Author + information
- aUniversity of California, San Francisco, Fresno, California
- bAdvanced Cardiovascular Imaging, National Heart, Lung, and Blood Institute, Washington, DC
- ↵∗Address for correspondence:
Dr. Prakash Deedwania, University of California, San Francisco, UCSF Fresno, Division of Cardiology Academic Offices, 2335 East Kashian Lane, Suite 460, Fresno, California 93701.
Breakfast is the first meal of the day, and it is generally believed to be the most important meal because it provides balanced and nutritious food rich in fiber, vitamins, and other essential nutrients. Consumption of a hearty breakfast that provides at least 20% of the daily energy intake is generally associated with less frequent nibbling of unhealthy food later in the day.
During the past decade, a number of studies have shown that skipping breakfast is associated with adverse cardiometabolic perturbations that can lead to the development of metabolic syndrome and diabetes, and eventually increase the risk of coronary heart disease (CHD) and stroke (1–8). The paper by Uzhova et al. (9) in this issue of the Journal provides a new insight into the chain of events by demonstrating a higher prevalence of subclinical atherosclerosis in breakfast skippers.
There is considerable evidence for ill effects of altered eating patterns and skipping breakfast in the published reports (1–8). For example, young breakfast skippers in the NHANES (National Health and Nutrition Examination Survey) (1999 to 2002) were found to have 30% to 40% more obesity, higher blood pressure, cholesterol, low-density lipoprotein cholesterol, and insulin levels, and lower HDL-C high-density lipoprotein cholesterol compared with those that regularly consumed cereal breakfast (1). This accumulation of risk factors when persistent can certainly manifest as clinical cardiovascular (CV) disease. In the Health Professionals Follow-up Study, men who skipped breakfast had a 27% higher risk of CHD (2). In a population-based study from Japan, Kubota et al. (3) demonstrated that stroke and hemorrhagic stroke risk increased by 18% and 36%, respectively, in breakfast skippers without an increase in CHD risk. The authors explain that the Japanese have more stroke, especially hemorrhagic stroke, and less CHD compared with the West due to more prevalent hypertension and less prevalent hypercholesterolemia. This geographic/genetic variation may explain the differential involvement of vascular beds. Skipping breakfast via overactivity in the hypothalamic–pituitary–adrenal axis from prolonged fasting leads to elevated blood pressure (4)—which in turn causes more strokes. Having breakfast conversely decreases systolic and diastolic blood pressure (5).
Dietary patterns have changed significantly over the last few decades such that an estimated 20% to 30% of adults skip breakfast (6). These trends mirror the increase in obesity and associated cardiometabolic derangements. It is less clear whether skipping breakfast causes more people to be obese or if the obese skip breakfast with the misguided goal of losing weight. This “chicken or egg” situation notwithstanding, it is apparent that the relationship is complex.
There are multiple possible mechanisms to explain how alterations in dietary habits such as skipping breakfast can have an impact on cardiometabolic health. The adverse effects of skipping breakfast begin in early childhood. In a study of 5,625 school students (10 to 18 years of age), the average triglycerides, low-density lipoprotein cholesterol, systolic blood pressure, and body mass index were higher and high-density lipoprotein cholesterol was lower in “seldom breakfast eaters” compared with their peers, and the risk of metabolic syndrome was significantly greater (7). Breakfast skippers end up eating more unbalanced meals later in the day and tend to consume more fatty foods at night, thus effectively increasing the overall energy intake through unhealthy foods (2). They are also more likely to make other poor lifestyle choices such as smoking, alcohol consumption, and less frequent exercise (8). Additionally, skipping breakfast and eating at odd hours of night can cause neurohormonal imbalances and alter circadian rhythms (10). Peripheral circadian clocks are entrained by food intake, and polymorphisms in circadian regulation genes such as CLOCK and BMAL1 are implicated in the development of metabolic syndrome, diabetes, and hypertension (11).
There is a significant lag-time between the onset of metabolic derangements leading to CV risk factors and subsequent clinical CV events such as heart attacks and strokes. What happens in the interim, in the form of subclinical atherosclerosis, is an important link in this chain of events. The paper by Uzhova et al. (9) provides clinically important information by demonstrating evidence of subclinical atherosclerosis in breakfast skippers.
This study is unique in that it evaluates the association of eating patterns, especially breakfast intake, with the objective evidence of subclinical atherosclerosis such as carotid, iliofemoral, and descending aorta plaque and coronary artery calcium (CAC) evaluated by well-established imaging techniques such as vascular ultrasound and cardiac computed tomography. In this cross-sectional analysis of the PESA (Progression of Early Subclinical Atherosclerosis) cohort (40 to 54 years of age), skipping breakfast (SBF) was associated with higher odds of generalized atherosclerosis (4 to 6 vascular sites) and noncoronary atherosclerosis. In the completely adjusted model, SBF was significantly associated with CAC when CAC was >100, but not with 0> CAC >100. This weaker association of SBF with CAC is not surprising because subclinical atherosclerosis is more readily detectable in the iliofemoral system (44%), carotids (31%), and aorta (25%) compared with coronary arteries (18%) (12).
The authors demonstrate that a common dietary pattern, skipping breakfast, can be an excellent marker of a larger lifestyle problem. Though intending to lose weight, people in the SBF group overcompensated by increasing their energy intake at lunch. Additionally, they made poor dietary choices with excessive consumption of red and processed meat, appetizers, sweetened beverages, and alcohol, and lower intake of fruits, vegetables, and fiber. Almost one-half of the SBF group consumed an atherogenic social–business diet (13), and only a quarter was on the cardioprotective Mediterranean diet (14).
Disentangling the effect of breakfast from other dietary and nondietary predictors, and establishing SBF as an independent marker of atherosclerosis is a daunting task. Apart from dietary differences, the SBF group had significantly more males, smokers, and obese, hypertensive, dyslipidemic, and diabetic individuals, making the comparisons groups quite dissimilar. Statistical adjustment to tease out the effects of predictors independent of confounders in significantly disparate groups may be difficult. However, epidemiological studies controlling for most variables might be somewhat impractical. It is also important to keep in mind that this cross-sectional study evaluates for an association and not causality.
The important message of this study, as pointed out by the authors, is that skipping breakfast serves as a marker of poor dietary and lifestyle choices that are linked to subclinical atherosclerosis. These dietary choices are generally made relatively early in life and, if they remain unchanged, can lead to clinical CV disease later on. Modification of dietary patterns with healthy eating and specifically not skipping breakfast can reduce the burden of atherosclerotic CV disease.
There is an urgent need for corrective public health measures to curb the global epidemic of obesity. Given the emerging evidence of association between altered dietary patterns and increased risk of obesity, metabolic syndrome, diabetes, subclinical atherosclerosis, and clinical CV events, it seems prudent to pay attention to diet and educate the public to implement simple lifestyle changes that include emphasis on a regular, hearty, and nutritious breakfast. These easy and economical public health measures can curb the oncoming tsunami of diabetes and CV disorders. Indeed, the wisdom of the ages that breakfast is the most important meal of the day has been proven right in the light of emerging evidence.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
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