RESEARCH

Original Research

The Relationship of Breakfast Skipping and Type of Breakfast Consumption with Nutrient Intake and Weight Status in Children and Adolescents: The National Health and Nutrition Examination Survey 1999-2006
PRIYA R. DESHMUKH-TASKAR, MSc; THERESA A. NICKLAS, DrPH; CAROL E. ONEIL, PhD, MPH, RD, LDN; DEBRA R. KEAST, PhD; JOHN D. RADCLIFFE, PhD, RD; SUSAN CHO, PhD Results Twenty percent of children and 31.5% of adolescents were breakfast skippers; 35.9% of children and 25.4% of adolescents consumed RTE cereal. In children/adolescents, RTE cereal consumers had lower intakes of total fat and cholesterol and higher intakes of total carbohydrate, dietary ber, and several micronutrients (P0.05 for all) than breakfast skippers and other breakfast consumers. RTE cereal consumers had the highest MAR for micronutrients, and MAR was the lowest for breakfast skippers (P0.05). In children/adolescents, breakfast skippers had higher body mass index-for-age z scores (P0.05) and a higher waist circumference (P0.05) than RTE cereal and other breakfast consumers. Prevalence of obesity (body mass index 95th percentile) was higher in breakfast skippers than RTE cereal consumers (P0.05) in children/adolescents and was higher in other breakfast consumers than RTE cereal consumers only in adolescents (P0.05). Conclusions RTE cereal consumers had more favorable nutrient intake proles and adiposity indexes than breakfast skippers or other breakfast consumers in US children/adolescents. J Am Diet Assoc. 2010;110:869-878.

ABSTRACT Background National data comparing nutrient intakes and anthropometric measures in children/adolescents in the United States who skip breakfast or consume different types of breakfasts are limited. Objective To examine the relationship between breakfast skipping and type of breakfast consumed with nutrient intake, nutrient adequacy, and adiposity status. Subjects Children aged 9 to 13 years (n4,320) and adolescents aged 14 to 18 years (n5,339). Design Cross-sectional data from the National Health and Nutrition Examination Survey 1999-2006. Methods Breakfast consumption was self-reported. A 24hour dietary recall was used to assess nutrient intakes. Mean adequacy ratio (MAR) for micronutrients and anthropometric indexes were evaluated. Covariate-adjusted sample-weighted means were compared using analysis of variance and Bonferronis correction for multiple comparisons among breakfast skippers (breakfast skippers), ready-to-eat (RTE) cereal consumers, and other breakfast (other breakfast) consumers.

P. R. Deshmukh-Taskar is a research coordinator II, and T. A. Nicklas is a professor, US Department of Agriculture, Agricultural Research Service Childrens Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX. C. E. ONeil is an alumni professor, Louisiana State University AgCenter, Baton Rouge, LA. D. R. Keast is a statistician, Food and Nutrition Database Research Consulting, Okemos, MI. J. D. Radcliffe is a professor, Department of Nutrition, Texas Womans University, Houston. S. Cho is a statistician, NutraSource Inc, Clarksville, MD. Address correspondence to: Theresa A. Nicklas, DrPH, USDA/ARS Childrens Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates Ave, Houston, TX 77030-2600. E-mail: tnicklas@bcm.edu Manuscript accepted: December 7, 2009. Copyright 2010 by the American Dietetic Association. 0002-8223/$36.00 doi: 10.1016/j.jada.2010.03.023

ediatric overweight is epidemic in the United States (1). Childhood overweight tracks into adulthood (2), increasing the risk for chronic diseases that occur commonly among overweight/obese adults (3). Dietary habits may contribute to the incidence and severity of overweight/obesity in children/adolescents (4,5). Skipping breakfast has been associated with higher adiposity measures in children/adolescents and is more prevalent than in the past among these age groups (6,7). A previous nationally representative study showed that in 1965, 5% and 12% of children/adolescents aged 11 to 14 years and 15 to 18 years, respectively, skipped breakfast (6). The 1999-2000 National Health and Nutrition Examination Survey (NHANES) showed that 20.5% of 9- to 13-year-old children and 36.1% of 14- to 18-year-old adolescents, respectively, skipped breakfast (7). Breakfast skipping may have public health consequences for children/adolescents (4-5,8-11). Compared to breakfast consumers, those who skipped breakfast had reduced intakes of many nutrients, including vitamins A,

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E, C, B-6, and B-12; folate; iron; calcium; phosphorus; magnesium; potassium; and dietary ber (8), that were rarely compensated for at other meals. Breakfast skippers were also less likely to meet the daily recommendations for food groups such as vegetables and fruits (9). Skipping breakfast has been associated with a higher body mass index (BMI) compared to those who consumed breakfast (10,11). Skipping breakfast in childhood or adolescence may persist into adulthood (12). One strategy to increase the prevalence of those consuming breakfast was the introduction of the School Breakfast Program, which provides 25% of the Recommended Dietary Allowance (RDA) for energy, protein, vitamins A and C, calcium, and iron (13). However, not all schools or all children/adolescents participate in this program (14). Many ready-to-eat (RTE) cereals are convenient, palatable, nutrient-dense foods that do not require further preparation or cooking. Most RTE cereals are low in fat, are good sources of complex carbohydrates, and are fortied with vitamins and minerals (15-17). Higher consumption of RTE cereals at breakfast has been associated with better dietary intakes (5,11,17-19) when compared to lower or no consumption. Consumption of RTE cereals has also been related to a lower BMI and to weight loss (5,11,20) when compared to nonconsumers. Nonetheless, studies exploring the relationship of breakfast consumption to nutrient intake (10,11), nutrient adequacy, and anthropometric measures (10,11) in a recent nationally representative sample of US children/adolescents are limited. The goal of this study was to examine differences in the relationship between breakfast skipping and type of breakfast consumed using nutrient intake, nutrient adequacy, and anthropometric measures in a nationally representative sample of US children/adolescents. SUBJECTS AND METHODS Study Population This study involved analyses of cross-sectional data from US children aged 9 to 13 years (n4,320) and adolescents aged 14 to 18 years (n5,339) participating in the 19992006 NHANES (21). Pregnant or lactating subjects (n129) were excluded. Due to the nature of the analysis (secondary data analysis) and the lack of personal identiers, this study was exempted by the Institutional Review Board of the Baylor College of Medicine. Dietary Assessment The dietary data collection procedures are described elsewhere (22-24). Briey, data from a single multipass 24hour dietary recall were used (22-24). For years where 2-day diet recalls were available from NHANES (ie, from 2003 onward), only the rst day of dietary recall data were used. The 24-hour diet recall was assisted by parent/ caregivers for children aged 6 to 11 years and was selfreported for those older than age 11 years (22). Only participants with complete and reliable dietary data, as determined by the National Center for Health Statistics staff, were included. Breakfast consumption was dened as self-reported and included consumption of any food or beverage at a meal occasion named by the respondent as breakfast or desayuno/almuerzo (Spanish). Subjects who

consumed no food or beverages, excluding water, at breakfast were categorized as breakfast skippers. RTE cereal breakfast consumers were dened as those who ate RTE cereal at a breakfast meal occasion (regardless of other foods or beverages consumed at that meal occasion), and other breakfast consumers were dened as those who consumed other foods or beverages at the breakfast meal. Intakes of total energy, total and percent energy from macronutrients, and micronutrients were assessed. Nutrient content of survey foods in NHANES 2003-2004 were determined using the US Department of Agriculture (USDA) Nutrient Database for Standard Reference (release 20, 2007, University of Minnesota Nutrition Coordinating Center, Minneapolis) and the SR-Link le (the recipe database) of the Food and Nutrient Database for Dietary Studies, (version 2.0, 2006, Food Surveys Research Group, Beltsville, MD). The Food and Nutrient Database for Dietary Studies version 1 (2004, Food Surveys Research Group, Beltsville, MD) was used for processing the dietary interview data for 2001-2002, and technical support les included an earlier version of the recipe database used in NHANES 1999-2000. The versions of the nutrient databases linked to the survey foods were the SR-18 (2005, University of Minnesota Nutrition Coordinating Center) in NHANES 2001-2002 and the SR-16.1 (2004, University of Minnesota Nutrition Coordinating Center) in NHANES 1999-2000. The data for some nutrients (eg, vitamins A and E and folate in their current accepted nutrient forms) and total sugars were appended from the USDA dietary database for vitamins A and E (2006, Agricultural Research Service, Food Surveys Research Group, Beltsville, MD) and the Food and Nutrient Database for Dietary Studies version 2.0, respectively. The intake of added sugars (ie, sugars added to foods/beverages during processing or home preparation and not natural sugars) was obtained from the USDA (25). A mean adequacy ratio (MAR) of micronutrient intake was calculated by estimating the percent of the adequacy value (either RDA or Adequate Intake [AI] cut-off) (26) that met the RDA/AI cut-off. Those values greater than the cut-off were truncated at 100% to prevent an excess intake of one nutrient from compensating for inadequate intake of other nutrients. These values were averaged over 13 selected micronutrients (vitamins A, E, C, B-6, and B-12; thiamin; riboavin; niacin; folate; phosphorus; magnesium; iron; and zinc). The MAR for shortfall nutrients for children/adolescents as outlined by the Dietary Guidelines for Americans, 2005, was calculated the same way as described above for ve shortfall nutrients (vitamin E, calcium, magnesium, potassium, and dietary ber) (27). Although there is no denite score for the interpretation of the MAR, a conservative score of 90 was selected as nutritionally adequate (28). Assessment of Adiposity Status Adiposity status was assessed by using anthropometric measurements (ie, weight, height, and waist circumference) conducted by NHANES personnel in the Mobile Examination Center (21,29,30). BMI was calculated as kg/m2. The z scores and percentiles for BMI-for-age and weight-for-age were calculated using the Statistical Analysis Software program for the Centers for Disease Con-

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trol and Prevention Growth Charts (2000, Centers for Disease Control and Prevention, Atlanta, GA). For children/adolescents, overweight was dened as a BMI 85th percentile and 95th percentile and obesity was dened as a BMI 95th percentile (31). Statistical Analyses Details regarding statistical methods are accessible elsewhere (32). Briey, sample-weighted data were analyzed using Statistical Software for Analysis of Correlated Data (SUDAAN, version 9.0.1, 2008, Research Triangle Institute, Research Triangle Park, NC) to account for unequal probability of selection from over-sampling and for the stratied multistage probability sample design (33). Sample-weighted percentsstandard errors were calculated for the demographic variables using cross-tabulations and were compared using 2 tests. Mean macronutrient and micronutrient intakes, MAR, BMI z scores, and waist circumference were determined and are presented as least-square meansleast-square standard errors. The covariate-adjusted prevalence of overweight/obesity was determined by calculating the mean of a dichotomous variable giving the mean prevalence percents and standard errors. Total energy intake, demographics (age, sex, ethnicity, ethnicitysex), socioeconomic status (ie, poverty income ratio [PIR]), and physical activity were covariates in the analyses. Demographic, socioeconomic, and physical activity information was obtained from their respective NHANES questionnaires (21). Ethnicity of children/adolescents was self-reported and categorized into whites, blacks, Mexican Americans/Hispanics, and other/mixed races. The PIR of the households was categorized in groups ranging from 1 to 5. Physical activity of the children/adolescents was categorized into vigorous (7 times per week), moderate (four to six times per week), and low (zero to three times per week). Tests for comparisons of means for dietary and anthropometric variables among the breakfast consumption groups were performed after adjusting for covariates using Bonferronis correction (P0.05/3P0.0167) to adjust the signicance level for multiple comparisons. The signicance for categorical variables was set at P0.05. RESULTS Demographic Characteristics Twenty percent of children were breakfast skippers, 35.9% consumed RTE cereals, and 44% consumed other breakfast. A lower percentage of Mexican-American/Hispanic and white children were breakfast skippers (16.1% and 19.4%) than consumed RTE cereals (35.5% and 37.6%) or other breakfast (48.4% and 43.1%), respectively. A lower percentage of children from households with PIR 5 were breakfast skippers (15.4%) than consumed RTE cereal (30.4%) or other breakfast (54.2%), respectively (Table 1). Thirty-two percent of adolescents were breakfast skippers, 25.3% consumed RTE cereal, and 43.2% consumed other breakfast. Fewer white adolescents skipped breakfast (28.3%) or consumed RTE cereal (28.6%) than consumed other breakfast (43.1%). A lower percentage of black adolescents consumed RTE cereal (19.8%) than

skipped breakfast (40%) or consumed some other breakfast (40.2%). A higher percentage of Mexican-American/ Hispanic adolescents consumed other breakfast (45%) than skipped breakfast (32.9%) or consumed RTE cereal (22.2%). A lower percentage of adolescents from households with PIR 1 consumed RTE cereal (19.7%) than skipped breakfast (40.2%) or consumed other breakfast (40.1%) (Table 1). A lower percentage of adolescents from single-parent homes consumed RTE cereal (20.7%) than skipped breakfast (35.4%) or consumed other breakfast (43.9%) (data not shown). Covariate-Adjusted Mean Nutrient Intakes from a Reported 24-Hour Dietary Recall by Type of Breakfast Consumption Groups In children, total energy intake in the group of breakfast skippers was lower than those consuming RTE cereal or other breakfast. Percentages of energy from carbohydrate and total sugars were higher in RTE cereal consumers than in breakfast skippers or those who ate a breakfast other than cereal. Percent energy from added sugars was higher in breakfast skippers than in other breakfast consumers. Dietary ber intake was higher in RTE cereal consumers than in breakfast skippers or other breakfast consumers. Percentages of energy from total fat, monounsaturated fatty acids, and polyunsaturated fatty acids were all lower in RTE cereal consumers than the other two breakfast groups (Table 2). Sex differences (data not shown) showed a similar pattern, except for a few macronutrients. Percent energy from added sugars was not different among the three breakfast groups in boys, but in girls it was higher in breakfast skippers than in RTE cereal and other breakfast consumers. Percent energy from total sugars was higher in RTE cereal consumers than breakfast skippers in boys but not in girls. Percent energy from total sugars was higher in breakfast skippers than in other breakfast consumers in girls but not in boys. In children, intakes of vitamins A, C, B-6, and B-12; thiamin; riboavin; niacin; folate; calcium; phosphorus; magnesium; iron; zinc; and potassium were all higher in RTE cereal consumers than in breakfast skippers. Other breakfast consumers had lower intakes of vitamins A, B-6, and B-12; thiamin; riboavin; niacin; folate; calcium; phosphorus; magnesium; iron; zinc; and potassium but had a higher intake of sodium than RTE cereal consumers. Other breakfast consumers had higher intakes of only riboavin and phosphorus when compared to breakfast skippers (Table 2). Sex differences (data not shown) showed that girls consuming breakfast other than cereal had higher intakes of riboavin, vitamin B-12, calcium, phosphorus, magnesium, and potassium than girls who were breakfast skippers; however, this was not shown in boys. In adolescents, the total energy intake for breakfast skippers was lower than in RTE cereal and other breakfast consumers. Percent energy from total carbohydrate, total sugars, and dietary ber intake were all higher in RTE cereal consumers than in breakfast skippers and other breakfast consumers. Percent energy from added sugars was higher in breakfast skippers than in RTE cereal and other breakfast consumers. Percent energy from saturated fatty acids was higher in other breakfast

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Table 1. Demographic characteristics of children/adolescents by type of breakfast consumption (breakfast skippers, ready to eat [RTE] cereal consumers, or other breakfast consumers), based on data from the National Health and Nutrition Examination Survey 1999-2006a
Breakfast Skippers Characteristic Sample size (n) 9-13 y age group 14-18 y age group Sample size (%standard error) 9-13 y age group 14-18 y age group Age (y) (meanstandard error) 9-13 y 14-18 y Ethnicity 9-13 y (%standard error) Non-Hispanic white Non-Hispanic black Mexican American Other/mixed race Column P value Ethnicity 14-18 y (%standard error) Non-Hispanic white Non-Hispanic black Mexican American Other/mixed race Column P value Family PIRb (%standard error) 9-13 y 1 1 and 2 2 and 3 3 and 5 5.0 Column P value Family PIR (%standard error) 14-18 y 1 1 and 2 2 and 3 3 and 5 5.0 Column P value Physical activity (%standard error) 9-13 y Sedentary Moderate Vigorous Column P value Physical activity (%standard error) 14-18 y Sedentary Moderate Vigorous Column P value Total Boys Girls Total RTE Cereal Consumers Boys Girls Other Breakfast Consumers Total Boys Girls Total P Value Boys Girls

930 1,805 20.10.9 31.50.9 11.40.1 16.20.1 19.41.2 25.71.2 16.11.2 26.35.0 * 28.31.2 40.01.2 32.91.6 41.14.5 * 23.51.9 24.11.9 17.82.0 17.81.8 15.42.3 * 40.21.9 32.51.9 30.92.0 29.01.9 23.32.2 * 21.02.5 18.51.8 20.51.1 37.72.6 35.22.5 30.11.0

459 904 20.61.2 30.31.2 11.30.1 16.20.1 19.71.8 25.11.7 16.51.7 29.57.2 * 27.31.7 40.01.7 30.32.2 40.26.3 * 26.33.0 22.02.5 18.12.8 17.72.5 18.43.5 38.02.7 34.92.8 28.73.0 26.72.5 22.42.9 24.24.4 18.92.8 20.41.4 45.14.4 32.84.1 28.81.3

471 901 19.71.2 32.71.3 11.40.1 16.10.1 18.91.7 26.31.7 15.81.8 21.76.2 * 29.31.8 39.91.8 35.62.4 41.86.3 * 20.62.2 26.02.7 17.62.9 17.82.6 12.23.0 * 42.32.7 29.92.8 33.23.3 31.42.8 24.33.2 * 18.52.9 18.12.3 20.61.6 33.33.0 36.73.1 31.71.6

1,536 1,233 35.91.0 25.30.9 10.90.1 15.80.1 37.61.5 33.11.3 35.51.7 26.24.6 * 28.61.2 19.81.0 22.21.4 12.12.6 * 33.41.9 37.52.2 38.42.6 38.22.3 30.43.0 19.71.5 25.61.9 24.72.1 29.11.9 28.62.3 * 36.92.9 33.82.3 36.521.3 16.51.9 23.92.2 27.21.0 *

785 707 37.71.0 27.80.9 11.00.1 15.70.1 40.51.5 34.71.3 35.71.7 22.64.6 * 30.31.2 22.71.0 26.51.4 15.02.6 * 30.31.9 40.92.2 41.62.6 41.82.3 30.33.0 * 22.01.5 26.61.9 27.52.1 33.31.9 29.32.3 * 38.02.9 33.62.3 38.51.3 17.91.9 26.32.2 29.01.0 *

751 526 34.01.4 22.81.2 10.90.1 15.80.1 34.52.1 31.61.8 35.22.5 31.67.1 26.81.7 16.81.3 17.61.7 9.43.4 * 36.42.7 34.12.9 34.93.7 34.13.2 30.64.2 17.52.0 24.52.8 21.72.9 24.72.6 27.83.4 * 36.13.6 34.02.9 34.11.8 15.72.4 22.52.7 24.91.5 *

1,854 2,301 44.01.1 43.21.0

878 1,146 41.81.5 41.91.3

976 1,155 46.31.5 44.61.4 11.00.1 15.90.1 46.62.2 42.21.9 49.02.6 46.77.4 43.91.9 43.31.8 46.82.5 48.76.3 43.02.7 39.93.0 47.63.8 48.13.4 57.24.5 * 40.22.7 45.63.1 45.13.5 44.03.0 47.93.8 45.53.7 47.93.0 45.32.0 51.13.4 40.83.1 43.41.7

* *

* *

* *

11.00.04 11.00.1 15.90.0 15.90.1 43.11.6 41.21.4 48.41.8 47.55.3 * 43.11.4 40.21.2 45.01.7 46.84.4 43.22.1 38.52.2 43.82.6 44.02.3 54.23.3 * 40.11.9 41.92.1 44.42.4 42.02.1 48.12.6 42.12.9 47.82.4 43.01.3 45.82.7 40.82.5 42.71.1 39.72.2 40.21.9 47.82.5 48.07.3 * 42.31.9 37.31.6 43.32.2 44.76.3 43.43.1 37.13.2 40.33.6 40.53.2 51.44.7 40.02.7 38.52.8 43.83.4 40.12.9 48.33.5 37.84.4 47.63.8 41.21.8 37.04.1 40.94.2 42.21.5

* * * *

* * *

* * *

* * * *

* * * *

* * * *

* * * * *

* * * * *

* * * * *

* * * * *

* * * * *

* * * * *

* * *

* *

* * *

* * *

* *

* * *

a Mean percentages across the three breakfast groups in rows (Breakfast Skippers, RTE Cereal Consumers, and Other Breakfast Consumers) add to 100 and the signicance is indicated by row P values for both sexes. Column percentages (data not shown in text) are indicated with the column P values. b PIRpoverty income ratio. *P0.05.

consumers than in RTE cereal consumers, and was lower in RTE cereal consumers than in breakfast skippers. Cholesterol intake was higher in other breakfast consumers than in breakfast skippers and RTE cereal consumers (Table 2). In adolescents, those consuming RTE cereal had higher intakes of vitamins A, C, B-6, and B-12; thiamin; riboavin; niacin; folate; calcium; phosphorus; magnesium; iron; zinc; and potassium than breakfast skippers. Other breakfast consumers had higher intakes of vitamin A,

riboavin, calcium, phosphorus, magnesium, and potassium than breakfast skippers, whereas they had lower intakes of vitamins A, C, B-6, and B-12; thiamin; riboavin; niacin; folate; calcium; phosphorus; magnesium; iron; zinc; and potassium than RTE cereal consumers. Other breakfast consumers had a higher intake of sodium than RTE cereal consumers. Among other breakfast consumers, the intakes of thiamin; niacin; vitamins B-6, B-12, and K; folate; iron; zinc; and sodium did not differ from the breakfast skippers (Table 2). Few sex differences

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Table 2. Nutrient intakes and percent of energy from macronutrients in children and adolescents, by breakfast consumption group (breakfast skippers, ready-to-eat [RTE] cereal consumers, or other breakfast consumers), based on 24-hour recall from the National Health and Nutrition Examination Survey 1999-2006 Child Age 9-13 y (n4,320) Breakfast skippers RTE cereal consumers Other breakfast consumers Adolescent Age 14-18 y (n5,339) Breakfast skippers RTE cereal consumers Other breakfast consumers

Macronutrient Energy (kcal) Protein Total (g)y % Energyz Carbohydrate Total (g)y % Energyz Sugars Total (g)y % Energyz Added sugars Total (g)y % Energyz Fat Total (g)y % Energyz Saturated fatty acids Total (g)y % Energyz Monounsaturated fatty acids Total (g)y % Energyz Polyunsaturated fatty acids Total (g)y % Energyz Dietary ber (g)y Cholesterol (mg)y Micronutrients Vitamin A (g RAEa)y Tocopherol (mg)y Vitamin K (g)y Vitamin C (mg)y Thiamin (mg)y Riboavin (mg)y Niacin (mg)y Vitamin B-6 (mg)y Vitamin B-12 (g)y Folate (g DFEb)y Calcium (mg)y Phosphorus (mg)y Magnesium (mg)y Iron (mg)y Zinc (mg)y Sodium (mg)y Potassium (mg)y
a b

4 least square meanleast square standard error 3 2,033.054.2x 2,266.037.5y 2,270.036.0y 2,032.043.8x 2,462.047.5y 2,352.041.9y 77.31.2 13.70.2 295.22.6x 52.60.5x 151.43.5x 26.80.7x 118.73.2x 21.20.6x 85.61.0x 33.60.4x 29.30.4 11.50.2 32.30.4x 12.70.2x 17.30.4x 6.80.2x 13.30.3x 233.97.8x 537.127.2x 7.30.3x 60.23.1 75.64.4x 1.50.03x 1.80.04x 21.20.5x 1.50.1x 4.30.2x 327.79.1x 883.827.0x 1,245.021.0x 233.03.6x 13.50.3x 10.80.2x 3,404.054.2x,y 2,235.041.3x 78.20.9 13.90.2 311.12.2y 55.60.4y 163.22.6y 29.10.5y 112.32.6x,y 20.00.5x,y 78.70.8y 30.50.3y 28.60.4 11.10.1 28.70.3y 11.10.1y 15.00.3y 5.80.1y 14.50.3y 218.36.2x 832.921.1y 6.50.2y 59.85.3 95.73.7y 2.10.03y 2.80.03y 27.00.4y 2.40.04y 6.70.2y 535.411.7y 1,150.020.5y 1,406.015.8y 262.63.3y 20.40.3y 14.40.2y 3,398.043.8x 2,515.034.3y 78.00.9 13.90.2 297.82.2x 53.00.4x 150.02.5x 26.60.4x 108.32.5y 19.00.4y 84.10.8x 33.20.3x 29.00.4 11.40.1 31.80.3x 12.50.1x 16.50.3x 6.50.1x 13.30.2x 284.28.0y 613.223.0x 6.80.2x,y 60.22.8 84.43.4x 1.50.02x 2.00.03z 20.70.3x 1.50.04x 4.50.2x 332.26.0x 958.520.1x 1,320.015.4z 236.92.7x 13.70.2x 10.70.2x 3,520.041.4y 2,344.033.9x 73.81.1x 13.30.2 299.22.6x 53.10.5x 154.23.3x 27.70.5x 125.53.1x 22.50.6x 85.20.9x 33.60.4x 29.40.4xy 11.60.2x 32.70.4x 12.90.2x 16.70.4x 6.60.1x 12.60.3x 210.96.7x 444.021.5x 6.40.2 55.23.3 71.44.2x 1.40.03x 1.80.04x 20.20.5x 1.50.1x 4.20.2x 320.17.4x 875.621.5x 1,206.016.8x 221.53.2x 13.50.3x 10.70.2x 3,41853.4x,y 2,141.037.4x 77.91.1y 13.60.2 320.42.4y 56.40.4y 166.63.0y 29.10.5y 114.22.9y 20.00.5y 77.30.9y 30.00.3y 28.20.4x 10.90.2y 28.60.4y 11.10.1y 14.20.3y 5.50.1y 15.00.3y 216.36.8x 874.631.0y 6.60.3 47.63.1 98.44.6y 2.30.04y 3.00.04y 28.70.5y 2.50.1y 7.60.2y 591.812.2y 1,193.023.7y 1,426.018.2y 271.73.8y 22.80.4y 15.30.3y 3,355.050.4x 2,540.039.7y 77.41.0y 13.70.2 296.12.3x 52.60.4x 149.42.7x 26.50.4x 110.92.6y 19.10.4y 86.40.8x 33.70.3x 29.90.4y 11.70.1x 33.00.3x 12.80.1x 16.70.3x 6.50.1x 13.00.2x 289.18.2y 542.323.2z 6.70.2 55.12.7 85.33.7z 1.50.02x 2.00.04z 19.90.4x 1.40.04x 4.40.2x 320.56.2x 944.020.7z 1,307.016.9z 235.83.1z 13.40.2x 10.50.2x 3,516.044.2y 2,345.035.2z

RAEretinol activity equivalent. DFEdietary folate equivalent. x Mean values within a row with unlike superscript letters (x, y, z) were signicantly different (P0.0167) using a Bonferroni correction. Absolute P values using the F test of analysis of variance for those with signicant multiple comparisons were P0.0005. y Covariates: Energy intake (kcal), sex, ethnicity, age, sexethnicity, poverty income ratio, and physical activity. z Covariates for percent energy from macronutrients: sex, ethnicity, age, sexethnicity, poverty income ratio, and physical activity.

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13 micronutrients
Breakfast skippers RTE cereal consumers Other breakfast consumers

Five shortfall nutrients

Breakfast skippers RTE cereal consumers Other breakfast consumers

100
90 80

b a

b
a

c
a

b c a

b c a c
70 60 M 40 A 30 R 20
10 0 50

70
M A R 60

b b

c a

b c a

50
40 30

20
10

0
9-13y Both sexes 9-13y Boys 9-13y Girls Age groups 14-18y Both sexes 14-18y Boys 14-18y Girls

9-13y Both sexes

9-13y Boys

9-13y Girls

14-18y Both sexes

14-18y Boys

14-18y Girls

Age groups

Figure 1. Mean adequacy ratio (MAR) for nutrient intakes from a reported 24-hour dietary recall by type of breakfast consumption groups in children/adolescents based on data from the National Health and Nutrition Examination Survey 1999-2006. Values are sample-weighted least-square meansleast-square standard errors. RTEready-to-eat. Thirteen micronutrients were vitamins A, E, C, B-6, B-12, thiamin, niacin, riboavin, folate, phosphorus, magnesium, iron, and zinc. Five shortfall nutrients were vitamin E, calcium, magnesium, potassium, and dietary ber. Covariates (both sexes): Energy intake (kcal), age, sex, ethnicity, sexethnicity, poverty income ratio, and physical activity. Covariates (boys and girls): All above but sex and sexethnicity. Mean values within a row with unlike letters (a,b,c) were signicantly different (P0.0167) using a Bonferroni correction. Absolute P values using the F test of analysis of variance for those with signicant multiple comparisons were P0.0005.

(data not shown) were found. Girls who consumed breakfast other than cereal had higher intakes of vitamin C, thiamin, riboavin, folate, phosphorus, and potassium than girls in the breakfast skippers group; boys consuming other breakfast had higher intakes of riboavin, phosphorus, and potassium than boys in the breakfast skippers group. Covariate-Adjusted MAR by Type of Breakfast Consumption Groups In children, the MAR for 13 selected micronutrients was higher in RTE cereal consumers (91.3) than in breakfast skippers (79.0) and other breakfast consumers (84.7), and other breakfast consumers had a higher MAR than breakfast skippers. Similar results were observed within the age and sex groups. The MAR for ve shortfall nutrients was also higher in RTE cereal consumers (63.7) than in breakfast skippers (55.9) and other breakfast consumers (59.7), and other breakfast consumers had a higher MAR than breakfast skippers (Figure 1). In adolescents, the MAR for 13 selected micronutrients was higher in RTE cereal consumers (85.4) than in breakfast skippers (70.7) and other breakfast consumers (76.0), for both sexes. The MAR for ve shortfall nutrients was also higher in RTE cereal consumers (54.9) than in breakfast skippers (45.9) and other breakfast consumers (49.5). Other breakfast consumers had higher MAR for the 13 selected micronutrients and for the ve shortfall nutrients than breakfast skippers (Figure 1).

Covariate-Adjusted Mean Anthropometric Measures by Type of Breakfast Consumption Groups In children, breakfast skippers had a higher BMI z score for age than other breakfast consumers; overall, other breakfast consumers had a higher BMI z score for age than RTE cereal consumers (Figure 2A). Breakfast skippers had a higher waist circumference (79.2 cm) than RTE cereal consumers (75.9 cm); overall, other breakfast consumers had a higher waist circumference (77.5 cm) than RTE cereal consumers (Figure 2B). The prevalence of obesity (BMI 95th percentile) was higher in breakfast skippers (22.1%) than in RTE cereal consumers (15.2%), especially in boys (24.1% vs 14.3%) (Figure 2C). Breakfast skippers had a higher BMI percentile for age than RTE cereal consumers, and other breakfast consumers had a higher BMI percentile for age than RTE cereal consumers, in girls only (data not shown). In adolescents, the BMI z score for age was higher in breakfast skippers than in RTE cereal and other breakfast consumers and was higher in other breakfast consumers than in RTE cereal consumers (Figure 2A). Breakfast skippers had a higher waist circumference (78.5 cm) than RTE cereal consumers (75.0 cm), and in girls, the waist circumference was higher than in other breakfast consumers (breakfast skippers 77.2 cm vs other breakfast consumers 75.0 cm). Boys consuming other breakfast had a higher waist circumference (78.7 cm) than in boys consuming RTE cereal (76.3 cm) (Figure 2B). The prevalence of obesity was higher in breakfast skippers (20.7%) than in RTE cereal consumers (13.2%) in boys and girls. The prevalence of obesity was also higher

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Figure 2. Z scores of body mass index (BMI) for age (A), waist circumference (WC) (B), and prevalence of obesity (C) by type of breakfast consumption groups in children/adolescents, based on data from the National Health and Nutrition Examination Survey 1999-2006. RTEreadyto-eat. Obesity dened as a body mass index 95th percentile. Values are sample-weighted least-square means and least-square standard errors of a dichotomous variable. Covariates (both sexes): Energy intake (kcal), age, sex, ethnicity, sexethnicity, physical activity, and poverty income ratio. Covariates (boys and girls): All above but sex and sexethnicity. Mean values within a row with unlike superscript letters (a,b,c) were signicantly different (P0.0167) using a Bonferroni correction. Absolute P values using the F test of analysis of variance for those with signicant multiple comparisons were P0.0005. in other breakfast consumers (18.4%) than in RTE cereal consumers (13.2%) in boys and girls (Figure 2C). Breakfast skippers had a higher BMI percentile for age than RTE cereal consumers (both sexes). Boys consuming other breakfast had a higher BMI percentile for age than boys consuming RTE cereal (data not shown). DISCUSSION Breakfast has been regarded as the most important meal of the day, in part because of its nutritional benets (5,711,19). In this study spanning from 1999 to 2006, the prevalence of skipping breakfast was higher in adolescents, especially girls, than in children conrming results from previous studies (6,7,11,34,35). The percentage of those consuming RTE cereal was lower than those consuming other breakfast in all children/adolescents from this study. A higher percent of children/adolescents from singleparent or low-income households skipped breakfast than those with other household characteristics. Young populations are vulnerable to poor eating habits (36), especially if they belong to households with inadequate monetary resources to provide breakfast (37,38) or if their parents have limited time to prepare breakfast. Skipping breakfast may also occur because of a limited knowledge about health and nutrition (39), lack of time to eat or prepare breakfast (34), unavailability of foods for breakfast (34), or weight concerns (34,35), which was seen mainly among adolescent girls (35). Ethnic differences in breakfast consumption revealed that a higher percent of other/mixed race and black children/adolescents were breakfast skippers. Conversely, the percent of breakfast skippers was the lowest in Mexican-American/Hispanic children. In all ethnicities, RTE cereal consumption was low, but was lower in children/adolescents from black and other/mixed races compared to whites. High poverty rates or low income among minority groups in the United States (40,41) may affect their choices of healthy food consumption (42). A recent study showed that compared to whites, blacks had lower accessibility to supermarket stores that could hinder their access and availability of healthy foods (43), including fortied RTE cereal. The mean intake of dietary ber in all three breakfast consumption groups was below the AI value (26) for children (ie, 31 and 26 g/day in boys and girls, respectively), and for adolescents (ie, 38 and 26 g/day, in boys and girls, respectively). Nevertheless, RTE cereal consumers still had a higher dietary ber intake than breakfast skippers and other breakfast consumers. The dietary ber content of one serving of RTE cereal varies from 1% to 60% of the Daily Value. Further, RTE cereal consumption may also be a way to increase whole grains in the diet because an
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overwhelming majority of American children/adolescents fail to consume the recommended amounts for whole grains (44). The benets of consuming RTE cereal have been debated since they may contribute to added sugars in the diet (18) which, if consumed in high amounts (25% of total energy intake) (26), may promote weight gain (45,46). Our study showed that the intake of added sugars was higher in breakfast skippers than other breakfast consumers in children/adolescents, and in adolescents it was higher in breakfast skippers than RTE cereal and other breakfast consumers, suggesting that breakfast skippers consumed more added sugars during other times of the day. Consumption of added sugars did not exceed recommendations in any of the breakfast consumption groups. The American Academy of Pediatrics (47) recommends that children/adolescents, the age of those in this study, should not consume more than 25% to 35% energy from fat and 300 mg cholesterol daily. On average, all breakfast consumption groups in this study consumed 30% but 35% energy from total fat. The percent energy from total fat was lower in RTE cereal consumers than in breakfast skippers and other breakfast consumers in children/adolescents. The mean cholesterol intake in all three breakfast consumption groups was 300 mg/day; however, the cholesterol intake in other breakfast consumers was higher than in RTE cereal consumers and breakfast skippers in children/adolescents. A previous NHANES analysis suggested that other breakfast foods eaten by Americans older than age 2 years outside the home did not include RTE cereal, but included whole eggs, bacon/sausages, breads/rolls/sweet rolls, and fried potatoes (48). These foods may contribute to high intakes of fat, cholesterol, and added sugars in the diet. In a recent study (49), middle school children who participated in the School Breakfast Program had lower intakes of RTE cereal (although offered in more than 75% of the school menus), but had higher intakes of milk and 100% fruit juices as well as biscuits/croissants/corn bread than the nonschool breakfast consumers. Similarly, the adolescent school breakfast participants had lower intakes of unsweetened RTE cereal and fresh fruits compared to their nonschool breakfast consuming counterparts. Yet, there was no difference in overall milk consumption between the two adolescent breakfast groups. In our study, the mean RTE cereal consumption was lower in adolescents than in children, suggesting that as age increases, RTE cereal consumption also declines. Shortfall nutrients for children were identied by the 2005 Dietary Guidelines Advisory Committee (27); eating a healthy breakfast may help children/adolescents meet the recommendations for shortfall nutrients and other nutrient requirements (27,50). Albertson and colleagues (5) reported that the proportions of children not meeting their Estimated Average Requirement for vitamin A, folate, and zinc were the highest among those in the lowest tertile of RTE cereal consumption. In our study, RTE cereal consumers had higher intake of almost all vitamins and minerals, including B vitamins, shortfall minerals, and some antioxidants than breakfast skippers and other breakfast consumers. The increased intake of calcium among RTE cereal consumers may be attributed to

the increased intake of milk that occurs with RTE cereal consumption, as reported earlier (7) or to the fortication of the RTE cereal. In our study, 97% of children/adolescents consuming RTE cereal at breakfast did so with milk. Other breakfast consumers failed to consume higher intakes of many nutrients than breakfast skippers, including dietary ber; thiamin; niacin; vitamins A and C (in children only); vitamins E, B-6, and B-12; folate; calcium (in children only); iron; and zinc. Compared to other breakfast consumers and breakfast skippers, RTE cereal consumers had a higher MAR for the intake of selected micronutrients in children/adolescents. Although the MAR for shortfall nutrients fell below the selected cut-off (28) in our study among all breakfast consumption groups, it was still higher for RTE cereal consumers than for other breakfast consumers and breakfast skippers in children/adolescents. These results underscore the nutritional benets of RTE cereal consumption at breakfast. Nonetheless, these results must be interpreted with caution, since the contribution of breakfast by itself to the total daily intake of nutrients was not examined. Although the prevalence of overweight was not significantly different among breakfast consumption groups in children/adolescents, signicant differences were found for BMI z scores, waist circumference, and the prevalence of obesity. Waist circumference is a surrogate measure of abdominal obesity and is considered an important contributor of metabolic complications in children/adolescents (51). The mean waist circumference was higher in breakfast skippers compared to RTE cereal consumers in children/adolescents. The prevalence of obesity was higher in breakfast skippers than RTE cereal consumers in children/adolescents, and higher in other breakfast than RTE cereal consumers in adolescents. The results from this analysis of anthropometric measures for the three breakfast groups are in agreement with most previous studies (5,10,11,52). However, one longitudinal study (53) reported that overweight children (aged 9 to 14 years) who never ate breakfast had a larger decrease in their BMI compared to overweight children who ate breakfast nearly every day, whereas normalweight children who never ate breakfast gained weight relative to peers who ate breakfast nearly every day. Although mechanisms linking breakfast consumption and lower body weight are unclear, several possible explanations may exist. Whereas children/adolescents who consumed breakfast tended to consume a higher intake of total energy and total sugars than the breakfast skippers (8), as was also observed in our study, breakfast skippers may tend to eat more foods with low nutrient or higher energy density (8), such as fast foods (4), or may consume increased numbers of discretionary energy at other meals during the day. Skipping breakfast may also lead to excess hunger or rebound overeating (38) and consumption of large portion sizes (54) at subsequent meals. Conversely, breakfast consumption may be associated with an increased frequency of eating meals, which may reduce the efciency of utilization of metabolizable energy and promote diet-induced thermogenesis and energy expenditure (55). Moreover, healthy breakfast choices, such as fortied RTE cereal, may contribute to a lower fat intake, higher overall nutrient-density, including an in-

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creased intake of calcium (7), which has been suggested to play a role in reducing body fat (56). Lastly, RTE cereal consumption may lead to more regular eating habits, a consistent energy intake, and selection of more healthful food choices (7,9), which may all aid toward achieving or stabilizing a lower BMI. This study has some limitations. Due to the crosssectional design of NHANES, causality between breakfast skipping or consumption, nutrient intakes, and weight status cannot be established. A single 24-hour dietary recall used in this study may not capture the usual breakfast habits of the sample (57). Nevertheless, a single 24-hour recall is considered a reliable method of dietary assessment for large population groups (57). Parents assisted with the 24-hour recalls of children aged 9 to 11 years; parents can often report accurately what children eat in the home but may not know what their children eat outside the home, which could result in reporting errors. The intake of nutrients contributed by vitamin and mineral supplements was not considered. Also, this study did not determine the nutrient intakes solely from breakfast and dietary differences between breakfast consumption groups could be due to their intakes at other meals. It is also possible that RTE cereal consumers may have consumed other breakfast foods along with RTE cereal, which may have positively affected their nutrient intakes. CONCLUSIONS Dietetics practitioners need to reinforce the importance of not only eating breakfast, but also consumption of healthy breakfast choices, such as RTE cereal, by children/adolescents. More research is needed to examine the inuence of type of breakfast consumption on nutrient intakes and adiposity status over time in a nationally representative longitudinal sample of children/adolescents and using multiple days of dietary assessment. STATEMENT OF POTENTIAL CONFLICT OF INTEREST: No potential conict of interest was reported by the authors. FUNDING/SUPPORT: This research was supported by the Kelloggs Corporate Citizenship Fund, USDA/Agricultural Research Service Cooperative Agreement no. 586250-6-003, USDA Hatch Projects 940-36-3104 Project no. 93673, and LAB 93676 no. 0199070. ACKNOWLEDGEMENTS: This work is a publication of the USDA/Agricultural Research Service through specic cooperative agreement 58-6250-6-003Childrens Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX. The contents of this publication do not necessarily reect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement from the US government. The authors thank Pamelia Harris for formatting the manuscript. References
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42. Deshmukh-Taskar P, Nicklas TA, Yang SJ, Berenson GS. Does food group consumption vary by differences in socioeconomic, demographic, and lifestyle factors in young adults? The Bogalusa Heart Study. J Am Diet Assoc. 2007;107:223-234. 43. Morland K, Filomena S. Disparities in the availability of fruits and vegetables between racially segregated urban neighborhoods. Public Health Nutr. 2007;10:1481-1489. 44. Nutrition and Your Health: Dietary Guidelines for Americans, 2005. US Department of Agriculture Web site. http://www.health.gov/ dietaryguidelines/dga2005/document/pdf/DGA2005.pdf. Accessed January 28, 2009. 45. Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr. 2004;79:537-543. 46. Duffey KJ, Popkin BM. High-fructose corn syrup: Is this whats for dinner? Am J Clin Nutr. 2008;88(suppl):1722S-1732S. 47. Gidding SS, Dennison BA, Birch LL, Daniels SR, Gillman MW, Lichtenstein AH, Rattay KT, Steinberger J, Stettler N, Van Horn L; American Heart Association. Dietary recommendations for children and adolescents: A guide for practitioners. Pediatrics. 2006;117:544559. 48. Breakfast in America, 2002-2002. US Department of Agriculture Web site. http://www.ars.usda.gov/SP2UserFiles/Place/12355000/pdf/ Breakfast_2001_2002.pdf. Accessed January 13, 2009. 49. Condon EM, Crepinsek MK, Fox MK. School meals: Types of foods offered to and consumed by children at lunch and breakfast. J Am Diet Assoc. 2009;109(suppl 1):S67-S78. 50. Suitor CW, Gleason PM. Using Dietary Reference Intake-based methods to estimate the prevalence of inadequate nutrient intake among school-aged children. J Am Diet Assoc. 2002;102:530-536. 51. Li C, Ford ES, Mokdad AH, Cook S. Recent trends in waist circumference and waist-height ratio among US children and adolescents. Pediatrics. 2006;118:e1390-e1398. 52. Timlin MT, Pereira MA, Story M, Neumark-Sztainer D. Breakfast eating and weight change in a 5-year prospective analysis of adolescents: Project EAT (Eating Among Teens). Pediatrics. 2008;121:e638e645. 53. Berkey CS, Rockett HR, Gillman MW, Field AE, Colditz GA. Longitudinal study of skipping breakfast and weight change in adolescents. Int J Obes Relat Metab Disord. 2003;27:1258-1266. 54. Lioret S, Volatier JL, Lafay L, Touvier M, Maire B. Is food portion size a risk factor of childhood overweight? Eur J Clin Nutr. 2009;63:382391. 55. Drummond S, Crombie N, Kirk T. A critique of the effects of snacking on body weight status. Eur J Clin Nutr. 1996;50:779-783. 56. Zemel MB, Richards J, Milstead A, Campbell P. Effects of calcium and dairy on body composition and weight loss in African-American adults. Obes Res. 2005;13:1218-1225. 57. Willett WC. Nutritional Epidemiology. 2nd ed. New York, NY: Oxford University Press; 1998:20-23, 90, 101-141, 322.

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