Skipping breakfast linked to increased cardiovascular disease and death

Relation

Rong S, Snetselaar LG, Xu G, et al. Association of skipping breakfast with cardiovascular and all-cause mortality. (Link removed). 2019;73(16):2025-2032.

Study objective

The authors examined the association between skipping breakfast and cardiovascular and all-cause mortality.

Draft

This is a prospective cohort study. Breakfast frequency was compared with cardiovascular and all-cause mortality risk using weighted Cox proportional hazards regression models.

Participant

The study followed a cohort of 6,550 U.S. adults ages 40 to 75 who participated in the 1988 to 1994 National Health and Nutrition Examination Survey III. Breakfast frequency was recorded during an internal interview. Death and underlying causes of death were determined through linkage to death certificates through December 31, 2011.

Key insights

By following this cohort over a period of 17 to 23 years, researchers found that skipping breakfast was associated with a significantly increased risk of mortality from cardiovascular disease. 59% of the cohort ate breakfast daily. The other 40% ate breakfast less often: 5% never ate breakfast, 11% rarely ate breakfast, and 25% only ate breakfast on some days. The study provided 112,148 person-years of follow-up data in which 2,318 deaths occurred, including 619 deaths due to cardiovascular disease (CVD).

After adjusting for age, gender, race/ethnicity, socioeconomic status, dietary and lifestyle factors, body mass index, and cardiovascular risk factors, participants who never ate breakfast compared to those who ate breakfast daily had a hazard ratio of 1.87 (95% confidence interval [CI]: 1.14–3.04) for cardiovascular mortality and 1.19 (95% CI: 0.99–1.42) for all-cause mortality. The latter upward trend did not reach statistical significance.

After adjusting for age, gender, and race/ethnicity, participants who never ate breakfast had a 75% higher risk of all-cause mortality (hazard ratio [HR]: 1.75; 95% CI: 1.46-2.10) and a 2.58-fold higher risk of cardiovascular mortality (HR: 2.58; 95% CI: 1.64–4.06) compared to those who ate breakfast daily. The associations of breakfast consumption with heart disease-specific and stroke-specific mortality were further investigated. Compared to those who ate breakfast every day, participants who never ate breakfast had a higher risk of heart disease-specific mortality (HR: 2.34; 95% CI: 1.44-3.80) and stroke-specific mortality (HR: 3.53; 95% CI). : 1.40-8.95) in models adjusted for age, gender, and race/ethnicity. In the fully adjusted model, the association between skipping breakfast and stroke-specific mortality remained significant (HR: 3.39; 95% CI: 1.40-8.24).

Practice implications

According to this study, eating a regular breakfast reduces the risk of dying from cardiovascular disease and probably a stroke. Or to put it another way: Not eating breakfast significantly increases the risk. We should encourage the habit of eating breakfast in our patients.

Remember, more people die from cardiovascular disease than from any other cause – not just in the United States but worldwide.¹Even small reductions in risk have the potential to have a large impact on disease and illness.

We often hear that “breakfast is the most important meal of the day.” I had always assumed that this was just an advertising slogan that Kellogg's invented a century ago to sell its breakfast cereals. According to surveys, almost a quarter of younger people skip breakfast every day.^2.3It looks like this could have long-term adverse effects on her health.

Although there is limited evidence, it suggests that skipping breakfast is associated with an increased risk of overweight/obesity.⁴dyslipidemia,⁵Hypertension,⁶type 2 diabetes,⁷metabolic syndrome,⁸coronary heart disease,⁹and cerebrovascular diseases.¹⁰

It's not just about breakfast. Skipping breakfast can also indicate other unhealthy diet and lifestyle habits. Teens who skip breakfast tend to display a number of other characteristics that can also put their health at risk (e.g., eating more fast food, having more emotional problems).¹¹Asking patients if they eat breakfast is somewhat similar to the old patient intakes where we asked patients if they used seatbelts. A negative reaction may indicate a pattern of unhealthy lifestyle habits.

Asking patients if they eat breakfast is somewhat similar to the old patient intakes where we asked patients if they used seatbelts. A negative reaction may indicate a pattern of unhealthy lifestyle habits.

This isn't the first study to suggest a negative association with skipping breakfast. Cahill et al. reported in 2013 that they had assessed the eating habits of 26,902 American men from the Health Professionals Follow-up Study. During a 16-year period, 1,527 cases of heart disease were diagnosed in these men. Men who skipped breakfast had a 27% higher risk of coronary heart disease (CHD) compared to men who did not (relative risk (RR): 1.27; 95% CI: 1.06-1.53). Additionally, we should note that men who ate late at night had a 55% higher risk of CHD compared to men who did not eat late at night (RR: 1.55; 95% CI: 1.05-2.29).⁹

Kubota et al. reported results from a large group of 82,772 participants (38,676 men and 44,096 women) in Japan in a 2016 publication. Those who skipped breakfast had a 14% higher risk of cardiovascular disease, an 18% higher risk of a stroke and a 36% higher risk of a hemorrhagic stroke.¹⁰

The discussion is not nowifSkipping breakfast is badWhy. Several theories have been postulated. Skipping breakfast can lead to overeating and impaired insulin sensitivity later in the day.¹²Eating breakfast helps regulate appetite and improves glycemic response at the next meal, thereby increasing insulin sensitivity.¹³Skipping breakfast is stressful, and the prolonged fasting period leads to increased blood pressure in the morning due to an adrenal response triggered by the hypothalamic-pituitary gland.⁶

Breakfast, on the other hand, lowers blood pressure and reduces artery stiffness. For this reason, the measurements of these parameters are carried out in a fasting state.¹⁴Skipping breakfast can also trigger unwanted changes in blood lipids, particularly an increase in LDL cholesterol.⁵

Whatever the reasons, the data consistently shows that skipping breakfast increases the risk of cardiovascular disease. The advice to eat breakfast may be met with resistance by those who are fasting overnight for their health.

Carol Marinac noted the connection between prolonged nighttime fasting and a lower risk of breast cancer recurrence in a 2016 article. Specifically, the data showed that those who fasted for more than 13 hours had fewer breast cancer recurrences.^fifteenWe covered this study in 2016.

The problem with promoting this type of fasting is that many people meet the 13-hour fast suggestion by simply skipping breakfast. The resulting increase in cardiovascular risk could outweigh any reduction in breast cancer risk. We need an approach that both allows for longer nighttime fasts and encourages breakfast, so the obvious solution would be to eat dinner earlier. Such a meal pattern of eating an early dinner was demonstrated by the study of Kogevinas et al. funded from 2018. Compared to participants who went to sleep immediately or shortly after dinner, those who delayed going to sleep for 2 or more hours after dinner had a 20% lower risk of breast and prostate cancer combined (adjusted odds ratio). [OR]: 0.80; 95% CI: 0.67-0.96) and for each cancer individually (prostate cancer OR: 0.74; 95% CI: 0.55-0.99 and breast cancer OR: 0.84; 95% CI: 0.67-1.06).¹⁶Read our coverage of this study.

Combining Kogevinas' findings with Marianac's, we should encourage an early dinner (at least 2 hours before bed) and breakfast 13 hours later. Once again, the research suggests thisIfwe eat can deserve just as much attention asWhatwe eat.