumed as well as the consumers’ weight and adiposity, they discovered that, overall, breakfast had a positive impact on nutrient intake and diet quality compared with skipping breakfast, and that breakfast patterns including nutrient-dense foods, such as fortified cereals, fruit, and lowfat milk, might have an even greater impact on nutrient intake, diet quality, and weight loss and maintenance. These tantalizing observations from the NHANES population-based cross sectional study need to be confirmed with more definitive evidence from experimental studies on the associations of breakfast with energy balance. Is it simply that those who eat breakfast also have other characteristics and lifestyles that may alter energy balance for the better and favor weight maintenance, or is it that breakfast actually changes energy balance for the better? There is some new evidence from a randomized study of English adults who were told to eat a large breakfast of about 700 kcal or no breakfast at all until noon, and who were then monitored over a 6-week period. By the end of the study, no metabolic adaptation to breakfast was apparent in resting metabolic rates of the eaters vs those who had no breakfast. Total daily intakes remained almost 500 kcal per day greater than in the no breakfast after fasting group, suggesting imperfect compensation. Over time, if there were little or no compensation either by decreased energy intake at other times of the day or increased physical activity, one might expect very large breakfasts to increase overall energy intakes. Body mass and fatness were similar in the breakfast and no breakfast groups at both baseline and at follow up. Neither adipose tissue glucose uptake nor systemic indices of S6

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cardiovascular health differed at the end of the study, although by the sixth week of the study, continuously measured blood sugar levels were more variable during the afternoon and evening among those who had been in the no breakfast arm than in those in the breakfast group.5 However, this was a small study, with only 33 subjects in all, and the breakfasts served were very large by American standards. It would be useful to repeat the study in the United States with a “quality” breakfast similar to some of the lower-calorie patterns identified in this supplement to the Journal, and to carry out the intervention for a longer time. Another recently published article focuses on whether breakfast recommendations are helpful in weight loss, a logical inference from some cross-sectional studies that report that breakfast eaters have lower body weights than breakfast skippers.6 The randomized clinical trial of 16 weeks duration was among overweight and obese people with body mass indices from 25 to 40 who were stratified according to their pre-randomization breakfast eating habits. Weight changes were observed over a 4-month period among the experimental group, who were told to eat breakfast, and another control group, who were told to skip breakfast. Among the 283 participants who completed the study, adherence to their assigned groups was good. However, neither their initial breakfast-eating status nor the treatment to which they were randomized had any effect on changes in weight and, at the end of the study, there were no discernable differences in weight loss between the two groups. The authors of the articles in this supplement are to be commended for putting together this complex and confusing literature. Taken together, they advance the understanding of breakfast and its impact on health by establishing a consistent definition of breakfast for use in research, identifying existing breakfast consumption patterns, and proposing optimal components and guidance for the composition of a nutritious breakfast for both adults and children. With this knowledge, nutrition and dietetics practitioners will be wellequipped to educate consumers and policymakers alike on the important benefits a nutritious breakfast can provide. There is much evidence from the studies reviewed here and others that eating breakfast can add to the quality of overall nutrient intakes and some health indices.7 But it is the type of breakfast that determines the size and direction of these effects. This is the message we need to remember ourselves and impress upon consumers.

References 1.

O’Neil CE, Byrd-Bredbenner C, Hayes D, Jana L, Klinger SE, StephensonMartin S. The role of breakfast in health: Definition and criteria for a quality breakfast. J Acad Nutr Diet. 2014;114(suppl 3):S8-S26.

2.

Edefonti V, Rosato V, Parpinel M, et al. The effect of breakfast composition and energy contribution on cognitive and academic performance: A systematic review. Am J Clin Nutr. 2014;100(2): 626-656.

3.

Levitsky DA. Next will be apple pie. Am J Clin Nutr. 2014;100(2):503504.

4.

O’Neil CE, Nicklas TA, Fulgoni VL III. Nutrient intake, diet quality, and weight/adiposity parameters in breakfast patterns compared with no breakfast in adults: National Health and Nutrition Examination Survey 2001-2008. J Acad Nutr Diet. 2014;114(suppl 3):S27-S43.

5.

Betts JA, Richardson JD, Chowdhury EA, Homan GD, Tsintzas K, Thompson D. The causal role of breakfast in energy balance and health: A randomized controlled trial in lean adults. Am J Clin Nutr. 2014;100(2):539-547.

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Dharandhar EJ, Dawson J, Alcorn A, et al. The effectiveness of breakfast recommendations on weight loss: A randomized controlled trial. Am J Clin Nutr. 2014;100(2):507-513.

7.

Williams PG. The benefits of breakfast cereal consumption: A systematic review of the evidence base. Adv Nutr. 2014;5(5): 636S-673S.

AUTHOR INFORMATION J. Dwyer is professor of medicine, Tufts Medical School, and senior nutrition scientist, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA. Address correspondence to: Johanna Dwyer, DSc, RD, Frances Stern Nutrition Center, Box 783, Tufts Medical Center, 800 Washington St, Boston, MA 02111. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTEREST J. Dwyer owns stock in Kellogg’s, General Mills, and ConAgra Foods, and is a Public Trustee of ILSI North America.

FUNDING/SUPPORT Publication of this article was supported by an unrestricted educational grant from the Kellogg Company. J. Dwyer received an honorarium from the Academy of Nutrition and Dietetics for serving as guest editor of this supplement.

ACKNOWLEDGEMENTS The assistance of Ryan Baechler is acknowledged with thanks.

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Defining nutritious breakfasts and their benefits.

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