European Journal of Clinical Nutrition (2014) 68, 829834

2014 Macmillan Publishers Limited All rights reserved 0954-3007/14

www.nature.com/ejcn

PUBLIC HEALTH NUTRITION HIGHLIGHTS ORIGINAL ARTICLE

No breakfast at home: association with cardiovascular disease

risk factors in childhood
S Papoutsou1, G Briassoulis2, M Wolters3, J Peplies3, L Iacoviello4, G Eiben5, T Veidebaum6, D Molnar7, P Russo8, N Michels9,
LA Moreno10 and M Tornaritis1 on behalf of the IDEFICS consortium
BACKGROUND/OBJECTIVES: Limited data exist regarding breakfast consumption and its association with cardiovascular disease
(CVD) risk factors. This study investigates the relationship between breakfast routine and CVD risk factors in a multinational sample.
SUBJECTS/METHODS: Cross-sectional data from eight European countries participating in the IDEFICS (Identication and
prevention of dietary- and lifestyle-induced health effects in children and infants) survey (20072008) were used. The sample
included children 2 to o10 years of age (n = 8863, 51.2% boys). The MannWhitney U-test and logistic regression were used
to assess CVD risk factors among no breakfast (NBrH), occasional breakfast and daily breakfast at home (DBrH) consumption.
RESULTS: Male school-aged NBrH consumers, compared with DBrH consumers, were more likely to be overweight/obese (odds
ratio (OR): 1.37, 95% condence interval (CI) = 1.051.79), to have higher risk for high-density lipoprotein (HDL) cholesterol levels
lower than 40 mg/dl (OR: 1.69, 95% CI = 1.242.30), triglycerides (TG) above 75 mg/dl (OR: 1.65, 95% CI = 1.242.19) and sum of
skinfolds greater than the 90th percentile (OR: 1.32, 95% CI = 1.01.76). Female school-aged NBrH consumers compared with DBrH
consumers had a higher risk for waist circumference greater than the 90th percentile (OR: 1.70, 95% CI = 1.142.51), HDL cholesterol
levels lower than 40 mg/dl (OR: 1.65, 95% CI = 1.232.21), TG above 75 mg/dl (OR: 1.65, 95% CI = 1.262.17) and total cholesterol/
HDL cholesterol ratio >3.5 (OR: 1.39, 95% CI = 1.091.77). Results remained signicant after adjusting for daily physical activity in
moderate-to-vigorous physical activity (MVPA) periods (in min/day). Male DBrH consumers, 6 to o10 years of age, had longer daily
periods of MVPA compared with NBrH consumers (32.0 21.4 vs 27.5 18.8, P o0.05). For preschoolers, breakfast consumption was
negatively associated with CVD risk factors but results of regression models were mostly insignicant.
CONCLUSIONS: Daily breakfast consumption contributes to controlling school-aged childrens weight and lipid prole and
promotes higher PA.
European Journal of Clinical Nutrition (2014) 68, 829834; doi:10.1038/ejcn.2014.88; published online 21 May 2014

INTRODUCTION
Risk factors that accelerate the development of atherosclerotic
cardiovascular disease (CVD) begin in childhood. Among others,
obesity, lipid levels, blood pressure levels, physical avtivity (PA),
age and gender are known factors associated with atherosclerosis
development in childhood.1 Effective primary prevention of CVD,
beginning in early childhood, is crucial and urgent to address this
major public health problem. Most prevention programmes are
initiated in preschool and extend through high school, focusing
on the promotion of physical tness and the prevention of
smoking. Nutritional education is also essential to control many of
the alterable CVD risk factors. Nutritional interventions typically
include the reduction of sodium, fat, saturated fat and sugar
intake while encouraging high bre intake,2 but other diet-related
behaviours, such as daily breakfast consumption, might need to
be promoted.
Several studies in the past two decades have shown that
breakfast consumption improves the nutritional prole and is
inversely associated with overweight/obesity status in children.35

Many studies also examined the quality of breakfast consumed by

children and its key role on CVD risk factors, focusing on the
benecial consumption of ready-to-eat-cereals, as their consumption results in a higher intake of calcium, folic acid and dietary
bres and a lower intake of saturated fat and cholesterol.68
Sandercock et al.9 propose that the association of breakfast with lower body mass index (BMI) is unlikely to be of purely
dietary nature, as breakfast eaters consume higher energy
throughout the day but control their body weight, suggesting
that they might have higher activity levels, which could positively
affect CVD risk factors other than the BMI. Regarding the
association of daily breakfast consumption with serum lipids,
blood pressure and cardiovascular indices other than body weight
and fat, studies have demonstrated a benecial effect for adults
and adolescents but a lack of data for preschoolers and young
school-aged children was noticed.10,11 Existing data support that
even for obese children and adolescents, breakfast habits
affect blood lipid and glucose levels.12 In adolescents, studies
linking breakfast and PA reveal controversial results; ndings
suggest a positive association of frequent breakfast consumption

1
Research and Education Institute of Child Health, Nicosia, Cyprus; 2Faculty of Medicine University of Crete, Pediatric Intensive Care Unit, University Hospital, Heraklion Crete,
Greece; 3Leibniz Institute for Prevention Research and Epidemiology BIPS GmbH, Bremen, Germany; 4Laboratory of Molecular and Nutritional Epidemiology, Department of
Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy; 5Department of Public Health and Community Medicine, University of
Gothenburg, Gothenburg, Sweden; 6National Institute for Health Development, Tallinn, Estonia; 7Department of Pediatrics, Medical Faculty, University of Pecs, Pecs, Hungary;
8
Epidemiology & Population Genetics, Institute of Food Sciences, CNR, Avellino, Italy; 9Department of Public Heath faculty of Medicine and Health Sciences, Ghent University,
Ghent, Belgium and 10Growth, Exercise, Nutrition and Development Research Group, University of Zaragoza, Zaragoza, Spain. Correspondence: S Papoutsou, Nutrition
Department, Research and Education Institute of Child Health, 8 Attikis Street, Strovolos, 2027 Nicosia, Cyprus.
E-mail: stalo.papoutsou@gmail.com
Received 20 July 2013; revised 24 March 2014; accepted 27 March 2014; published online 21 May 2014

Breakfast at home enhances childrens health

S Papoutsou et al

830

and PA levels or cardiorespiratory tness1315 while neutral results

were also shown in a large epidemiological study,16 suggesting
that further research is needed. The purpose of this study is to
investigate the association of breakfast frequency consumption
and CVD risk factors in a large multinational study sample of 2- to
o10-year-old children and test the hypothesis that children who
do not have breakfast have lower PA levels compared with daily
breakfast consumers, which might result in a less favourable lipid
prole. Findings could be very important for future family
intervention and/or prevention studies on nutritional education
and international health strategies.
MATERIALS AND METHODS
Participants
The present study is based on the baseline survey (20072008) of IDEFICS
(Identication and prevention of dietary- and lifestyle-induced health
effects in children and infants) with 16 224 participants from eight
European countries: Belgium, Cyprus, Estonia, Germany, Hungary, Italy,
Spain and Sweden. The IDEFICS study aims to understand the association
of unbalanced dietary habits, an increasingly sedentary lifestyle and a
changing social environment on the health and well-being of children to
develop effective prevention strategies. Detailed information on design,
sampling and procedures of the IDEFICS baseline survey can be retrieved
from a previous publication.17 The study protocol was approved by the
ethics committee at each study centre, and written informed consent was
obtained from all parents or guardians.
Inclusion criteria for the present report involved complete data on
gender, age, weight, height, waist circumference, systolic blood pressure
(SBP), diastolic BP, total cholesterol (TC), high-density lipoprotein
cholesterol (HDL cholesterol), triglycerides (TG), low-density lipoprotein
cholesterol (LDL cholesterol), triceps skinfold, sub-scapular skinfold,
mothers and fathers BMI, educational level and information on breakfast
consumption frequency. The nal study sample that entered the analysis
consisted of 8863 boys and girls aged 2 to o10 years, 4647 of them with
accelerometry records.

Breakfast at home frequency

Breakfast frequency pattern was obtained through the Child Eating Habit
Questionnaire that included a food frequency questionnaire, an instrument
that was created to investigate food consumption frequency and
behaviours associated with overweight, obesity and general health in
children.18 Proxies (parents or guardians) answered the qustionnaire,
which included the following: How often does your child usually eat
breakfast at home or at other peoples home? Five answer choices were
given: (a) daily, (b) only during weekdays, (c) only during weekends, (d)
several times a week and (e) rarely. For statistical analysis three groups
were created: daily breakfast at home (DBrH, for answer a), occasional
breakfast at home (for answers b and d; around 36 days a week) and no
breakfast at home (NBrH, for answers c and e; 2 or less days a week).

Physical examinations
Childrens weight was measured in light underwear using an electronic
scale (TANITA BC 420 SMA, Tanita Europe GmbH, Sindelngen, Germany)
and height was measured without shoes using a stadiometer (Seca 225,
Birmingham, UK). BMI for age was calculated (as kg body weight/m2) and
categorized using the proposed procedures and cutoffs by the International Obesity Task Force.19 Waist circumference was measured and
categorized according to the Centers of Disease Control and Prevention
criteria.20 Skinfold thicknesses were measured twice with a caliper (Holtain
Ltd, Croswell, UK) at the triceps and sub-scapular sites and the mean of the
two measurements was taken. Blood pressure was measured with an
electronic sphygmomanometer (Welch Allyn 4200B-E2, Welch Allyn Inc.,
Skaneateles Falls, NY, USA) on the right arm with the child in a sitting
position. Two measurements were taken at 2- min intervals; differences of
5% led to a third measurement; then means of replicate measurements
were used in analyses. Pre-hypertension and hypertension levels of SBP
and diastolic BP were categorized according to the National Institutes of
Health criteria (above the 90th percentile of the reference population).2122
All physical examinations were taken by trained eldworkers.
European Journal of Clinical Nutrition (2014) 829 834

Blood test
A detailed description of the blood sampling procedures is published
elsewhere.23 Blood samples were obtained after an overnight fast. Blood
glucose, TC, LDL cholesterol, HDL cholesterol and TG were assessed at each
study centre by point-of-care analysis using the Cholestech LDX analyzer
(Cholestech Corporation, Hayward, CA, USA). Abnormal serum lipid levels
were assigned according to the American Academy of Pediatrics criteria.2

PA evaluation
PA was recorded with the use of an accelerometer (ActiGraph GT1M or
ActiTrainer, Actigraph LLC, Pensacola, FL, USA) for a minimum of 3 up to
11 days during waking hours. Cutoff criteria for periods (min/day) of
moderate-to-vigorous PA (MVPA) and for number of bouts/day were
classied according to the protocol followed by Evenson et al.24

Parental demographic characteristics and socioeconomic status

Parents self-reported their age, weight and height. The International
Standard Classication of Education (ISCED)25 was used as an indicator for
the socioeconomic status given the parents reports on their education
level. The maximum ISCED level of both parents was included in the
analysis.

Statistical methods
All statistical calculations were performed on SPSS software, version 20.0
(IBM, New York, NY, USA). Continuous variables are presented as mean s.d.
The KolmogorovSmirnov Test revealed that continuous variables were not
normally distributed. Therefore, the MannWhitney U-test was selected to
assess whether continuous variables were signicantly different between
breakfast groups within gender and age groups. Logistic regression was
carried out to compute odds ratios (OR) with 95% condence interval (CI) for
children having unhealthy/unsteady breakfast behaviour compared
with daily breakfast consumers of the same age and gender reference
group. In model 1, results were adjusted for age and country. In model 2,
results were additionally adjusted for fathers BMI, mothers BMI and parental
higher level of education level. Finally, for children with accelerometer data,
results were also adjusted for time spent performing MVPA in minutes
(model 3). In all three models, blood pressure and lipid variables were
adjusted for BMI.

RESULTS
Characteristics and measurements of the study population by two
age groups (preschool-aged children (2 to o6 years old) and
school-aged children (6 to o10 years old)), by gender and by
breakfast at home frequency are shown in Table 1. Overweight/
obesity prevalence was signicantly higher (P o0.05) among
females in both age groups; 11.5% of preschool-aged boys, 15.8%
of preschool-aged girls, 22.9% of school-aged boys and 25.4% of
school-aged girls were overweight or obese.
Overall, 70.2% of preschoolers and 79.8% of school-aged
children consume breakfast at home on a daily basis. Around
22% of young boys and girls consume breakfast at home only over
the weekend or less frequently. For older children, 6 to o10 years
of age, proxies reported that 14.9% of children have breakfast only
on weekends or less frequently.
To dichotomize the study population into two subgroups for
the sum of skinfolds variable, the 90th percentile was set as
the cutoff point. The 90th percentile cutoff for 2- to o6-year-old
boys was 20.2 mm, for 2- to o6-year-old girls was 24.0 mm and
for that 6- to o10-year-old boys and girls was 29.9 mm and
34.8 mm, respectively.
Among preschool boys, after adjusting for age, country and
parental characteristics (model 2), NBrH consumers had a higher
risk for elevated SBP (OR = 1.67, 95% CI = 1.132.47) and LDL
cholesterol levels higher than 110 mg/dl (OR = 1.38, 95% CI = 1.08
1.76), whereas after adjusting for all confounding variables
(model 3) NBrH consumers were shown again to be more likely to
have elevated SBP (OR = 1.71, 95% CI = 1.032.83) and LDL
cholesterol (OR = 2.06, 95% CI = 1.452.93). Logistic regression
2014 Macmillan Publishers Limited

Breakfast at home enhances childrens health

S Papoutsou et al

2014 Macmillan Publishers Limited

Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; DBrH, daily breakfast at home; HDL chol, high-density lipoprotein cholesterol; LDL chol, low-density lipoprotein cholesterol; NBrH, no
breakfast at home; OBrH, occasional breakfast at home; SBP, systolic BP; TC, total cholesterol; TG, triglycerides. Bold font, Po0.05, the MannWhitney U-test for comparisons within gender and age group,
compared with daily breakfast consumers. Values are presented as mean (s.d.).

(0.8)
(6.2)
(6.7)
(2.9)
(7.8)
(10.0)
(9.3)
(6.4)
(28.9)
(13.7)
(38.5)
(26.2)
(1.19)
7.4
27.5
126.1
17.1
58.1
22.1
103.2
64.1
162.2
51.5
67.8
97.2
3.37
(0.8)
(6.1)
(7.7)
(2.8)
(7.4)
(9.8)
(9.5)
(6.4)
(36.4)
(13.8)
(29.2)
(34.0)
(1.13)
7.5
26.4
125.8
16.6
56.6
20.4
101.8
64.0
167.9
54.3
62.1
101.1
3.27
(0.8)
(6.3)
(7.4)
(2.8)
(7.2)
(9.4)
(8.9)
(6.5)
(31.0)
(13.9)
(25.7)
(28.6)
(1.07)
7.5
27.1
126.2
16.8
56.8
21.3
102.4
64.2
163.8
55.1
59.0
96.9
3.16
(0.9)
(3.8)
(8.0)
(1.8)
(4.9)
(5.3)
(8.9)
(6.5)
(28.8)
(13.2)
(30.2)
(26.0)
(1.18)
4.4
18.1
106.6
15.8
51.0
17.8
97.3
62.5
155.2
46.0
62.7
96.7
3.64
(0.8)
(2.9)
(7.3)
(1.5)
(3.9)
(4.7)
(8.8)
(6.5)
(33.9)
(13.1)
(19.7)
(27.7)
(0.88)
4.3
17.6
106.2
15.6
50.7
17.8
97.1
63.1
160.2
48.1
58.6
100.4
3.50
(0.9)
(3.6)
(7.9)
(1.8)
(4.8)
(5.4)
(8.0)
(6.2)
(31.6)
(13.4)
(24.1)
(28.8)
(1.21)
4.3
17.8
105.5
15.9
50.6
17.9
96.6
62.0
157.1
47.8
58.8
97.5
3.52
(0.8)
(7.0)
(7.5)
(3.2)
(8.4)
(9.6)
(9.2)
(6.9)
(29.4)
(14.6)
(29.3)
(25.9)
(1.09)
7.4
27.9
126.7
17.2
58.9
19.0
103.4
63.3
158.2
53.8
62.1
92.0
3.14
(0.8)
(7.0)
(7.2)
(2.9)
(7.2)
(8.1)
(9.7)
(7.1)
(27.5)
(13.9)
(22.9)
(23.9)
(0.84)
7.5
27.7
128.3
16.7
57.8
17.6
104.1
63.8
157.6
55.1
57.6
91.0
3.02
(0.8)
(6.5)
(7.3)
(2.8)
(7.4)
(8.9)
(8.9)
(6.7)
(29.8)
(13.9)
(23.2)
(27.5)
(0.95)
7.5
27.6
127.3
16.9
57.7
18.2
103.0
63.5
159.1
56.1
56.5
91.7
3.00
(0.9)
(4.1)
(7.9)
(1.9)
(5.0)
(5.0)
(9.2)
(6.7)
(29.6)
(12.6)
(24.3)
(27.2)
(1.07)
4.4
18.7
107.7
16.0
51.8
16.1
98.3
61.7
156.5
48.5
57.2
96.5
3.42
(0.9)
(3.3)
(7.7)
(1.4)
(4.0)
(3.5)
(10.0)
(6.9)
(24.1)
(13.4)
(19.7)
(24.3)
(1.22)

NBrH
n = 416
OBrH
n = 150

2 to o6 years

4.2
18.0
106.6
15.7
50.8
15.2
95.9
60.4
149.2
48.1
56.5
89.8
3.35
(0.9)
(3.5)
(7.9)
(1.7)
(4.2)
(4.0)
(8.1)
(6.2)
(30.2)
(13.6)
(25.2)
(27.6)
(1.07)

OBrH
n = 136
OBrH
n = 145
OBrH
n = 139
DBrH
n = 2016

6 to o10 years

NBrH
n = 387

DBrH
n = 1215

2 to o6 years

NBrH
n = 412

Girls
Boys

DBrH
n = 1426

4.4
18.3
106.7
15.9
51.1
15.6
96.6
61.4
154.9
49.8
57.0
93.7
3.32
Age (years)
Weight (kg)
Height (cm)
BMI (kg/m2)
Waist (cm)
Skinfold sum (mm)
SBP (mm Hg)
DBP (mm Hg)
TC (mg/dl)
HDL chol (mg/dl)
TG (mg/dl)
LDL chol (mg/dl)
TC/HDL chol

Table 1.

Characteristics and measurements of the study sample in relation to age group and gender and breakfast at home frequency consumption

DBrH
n = 2050

6 to o10 years

NBrH
n = 371

831
revealed no signicant risk for obesity, elevated blood pressure or
abnormal serum lipids for preschool girls. The results of the logistic
regression analysis for preschoolers are not presented in tables.
The results of the logistic regression for school-aged boys are
shown in Table 2. Boys who consume breakfast at home only on
weekends, or on fewer occasions, have a higher risk of being
overweight or obese and of having abnormal serum HDL
cholesterol and TG levels. When adjusted for parental characteristics and weight status (model 2), the results remained the same.
Moreover, for about half of the study population, results, adjusted
also for daily MVPA period (model 3), revealed that male NBrH
consumers have a signicantly higher risk for low HDL cholesterol
levels and elevated TG levels compared with DBrH consumers. For
girls of the same age, results are presented in Table 3. In model 2,
results revealed that odds ratios for central obesity, elevated TG,
high TC/HDL cholesterol ratio and low HDL cholesterol levels were
higher among NBrH consumers compared with DBrH consumers.
Again, in model 3, results remained signicant for blood lipids.
Table 4 presents daily MVPA in minutes and in MVPA bouts. For
preschool-aged boys, 3.9 days (s.d. = 1.1), for preschool-aged girls
3.8 days (s.d. = 1.1) and for school-aged boys and girls 3.6 days
(s.d. = 1.0) were recorded. Male school-aged NBrH consumers had
signicantly lower PA levels compared with DBrH consumers.
Among female school-aged NBrH consumers, only a tendency for
a lower daily MVPA period was detected compared with DBrH
consumers (20.3 15.5 vs 18.7 15.7 min/day, P = 0.09).
DISCUSSION
Findings of the current study point to a negative association of
breakfast frequency at home consumption with CVD risk factors in
a large multinational population of school-aged children. In
particular, male school-aged NBrH consumers were found to have
a signicantly higher risk for abnormal TG and HDL cholesterol
levels, whereas female school-aged NBrH consumers were additionally found to have a greater risk for high TC to HDL cholesterol
ratio compared with daily consumers, after adjustment for several
confounding factors, including PA levels. School-aged children not
consuming breakfast at home had also signicantly lower records
of MVPA activity compared with daily consumers. PA levels in
previous studies comparing CVD factors with breakfast consumption in children and adolescents were mainly assessed through
self-reported methods.2628 Only one study in 9- to 10-year-old
British children measured PA level by accelerometry: only boys
who never or rarely consumed breakfast had less MVPA compared
with regular consumers, concluding that breakfast consumption
could be more important for boys, as they are generally more
physically active than girls.29 Our ndings in school-aged children
support that breakfast is important probably for both boys and
girls, assuming that children consuming breakfast are more
energetic throughout the day. To support the same hypothesis,
Pereira et al. conducted a well-structured experimental study in
28 healthy children (913 years old, 50% boys): each child
experienced three breakfast conditions, 2 weeks apart. The rst
condition was a high-bre breakfast meal with a whole fruit, the
second was a rened pastry with a rened fruit drink and the third
(skipped) breakfast condition included only water or a diet drink.
After 2 h, the differences in hunger levels between skipping and
eating (any) breakfast conditions were very strong. The same was
observed for the self-reported tiredness score, concluding that
breakfast consumption, even if not of the optimal nutrient
composition, indeed helps children feel energetic and be more
active.30
Researchers so far have mainly focused on the favourable
association between consumption of ready-to-eat cereals (usually
eaten at breakfast time), obesity and blood lipids in children and
adolescents.6,7 Scant studies exist on the association of breakfast
consumption frequency and CVD risk factors, and only for older
European Journal of Clinical Nutrition (2014) 829 834

Breakfast at home enhances childrens health

S Papoutsou et al

832
Table 2. Results of logistic regression analysis for CVD risk factors among school-aged boys depending on breakfast at home frequency
consumption
Boys 6 to o10 years (n = 2542)
Model 1
DBrH
d

Overweight or obese
Waist > 90the
Skinfold sum>90th
SBP: prehypertension/hypertensionf
DBP: prehypertension/hypertensionf
TC > 170 mg/dlg
HDL cholesterol o40 mg/dlg
TG > 75 mg/dlg
LDL cholesterol > 110 mg/dlg
TC/HDL cholesterol ratio > 3.5

1
1
1
1
1
1
1
1
1
1

NBrH
1.46
1.51
1.43
0.93
1.08
0.88
1.71
1.65
1.0
1.13

(1.141.88)
(1.062.17)
(1.081.88)
(0.661.31)
(0.711.64)
(0.691.11)
(1.252.33)
(1.242.19)
(0.771.30)
(0.871.47)

Model 2
DBrH
1
1
1
1
1
1
1
1
1
1

Boys 6 to o10 years (with accelerometer data, n = 1394)

b

NBrH
1.37
1.39
1.32
0.93
1.09
0.88
1.69
1.65
1.01
1.13

(1.05-1.79)
(0.952.03)
(1.01.76)
(0.661.32)
(0.721.65)
(0.701.12)
(1.242.30)
(1.242.19)
(0.781.31)
(0.871.47)

Model 3c

Model 1
DBrH
1
1
1
1
1
1
1
1
1
1

NBrH
1.42
1.54
1.33
0.91
0.95
0.91
1.97
1.96
1.20
1.31

DBrH

(1.02.03)
(0.912.61)
(0.901.97)
(0.571.46)
(0.511.76)
(0.651.28)
(1.293.0)
(1.302.95)
(0.831.72)
(0.911.90)

1
1
1
1
1
1
1
1
1
1

NBrH
1.19
1.25
1.07
0.92
0.95
0.93
1.88
1.92
0.94
1.29

(0.811.74)
(0.722.19)
(0.701.63)
(0.571.48)
(0.511.77)
(0.661.31)
(1.232.88)
(1.272.89)
(0.681.32)
(0.901.87)

Abbreviations: DBP, diastolic blood pressure; DBrH, daily breakfast at home; HDL, high-density lipoprotein; LDL, low-density lipoprotein; NBrH, no breakfast at
home; SBP, systolic BP; TC, total cholesterol; TG, triglycerides. aAdjusted for age and country. For BP and lipid variables also adjusted for body mass index (BMI).
b
Adjusted for age, country, fathers BMI, mothers BMI and parental higher level of education level. For BP and lipid variables also adjusted for BMI. cAdjusted
for age, country, fathers BMI, mothers BMI, parental higher level of education level and time spent performing MVPA (in min; average over all valid days). For BP
and lipid variables also adjusted for BMI. dAccording to the International Obesity Task Force criteria. eAccording to the Centers of Disease Control and Prevention
criteria. fAccording to the National Institutes of Health criteria. gAccording to the American Academy of Pediatrics criteria. Bold font indicates Po0.05.

Table 3. Results of logistic regression analysis for CVD risk factors among school-aged girls depending on breakfast at home frequency consumption
Girls 6 to o10 years (n = 2557)
Model 1a
DBrH
d

Overweight or obese
Waist > 90the
Skinfold sum > 90th
SBP: prehypertension/hypertensionf
DBP: prehypertension/hypertensionf
TC > 170 mg/dlg
HDL cholesterol o40 mg/dlg
TG > 75 mg/dlg
LDL cholesterol > 110 mg/dlg
TC/HDL cholesterol ratio > 3.5

1
1
1
1
1
1
1
1
1
1

NBrH
1.25
1.84
1.31
0.99
0.86
0.95
1.64
1.66
0.91
1.39

(0.981.61)
(1.252.69)
(0.921.87)
(0.721.36)
(0.591.25)
(0.761.19)
(1.232.21)
(1.272.18)
(0.711.16)
(1.091.78)

Girls 6 to o10 years (with accelerometer data, n = 1405)

Model 2b
DBrH
1
1
1
1
1
1
1
1
1
1

NBrH
1.13
1.70
1.18
1.0
0.88
0.95
1.65
1.65
0.91
1.39

(0.871.47)
(1.142.51)
(0.822.51)
(0.731.38)
(0.601.28)
(0.761.19)
(1.232.21)
(1.262.17)
(0.721.17)
(1.091.77)

Model 3c

Model 1
DBrH
1
1
1
1
1
1
1
1
1
1

NBrH
1.22
1.70
1.38
1.18
0.67
1.02
2.13
1.52
0.95
1.42

DBrH

(0.861.71)
(0.982.95)
(0.862.21)
(0.791.76)
(0.391.15)
(0.751.39)
(1.453.13)
(1.032.23)
(0.681.32)
(1.021.98)

1
1
1
1
1
1
1
1
1
1

NBrH
1.01
1.41
1.14
1.19
0.69
1.01
2.11
1.49
1.21
1.42

(0.701.46)
(0.792.52)
(0.691.87)
(0.801.77)
(0.401.18)
(0.741.38)
(1.433.10)
(1.012.19)
(0.841.75)
(1.021.98)

Abbreviations: CVD, cardiovascular disease; DBP, diastolic blood pressure; DBrH, daily breakfast at home; HDL chol, high-density lipoprotein cholesterol; LDL
chol, low-density lipoprotein cholesterol; NBrH, no breakfast at home; SBP, systolic BP; TC, total cholesterol; TG, triglycerides. aAdjusted for age and country. For
BP and lipid variables also adjusted for body mass index (BMI). bAdjusted for age, country, fathers BMI, mothers BMI and parental higher level of education
level. For BP and lipid variables also adjusted for BMI. cAdjusted for age, country, fathers BMI, mothers BMI, parental higher level of education level and time
spent performing MVPA (in min; average over all valid days). For BP and lipid variables also adjusted for BMI. dAccording to the International Obesity Task Force
criteria. eAccording to the Centers of Disease Control and Prevention criteria. fAccording to the National Institutes of Health criteria. gAccording to the
American Academy of Pediatrics criteria. Bold font indicates Po0.05.

children and adolescents.8,26 In a large longitudinal study in a

sample of 915-year-old Australian children, a follow-up after
around 20 years revealed that participants who skipped breakfast
during both childhood and adulthood had a greater waist
circumference and higher TC and LDL cholesterol concentrations
compared with those who ate breakfast at both time points.31
Finally, a recent large cross-sectional study in a European
population of adolescents revealed that breakfast consumption
was benecial for several CVD risk factors, especially in males.11
Results of the current study revealed a strong inverse association
between breakfast frequency and elevated CVD risk factors. As
mentioned before, lower MVPA periods were recorded in male
school-aged NBrH consumers compared with DBrH consumers; a
tendency, but not statistically signicant, for an adverse relation
among breakfast frequency and daily MVPA time was also noticed
European Journal of Clinical Nutrition (2014) 829 834

among school-aged girls. This observation could explain the

higher risk for lower HDL cholesterol levels and consequently
higher risk for high TC/HDL cholesterol ratio among school-aged
NBrH consumers compared with daily consumers. Also, in this
report, both male and female school-aged NBrH consumers had a
higher risk for fasting TG higher than 75 mg/dl. An assumption to
explain the above observation is that breakfast skippers, instead of
consuming 2035% of their daily energy needs in the rst couple
of hours in the morning,32 have higher energy intake in later
meals, including afternoon snacks and supper, and, despite the 8-h
fasting before blood drawing, they tend to have higher morning TG
levels. A different explanation could be that lower PA among
breakfast skippers results in longer inactivity periods, suppressing
lipoprotein lipase activity, which is involved in the regulation of HDL
cholesterol production, TG uptake and fat metabolism.33,34
2014 Macmillan Publishers Limited

Breakfast at home enhances childrens health

S Papoutsou et al

833
Table 4.

Childrens time spent in MVPA in relation to their breakfast at home frequency consumption
Boys

2 to o6 years, n
a

Time in MVPA bouts/day (min)

Number of MVPA bouts/day
6 to o10 years, n

Time in MVPA bouts/day (min)

Number of MVPA bouts/day

Girls

DBrH

OBrH

NBrH

DBrH

OBrH

NBrH

709

66

197

600

73

203

20.7 (17.7)
2.3 (1.7)

23.3 (16.7)
2.5 (1.6)

21.4 (17.6)
2.4 (1.9)

14.4 (12.6)
1.7 (1.4)

13.2 (10.1)
1.6 (1.2)

14.7 (12.4)
1.7 (1.3)

1131

79

184

1158

55

192

32.0 (21.4)
3.4 (2.0)

31.2 (19.5)
3.4 (1.8)

27.5 (18.8)
2.9 (1.8)

20.3 (15.5)
2.3 (1.6)

18.0 (13.6)
2.1 (1.4)

18.7 (15.7)
2.2 (1.6)

Abbreviations: DBrH, daily breakfast at home; MVPA, moderate-to-vigorous physical activity; NBrH, no breakfast at home; OBrH, occasional breakfast at home.
Bold font, Po0.05, the MannWhitney U-test for comparisons within gender and age group, compared with daily consumers. Values are presented as
mean (s.d.). aAccording to Evensons cutoff criteria.

To our knowledge, this is the rst study to examine breakfast

frequency consumption in relation to CVD risk factors and MVPA
levels among preschoolers, including toddlers. Young boys not
consuming breakfast at home had higher mean values for waist
circumference, SBP, LDL cholesterol and TC/HDL cholesterol ratio
compared with daily consumers. Young girls not consuming
breakfast at home had higher mean values for waist circumference, TG, TC/HDL cholesterol ratio and higher mean value for HDL
cholesterol compared with daily consumers. Nevertheless, results
of regression models were rather neutral. It is possible that the
reason for the weak association of breakfast frequency with CVD
risk factors is that in our study population prevalence of
overweight and obesity in preschoolers was signicantly lower
than in school-aged children. Also, at this point it is necessary to
highlight that breakfast frequency assessed in the current study is
breakfast eaten at home and not at kindergarten or at primary
school. A proposed denition of breakfast is the rst meal of the
day eaten before or at the start of daily activities, within 2 h of
waking, typically no later than 1000 hours in the morning and of
an energy level between 20 and 35% of total energy needs.32
Therefore, information about breakfast at home normally refers to
the meal that the child ate before travelling to school or any PA
during the morning. However, among preschoolers, time of
attendance and time of rst meal at kindergarten differs between
countries: in Cyprus, the rst meal at kindergarten is usually
around 09300945 hours, whereas in Sweden the rst meal is
served at 08:00 am. This could be an additional reason why results
in preschoolers are rather neutral; many preschool children
categorized as NBrH consumers might have breakfast at preschool
early in the morning close to their waking time. Tin et al.,35 in a
very large sample (n = 68 606) of fourth-grade children in Hong
Kong, revealed that breakfast at home rather than away from
home was protective against weight gain over a two 1-year
period. It is debatable whether having breakfast at home ensures
a higher quality in breakfast choices because of parental control,
in cases in which school canteens offer low-quality breakfast
choices, or whether having breakfast very early in the morning
increases satiety, which results in an unintentional control of the
energy intake over the day,36 or even both, acting as protective
factors over weight gain through childhood.
The current study is subject to certain limitations. The question
addressed to parents referred only to breakfast frequency
consumption; therefore, no information on what children usually
eat as breakfast was available. Dietary 24-h recalls (13 days) were
recorded in the IDEFICS baseline study, but mostly a single 24-h
dietary recall (would not be enough to capture the weekly
breakfast frequency consumption of children) was available for
around 65% of children included in the current study. Therefore, it
was decided not to investigate breakfast quality in relation to CVD
2014 Macmillan Publishers Limited

risk factors. The strengths of the current study include the large
multinational study sample and the objective measurements of PA
levels, using accelerometry. Finally, no similar studies have been
conducted for preschoolers previously, including toddlers aged
23 years.
In conclusion, breakfast consumption can be used as a broad
public health application in CVD prevention strategies. Findings of
the current study suggest that mechanisms other than appetite
control might counteract this protectiveness of breakfast against
elevated CVD risk factors; more denitive randomized controlled
trials are needed to investigate whether enhancing breakfast
consumption among school-aged children could result in higher
PA levels. Moreover, our suggestion is that future epidemiological
studies need to assess the location where breakfast is eaten (at
home, school or elsewhere), the content of breakfast, the weekly
frequency of breakfast consumption and how long apart from
waking time it is eaten to study, the impact of breakfast on CVD
risk factors in childhood.
CONFLICT OF INTEREST
The authors declare no conict of interest.

ACKNOWLEDGEMENTS
This study was conducted as a part of the IDEFICS study and was published on behalf
of its European Consortium (http://www.idecs.eu). We gratefully acknowledge the
nancial support of the European Community within the Sixth RTD Framework
Programme Contract no. 016181 (FOOD). We are also grateful for the support
provided by school boards, headmasters, teachers, school staff and communities. We
thank the IDEFICS children and their parents for participating in this extensive
examination.

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