For the time being, breakfast holds the grand title of "the most important meal of the day." Some critics say that the title is overblown, at least as far as weight loss goes, but a paper released Monday in the Journal of the American College of Cardiology adds to a growing body of research suggesting that breakfast's status as the king of meals is well-deserved, particularly when it comes to heart health.
This paper uses both surveys and death records to show that people who skipped breakfast were 87 percent more likely to have died of cardiovascular disease than those who had a morning meal. The analysis, co-authored by Wei Bao, Ph.D., an assistant professor of epidemiology at the University of Iowa, is the next step in an ongoing saga around breakfast's effects on heart disease. Just last week, another study estimated that heart attack patients who skipped breakfast exposed themselves to between four and five times greater chances of death during their recovery periods.
Bao's paper takes things a step further by examining the risks associated with skipping breakfast in generally healthy people.
The survey portion of the analysis involves responses from 6,550 participants who were surveyed between 1988 and 1994 as part of the National Health and Nutrition Examination Survey (NHANES). Overall, only 5.1 percent of those people didn't eat breakfast on a daily basis, and 59 percent of people ate breakfast every day (the remaining 35.9 percent ate breakfast intermittently). To illuminate the long-term effects of skipping breakfast, Bao checked death records through December 31, 2011, and found that 2,318 of that original cohort had died.
In that cohort, Bao found strong links between skipping breakfast and death. Specifically, breakfast skippers were 19 percent more likely to have died from any cause and 87 percent more likely to have died from heart disease - even after Bao adjusted for other risky activities like smoking, or factors like body mass index that might also affect death risk.
Those statistics alone sound like they belong on the front of a Cheerios box, but there is a mounting field of evidence showing similar results.
For example, a paper published in 2016 in Stroke showed that men who declined breakfast had 14 percent higher risks of heart disease. This study's shocking statistic really does crystallize the risks of breakfast skipping, as Borja Iban~ez, Ph.D., a cardiologist at the Spanish National Center for Cardiovascular Research, added in an accompanying commentary.
"What is clear is that a pattern of skipping breakfast identifies a population at risk," Iban~ez wrote.
That lingering question of why there's a connection between breakfast and heart disease is still outstanding. But this latest paper, in conjunction with another linked commentary, starts to put forth some explanations that fall into two categories.
First, there's the idea that skipping breakfast actually induces some kind of change in the body. For instance, Bao and his co-authors propose that the prolonged period of fasting may lead to elevated blood pressure, which, on its own, is a risk factor for heart disease. They also propose that skipping breakfast exacerbates levels of low-density lipoprotein (LDL), the "bad" type of cholesterol associated with buildup in the arteries. To highlight this hypothesis, they cite a 2017 paper, also in the Journal of the American College of Cardiology, showing that people who skipped breakfast had more than double the risk of having plaque buildup in their arteries even compared to people who ate high-calorie breakfasts.
On the other hand, skipping breakfast may just be a stand-in for other harmful lifestyle choices that can impact heart health. Speaking to CNN, Krista Varady, Ph.D., an associate professor of kinesiology and nutrition at the University of Illinois at Chicago who wasn't involved in the new study, implied that Bao's team's research also presents evidence to that effect.
"However, the major issue is that the subjects who regularly skipped breakfast also had the most unhealthy lifestyle habits," Varady said. "Specifically, these people were former smokers, heavy drinkers, physically inactive, and also had poor diet quality and low family income."
In the paper, the authors acknowledge that skipping breakfast might just be a "behavioral marker" of other risky factors, as Varady suggests, but they argue that their statistical adjustments helped offset those factors. Iban~ez also notes the power of their evidence but adds that health factors are so multidimensional that it is impossible to adjust for everything.
For now, it's still unclear which way this research will go. But what we already know is that skipping breakfast does seem to come at a price.
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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