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Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study
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Original Research
Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study Z. Ahadi a, M. Qorbani b, R. Kelishadi c, G. Ardalan d, M.E. Motlagh e, H. Asayesh f, M. Zeynali d, M. Chinian g, B. Larijani h, G. Shafiee a, R. Heshmat a,* a
Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran b Department of Public Health, Alborz University of Medical Sciences, Karaj, Iran c Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran d Department of School Health, Bureau of Population, Family and School Health, Ministry of Health and Medical Education, Tehran, Iran e Department of Pediatrics, Ahvaz University of Medical Sciences, Ahvaz, Iran f Department of Medical Emergencies, Qom University of Medical Sciences, Qom, Iran g Bureau of Health and Fitness, Ministry of Education and Training, Tehran, Iran h Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
article info
abstract
Article history:
Objective: The aim of this study is to assess the association between breakfast intake with
Received 31 May 2014
anthropometric measurements and blood pressure among Iranian children and adoles-
Received in revised form
cents. The second goal is to investigate the correction of breakfast consumption with other
8 March 2015
food consumption behaviors.
Accepted 16 March 2015
Research methods & procedures: In this national survey, 13,486 children and adolescents, aged
Available online xxx
6e18 years, were selected by multistage, cluster sampling method from rural and urban areas of 31 provinces of Iran (2011e2012). Physical measurements included height, weight,
Keywords:
waist circumference, and blood pressure. Food habits were assessed by self-reported
Breakfast skipping
questionnaire. Breakfast frequency was defined as skippers (eating breakfast 0e2 days/
Obesity
week), semi-skippers (eating breakfast 3e4 days/week) and non-skippers (eating breakfast
BMI
5e7 days/week). The data were analyzed by the STATA package.
Adolescents
Results: Of the participants, 18.9%, 13.2% and 67.9%, were breakfast skippers, semi-skippers and non-skippers respectively. The prevalence of overweight and obesity among breakfast skippers were higher than non-skippers counterparts (P-value < 0.001). The percentage rates of abdominal obesity among breakfast skippers and non-skippers group were 22.6%
* Corresponding author. # 111, 19th St, North Kargar Ave., Tehran, Iran. Tel.: +98 21 88354327; fax: +98 21 88637563. E-mail address: [email protected] (R. Heshmat). http://dx.doi.org/10.1016/j.puhe.2015.03.019 0033-3506/© 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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(CI 95%: 21e24.3) and 17.9% (CI 95%: 17e18.6), respectively. Blood pressure did not significantly differ between non-skippers students and breakfast skippers (P-value ¼ 0.1). Nonskipping adolescents ate more fresh fruits, dried fruits, vegetables and drank milk more frequently compared with breakfast skipper; while the skippers showed a higher intake of salty snack, soft drinks, packed fruit juice and fast foods (all P-value < 0.001). Conclusion: Regular breakfast consumption is significantly associated with lower body fatness and healthier dietary habits but that further study, using controlled intervention trials, is required to test whether this represents a causal relationship. © 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
Introduction Obesity is now the most prevalent nutritional problem among children and adolescents and its prevalence is increasing. Iran was one of the seven countries with the greatest prevalence rate of childhood obesity in 1998.1 The prevalence of obesity among Iranian adolescent was at 5.1%.2 Obesity is a multifactorial disorder. Low physical activity, genetic, socioeconomic status (SES), life style habits and food behavior are important risk factors in obesity.3 Unhealthy food habit is one of the most important causes of obesity.4 Food habit is as an unhealthy feeding habit. Breakfast is often considered to be the most important meal of the day. However, breakfast skipping is common among children and adolescents.5 It is estimated in children and adolescents that 14e22% skip breakfast.6e10 Children and adolescents who eat breakfast regularly have better memory function, cognitive function and school attendance.11 Several studies have assessed the association between breakfast consumption with health indicators. A large representative study among Hong Kong children showed that breakfast skipping was negatively associated with BMI and percentage of body fat,12 also these results were found in a New Zealand study.13 Breakfast intake has been inversely associated with visceral adiposity.14 The results of NHANES III presented that people who skipped breakfast have higher BMI,10 also breakfast skipping has been related to a higher rate of overweight and obesity.15,16 Although, the significant causal role of breakfast in weight loss was not observed in randomized controlled trials.17,18 A national survey has shown that skipping breakfast is related to higher blood pressure, serum total cholesterol, fasting insulin and LDL cholesterol,8 these results were confirmed by Sakata K's study.19 A number of studies have shown that children who consumed breakfast irregularly had a poor diet quality,20 lower intakes of fruits/vegetables21 and on the other hand had higher intakes of fat and energy.22 An observational study conducted among Spanish children has presented that children who intake breakfast have better diet quality with a higher intakes of fiber, vitamins and minerals.23 There is little information about the association between breakfast consumption with obesity and blood pressure among children and adolescents in the Middle Eastern countries especially Iran. So the primary aim of this study was to test the association between breakfast consumption and BMI and blood pressure among Iranian adolescents. The authors
hypothesized that breakfast skippers would have higher BMI and blood pressure values than breakfast eaters. A secondary aim was to investigate the association of breakfast consumption with food consumption behavior. The authors hypothesize that those who skipped breakfast would have unhealthy food habits, compared with those who had breakfast.
Methods This cross-sectional study was the fourth survey of Childhood and Adolescence Surveillance and PreventIon of Adult Noncommunicable Disease entitled CASPIAN-IV study (2011e2012). This study was performed among children and adolescents aged 6e18 years from elementary, intermediate and high schools of rural and urban areas of the central counties of 31 provinces of Iran. They were selected by multistage, cluster sampling methods (48 clusters of ten students in each province). Stratification was done according to the school grade (elementary, intermediate, high school) and location (urban/rural). The sample size was calculated as 480 students in each province. Thus, a total of 14,880 students were selected from 31 provinces. The population of this study included 13,486 students out of 14,880 invited subjects (participation rate of 90.6%). A detailed description of the protocol has been published previously,24 respectively, after complete explanation of the study objectives and protocols. Information about demographic, food habit, breakfast frequency, and physical measurements were gathered about students.
Physical measurements Height, weight, waist circumference and blood pressure were measured by trained research assistants according to standardized protocols. Weight was measured in light clothing to the nearest 0.1 kg on a digital scale (Seca, Germany), and height was recorded without shoes to the nearest 0.1 cm. As a measure of obesity, body mass index (BMI) was computed as weight in kilograms divided by the square of height in meters. Waist circumference (WC) was measured using a non-elastic tape to the nearest 0.1 cm, at a point midway between the lower border of the rib cage and the iliac crest at the end of normal expiration. The measurements of systolic and diastolic blood pressure (BP) were conducted using a mercury sphygmomanometer
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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(HEM-780-E) on the right arm with a suitable cuff size for each participant in the sitting position. Blood pressure was measured two times at five-minute intervals, and the average was considered as the actual value. Demographic information was collected by trained interviewers. Breakfast frequency was measured by a single item, ‘Usually on how many days of the week do you eat breakfast (drinking more than a cup of tea or milk)? On weekdays and weekends’. Responses raged from I don't eat at all to 6 days. Physical activity was assessed by two questions. 1) During the past week, on how many days were you physically active for overall 30 min per day? Responses options were from 0 to 7 days. 2) How much time do you spend in exercise class regularly in school per week? Responses ranged from 0 to 3 or more hours. Food habits were assessed by self-reported questionnaire that included nine items. Food habits were measured by following questions; ‘how many times do you eat each of these food groups?’. Response options were from daily to never. Cake, cookies, biscuits and chocolate were defined as sweet group; and chips, pretzels as salty snack; and sausage, pizza and hamburger as fast food.
Definition of terms Breakfast frequency was defined as skippers (eating breakfast 0e2 days/week), semi-skippers (eating breakfast 3e4 days/ week) and non-skippers (eating breakfast 5e7 days/week). SES included father's job and education, mother's job and education, owning a private car and computer, type of student's school (private, public) and ownership of house (private, leased and organizational house) variables. SES was categorized into tertiles. The first tertile was defined as a low SES, second tertile as an intermediate and third tertile as a high. BMI was categorized into underweight (BMI< 5th percentile), normal BMI (5th to 85th percentiles), overweight (85e94th BMI percentile); obese (>or ¼ 95th BMI percentile). Abdominal obesity was defined as waist to height ratio more than 0.5.25 BP was categorized into three groups: normal pressure (<90th percentile), pre hypertension (>90th percentile), and hypertension (>95th percentile).26 Physical activity was evaluated through principal component analysis (PCA) methods and was categorized into tertiles. The first tertile was defined as a low, second tertile as a medium and third tertile as a high. Screen time was assessed by asking how long students spent their time on watching TV/ video and on using computer.
Statistical analyses Categorical variables are presented as percentage and 95% confidence interval (CI). Mean of continuous variables were summarized with 95% CI. Comparisons of means were investigated by t-test and ANOVA. The Pearson Chi-square test was used to analyze categorical variables. The logistic regression was conducted to evaluate the association between breakfast frequency and anthropometric indices and blood pressure in different models for adjusting possible confounders. All statistical measures were estimated using survey data analysis methods. Data were analyzed by using
3
STATA package. P-value < 0.05 was considered as statistically significant.
Results The sample consisted of 13,486 adolescents aged 6e18 years (50.76% boys, 49.24% girls). The total data of South Khorasan was not available; hence, data of 30 provinces only was analyzed. Descriptive subject characteristics are shown in Table 1. Of the adolescents, 2537 (18.9%), 1771 (13.2%) and 9119 (67.9%), respectively, were breakfast skippers, semi-skippers and non-skippers. Height, weight, waist circumference (WC) and waist-to-height ratio (WHtR) of boys were significant higher than girls (P-value < 0.001), while BMI was greater in girls (P-value ¼ 0.002). The mean of systolic and diastolic blood pressure (SBP and DBP) were higher in boys compared with girls (P-value < 0.001). The female adolescents included more breakfast skippers than boys (22.5% vs 15.4%). 11.9% of adolescents were obese, the prevalence of obesity being greater among boys (13.6% vs 10.1%). Also, the percentage of abdominal obesity among boys was significant larger than in girls (Pvalue < 0.001). The boys had more high physical activity compared with girls (35.6% vs 22.4%).
Breakfast frequency The subject characteristics based on breakfast frequency are shown in Table 2. Adolescents who skipped breakfast were older (13.1 years, CI 95%:12.9e13.3), whereas those who ate breakfast daily were younger (12.1 years, CI 95%:12e12.3). The mean of weight, BMI, WC and WHtR in non-skipping students were significantly less than breakfast skippers (P-value < 0.001). And the mean of these anthropometric indices were linearly associated with breakfast frequency (P-trend < 0.001). The prevalence of overweight and obesity among breakfast skippers were higher than non-skipping counterparts (P-value < 0.001). Students who ate breakfast regularly had a significantly higher rate of normal weight compared with adolescents who did not eat breakfast (Pvalue < 0.001). The percentage rate of abdominal obesity among breakfast skippers and non-skipping group were 22.6% (CI 95%:21e24.3) and 17.9% (CI 95%:17e18.6), respectively. Which its percentage was respectively, significantly higher among breakfast skippers (P-value < 0.001). Blood pressure was categorized into three groups (normal, prehypertension, and hypertension), which they did not differ significantly between non-skipping students and breakfast skippers (P-value ¼ 0.1). There were significant association between breakfast frequency and physical activity (P-value < 0.001). So that nonskippers were more active than students who eat breakfast. On the other hand, students who intake breakfast regularly had less screen time compared with their breakfast skipping counterparts (P-value < 0.001). The adolescents who consumed breakfast regularly were more likely to live in a high SES region (P-value < 0.001).
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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Table 1 e Subject characteristics based on gender: the CASPIAN-IV Study. Age (Year) Height (cm) Weight (Kg) BMI (Kg/m2) WC (cm) WHtR SBP (mmHg) DBP (mmHg) Father education (%) Illiterate Diploma Bachelor and upper Mother education (%) Illiterate Diploma Bachelor and upper Breakfast eating Skippers Semi-skippers Non-skippers Screen time 4 h/day >4 h/day Weight status Underweight Normal Overweight Obese Abdominal obesity Physical activity Low Medium High SES Low Intermediate High
Boys (N ¼ 6845)
Girls (N ¼ 6641)
12.3 (12.1e12.6)a 148.1 (146.8e149.5) 43.0 (41.9e44.2) 18.7 (18.5e18.9) 67.8 (67.1e68.5) 0.458 (0.456e0.461) 102.7 (102.0e103.5) 65.5 (64.9e66.2)
12.5 145.7 41.7 18.9 66.1 0.454 100.2 64.1
775 (11.7)b 4943 (74.4) 927 (14.0)
696 (10.8) 4845 (75.2) 904 (14.0)
1471 (11.2) 9788 (74.8) 1831 (14.0)
0.2
1191 (17.6) 4982 (73.6) 596 (8.8)
1079 (16.4) 4943 (75.0) 571 (8.7)
2270 (17.0) 9925 (74.3) 1167 (8.7)
0.1
1050 (15.4) 885 (13.0) 4881 (71.6)
1487 (22.5) 886 (13.4) 4238 (64.1)
2537 (18.9) 1771 (13.2) 9119 (67.9)
<0.001
5301 (78.1) 1489 (21.9)
5598 (84.8) 1005 (15.2)
10,899 (81.4) 2494 (18.6)
<0.001
881 (13.0) 4333 (64.1) 627 (9.3) 918 (13.6) 1385 (20.4)
740 4497 660 666 1171
1945 (28.8) 2410 (35.6) 2410 (35.6) 2082 (33.2) 2050 (32.7) 2143 (34.2)
(12.3e12.8) (144.6e146.8) (40.7e42.6) (18.7e19.1) (65.6e66.7) (0.452e0.457) (99.5e100.8) (63.5e64.7)
Total (N ¼ 13,486)
P-value
12.4 (12.2e12.6) 146.9 (146.1e147.8) 42.4 (41.6e43.1) 18.8 (18.7e18.9) 67.0 (66.5e67.4) 0.456 (0.454e0.458) 101.5 (101.0e102.0) 64.8 (64.4e65.3)
<0.001 <0.001 <0.001 0.002 <0.001 0.001 <0.001 <0.001
(12.2) (66.3) (9.7) (11.9) (19.1)
<0.001
2608 (39.6) 2500 (38.0) 1476 (22.4)
4553 (34.1) 4910 (36.8) 3886 (29.1)
<0.001
2065 (33.8) 2050 (33.5) 2000 (32.7)
4147 (33.5) 4100 (33.1) 4143 (33.4)
0.2
(11.3) (68.5) (10.1) (10.1) (17.8)
1621 8830 1287 1584 2556
<0.001
BMI; body mass index, WC; waist circumference, WHtR; Waist-to-Height ratio, SBP; systolic blood pressure, DBP; diastolic blood pressure, SES; socio-economic status. a Mean ± CI 95%. b N (%). P < 0.05 is significant.
The odd ratios of obesity and blood pressure across breakfast frequency The odd ratios for obesity and blood pressure across breakfast consumption categories are shown in Table 3. The risk of abdominal obesity and general obesity among semi-skippers increased from 11% to 17% and 17e27% compare to nonskipping students, respectively. The students who skipped breakfast had a significantly higher risk of abdominal obesity (OR 1.35, CI 95%:1.18e1.53), overweight (OR 1.16, CI 95%:1.01e1.34) and general obesity (OR 1.61, CI 95%:1.39e1.89).
The b-coefficient values for anthropometric measurements and BP by breakfast frequency b-coefficient values for anthropometric measurements and BP by breakfast frequency are shown in Table 4. WC of breakfast skippers was 1.18e2.86 cm greater than non-skipping counterparts (P-value < 0.05). The amount of WHtR among students
skipping breakfast was greater by 0.0065e0.0076 compared with non-skipping group. In the multivariate model (model III), students who skipped breakfast had 0.65 (CI 95%:0.44e0.85) kg/m2 larger than non-skippers, it of semiskippers was 0.35 (CI 95%:0.72e0.57) kg/m2. The systolic and diastolic blood pressure of breakfast skippers was 1.1 (CI 95%:0.42e1.78) and 0.83 (CI 95%:0.21e1.44) mmHg greater than non-skipping students, respectively.
Food habits The students who ate breakfast daily follow a more healthy food pattern compared with breakfast skippers. Non-skipping adolescents ate more fresh fruits, dried fruits, vegetables and drank milk compared with breakfast skippers, while the skippers showed a higher intake of salty snack, soft drinks, packed fruit juice and fast food (all P-value < 0.001) (data not shown).
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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Table 2 e Subject characteristics based on breakfast frequency: the CASPIAN-IV Study. Breakfast frequency Non-skipper (N ¼ 9119)
P-valuec
P-trendd
12.1 (12.0e12.3) 145.7 (144.8e146.7) 40.9 (40.1e41.7) 18.4 (18.3e18.6) 66.2 (65.7e66.7) 0.455 (0.453e0.457) 101.1 (100.6e101.7) 64.6 (64.1e65.1)
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.001
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
(9.1e12.0) (64.5e69.0) (8.7e11.6) (10.9e14.1) (18.2e22.0)
13.0 (12.3e13.7) 67.0 (66.0e67.9) 9.1 (8.5e9.7) 10.8 (10.2e11.4) 17.9 (17.0e18.6)
<0.001
<0.001
<0.001
<0.001
93.0 (91.9e93.9) 3.0 (2.3e3.7) 4.0 (3.2e4.8)
92.5 (91.1e93.6) 3.1 (2.3e4.0) 4.4 (3.4e5.4)
93.3 (92.7e93.8) 3.2 (0.7e1.1) 3.5 (3.1e3.9)
0.1
0.1
41.8 (39.8e43.7) 33.5 (31.6e35.4) 24.7 (22.9e26.3)
38.4 (36.1e40.7) 35.1 (32.8e37.4) 26.5 (24.4e28.5)
31.1 (30.1e32.0) 38.0 (37.0e39.0) 30.9 (29.9e31.8)
<0.001
<0.001
78.3 (76.6e79.9) 21.7 (20.0e23.3)
79.5 (77.5e81.3) 20.5 (18.6e22.4)
82.6 (81.8e83.3) 17.4 (16.6e18.1)
<0.001
<0.001
36.9 (34.9e38.9) 32.8 (30.8e34.7) 30.3 (28.4e32.2)
33.1 (30.8e35.4) 34.8 (32.4e37.1) 32.1 (29.8e34.4)
32.5 (31.5e33.5) 32.8 (31.8e33.8) 34.7 (33.6e35.7)
<0.001
<0.001
Skipper (N ¼ 2537) Age (Year) Height (cm) Weight (Kg) BMI (Kg/m2) WC (cm) WHtR SBP (mmHg) DBP (mmHg) Weight status Underweight Normal Overweight Obese Abdominal obesity BP (mm Hg) Normal Prehypertension Hypertension Physical activity Low Medium High Screen time 4 h/day >4 h/day SES Low Intermediate High
13.1 149.9 46.0 19.8 69.1 0.461 102.2 65.4 10.3 63.6 11.0 15.1 22.6
(12.9e13.3)a (148.8e151.0) (45.0e47.0) (19.5e20.0) (68.4e69.7) (0.458e0.464) (101.6e102.9) (64.8e66.0) (9.1e11.5)b (61.1e65.5) (9.7e12.2) (13.6e16.5) (21.0e24.3)
Semi-skipper (N ¼ 1771) 12.9 149.2 44.7 19.3 67.9 0.456 102.2 65.2 10.6 66.8 10.2 12.5 20.1
(12.7e13.2) (148.0e150.5) (43.5e45.8) (19.0e19.5) (67.2e68.7) (0.452e0.459) (101.4e103.1) (64.5e65.9)
BMI; body mass index, WC; waist circumference, WHtR; Waist-to-Height ratio, SBP; Systolic blood pressure, DBP; Diastolic blood pressure, BP; Blood Pressure. SES; Socio-economic status. a P-values are resulted from analysis of variance (ANOVA). b P-values are for trend analysis. c Mean ± CI 95%. d % (CI 95%). P < 0.05 is significant.
Discussion The present study corroborated the association between breakfast frequency with overweight and obesity in a large representative sample of Iranian children and adolescents. The results showed skipping breakfast was associated with a greater risk of general and abdominal obesity. And the association between breakfast skipping with general and abdominal obesity remained significant after adjusting for known confounders. This study revealed that adolescents who skipped breakfast were older, had less physical activity, spent more screen time and were from lower SES regions. In the present study, an inverse association was found between breakfast intake with general and abdominal obesity. The results of this study are consistent with previous studies.12,27e29 Skipping breakfast may lead to reduced satiety later during the day with increased eating snacks.30 In contrast, eating breakfast may affect appetite control, energy intake and quality of diet (i.e. increased fiber intake and decreased saturated fat intake).31e33 So these mechanisms may lead to a lower BMI among breakfast consumers. A casual role of breakfast intake in weight loss was assessed by some
randomized clinical trials. Emily J Dhurandhar et al. investigated the effectiveness of breakfast intake on weight loss among healthy overweight and obese adults and the results of their study showed that eating or skipping breakfast did not effect weight loss.17 In another randomized clinical trial, the effect of breakfast intake on energy balance was assessed and it's results presented regular breakfast intake was causally associated with higher physical activity thermogenesis that suggested breakfast eaters spontaneously participant in physical activity.18 In this study, significantly non-skipper breakfast had more physical activity that breakfast skipper. Contrary to the hypothesis, skipping breakfast was not associated with elevated blood pressure. The results of present study showed that adolescents who skipped breakfast did not had higher SBP and DBP compared with breakfast eaters and the breakfast skipping did not lead to elevated blood pressure. The results of the study were supported by other studies.27,34 Breakfast intake is known to be a key factor of weight control;31 but, its effect on BP level is not known. The results of present study were in agreement with previous studies,21,35,36 and supported this hypothesis that breakfast skippers had unhealthy food patterns compared with breakfast consumers. These results indicated that
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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Table 3 e Odds ratios (CI 95%) for anthropometric indices and BP across breakfast frequency: the CASPIAN-IV Study.
Table 4 e b-coefficients (CI 95%) for anthropometric indices and BP across breakfast frequency: the CASPIANIV Study.
Breakfast frequency
Breakfast frequency
Non-skipper Abdominal obesity Model Ia Model IIb Model IIIc Overweight Model I Model II Model III General obesity Model I Model II Model III Elevated SBP Model I Model II Model III Model IVd Elevated DBP Model I Model II Model III Model IVd Elevated BP Model I Model II Model III Model IVd
Semi-skipper
Skipper
1 1 1
1.15 (1.01e1.31)* 1.11 (1.01e1.32)* 1.17 (1.02e1.36)*
1.34 (1.20e1.50)* 1.36 (1.22e1.53)* 1.35 (1.18e1.53)*
1 1 1
1.12 (0.94e1.33) 1.08 (0.91e1.28) 1.14 (0.94e1.37)
1.22 (1.06e1.41)* 1.16 (1.01e1.34)* 1.11 (0.95e1.30)
1 1 1
1.17 (1.00e1.30)* 1.21 (1.03e1.41)* 1.27 (1.07e1.51)*
1.46 (1.27e1.67)* 1.56 (1.36e1.79)* 1.61 (1.39e1.89)*
1 1 1 1
1.46 1.30 1.41 1.31
(9.17e2.34) (0.81e2.09) (0.84e2.35) (0.78e2.22)
1.36 1.31 1.53 1.41
(0.89e2.08) (0.85e2.01) (0.97e2.40) (0.89e2.24)
1 1 1 1
1.22 1.13 1.17 1.14
(0.89e1.68) (0.83e1.54) (0.83e1.65) (0.80e1.62)
1.17 1.11 1.24 1.19
(0.88e1.56) (0.83e1.49) (0.91e1.69) (0.87e1.63)
1 1 1 1
1.24 1.14 1.18 1.15
(0.93e1.66) (0.85e1.51) (0.86e1.62) (0.83e1.58)
1.13 1.06 1.16 1.11
(0.87e1.45) (0.82e1.37) (0.88e1.53) (0.84e1.46)
SBP; systolic blood pressure, DBP; diastolic blood pressure, BP; blood pressure, *P < 0.05. a Without adjusted (crude models). b Adjusted for age and sex. c Additionally adjusted for family history of chronic diseases, screen time, physical activity, socio-economic status. d Additionally adjusted for BMI in all abnormalities except for obesity.
breakfast skippers consumed more frequent salty snacks, soft drinks, packed fruit juice and fast food and less frequent fruits/vegetables and milk compared with non-skippers. Previous studies showed that breakfast eating was associated with higher intakes of calcium, cobalamin, folic acid and vitamin C,36 and lower intake of cholesterol, total fat and fiber,36,37 as well as lower daily intakes of energy36 and sugar.38 In particular, breakfast skippers appeared to follow unhealthier food habits. Also, breakfast skippers appeared to have unhealthier habits included more consumption of outmeals and variable hours for dinner.35 Maybe these differences in the food habits explain in some way why adolescents who omit breakfast have higher intakes of energy and higher anthropometric measurements.
Strengths and limitations The limitation was cross-sectional design of present study, which the authors could not distinguish whether breakfast skipping lead to higher anthropometric indices and an
Non-skipper WC Model Model Model WHtR Model
Ia IIb IIIc
1 1 1
I
1
Model II
1
Model III
1
BMI Model Model Model SBP Model Model Model DBP Model Model Model
I II III
1 1 1
I II III
1 1 1
I II III
1 1 1
Semi-skipper 1.72 (1.05e2.39)* 0.29 (0.24e0.84) 0.40 (0.16e0.97) 0.0009 (0.0025e0.0044) 0.0020 (0.0014e0.0054) 0.0023 (0.0013e0.0061) 0.80 (0.55e1.05)* 0.32 (0.11e0.53)* 0.35 (0.72e0.57)*
Skipper 2.86 (2.22e3.49)* 1.23 (0.71e1.74)* 1.18 (0.63e1.73)* 0.0065 (0.0032e0.0097)* 0.0081 (0.0048e0.1130)* 0.0076 (0.0041e0.0111)* 1.30 (1.07e1.53)* 0.69 (0.49e0.88)* 0.65 (0.44e0.85)*
1.10 (0.42e1.78)* 1.07 (0.27e1.87)* 0.02 (0.73e0.69) 0.01 (0.63e0.61) 0.14 (0.61e0.90) 0.09 (0.56e0.76) 0.64 (0.01e1.31) 0.01 (0.61e0.65) 0.11 (0.58e0.81)
0.83 (0.21e1.44)* 0.19 (0.39e0.78) 0.37 (0.26e1.02)
WC; waist circumference, WHtR; Waist-to-Height ratio, BMI; body mass index, SBP; Systolic Blood Pressure, DBP; Diastolic Blood Pressure, BP; Blood Pressure, *P < 0.05. a Without adjusted (crude models). b Adjusted for age and sex. c Additionally adjusted for family history of chronic diseases, screen time, physical activity, socio-economic status.
unhealthier food habits. Also, self-reported data were another limitation of the study and it is possible some students have miss reported. A large national representative sample of Iranian children and adolescents is the main strengths of present study as well as measuring of SES and lifestyle habits in this study and added to model to reduce confounders' effects.
Conclusion Regular breakfast consumption is significantly associated with lower body fatness and healthier dietary habits but that further study, using controlled intervention trials, is required to test whether this represents a causal relationship.
Author statements Acknowledgments This nationwide survey was performed among Iranian children and adolescents with corporation of Ministry of Education and Training, the Training, the Ministry of Health and Medical education, Child Health Promotion Research Center, Isfahan University of Medical Sciences, and Endocrinology
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and Metabolism Research center of Tehran University of Medical Sciences.
Ethical approval Study protocols were reviewed and approved by ethical committees and other relevant national regulatory organizations. A written informed consent and verbal consent was obtained from the parents and students; respectively, after complete explanation of the study objectives and protocols. Information about demographic, food habit, breakfast frequency, and physical measurements were gathered about students.
Funding None declared.
Competing interests None declared.
references
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10. Cho S, Dietrich M, Brown CJP, Clark CA, Block G. The effect of breakfast type on total daily energy intake and body mass index: results from the Third National Health and Nutrition Examination Survey (NHANES III). J Am Coll Nutr 2003;22(4):296e302. 11. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc 2005;105(5):743e60. 12. So H, Nelson E, Li AM, Guldan G, Yin J, Ng P, et al. Breakfast frequency inversely associated with BMI and body fatness in Hong Kong Chinese children aged 9e18 years. Br J Nutr 2011;106(5):742e51. 13. Duncan JS, Schofield G, Duncan EK, Rush EC, Duncan J, Schofield G, et al. Risk factors for excess body fatness in New Zealand children. Asia Pac J Clin Nutr 2008;17(1):138e47. 14. Alexander KE, Ventura EE, Spruijt-Metz D, Weigensberg MJ, Goran MI, Davis JN. Association of breakfast skipping with visceral fat and insulin indices in overweight Latino youth. Obesity 2009;17(8):1528e33. 15. Dubois L, Girard M, Potvin Kent M. Breakfast eating and overweight in a pre-school population: is there a link? Public Health Nutr Cab Int 2006;9(4):436. 16. Fiore H, Travis S, Whalen A, Auinger P, Ryan S. Potentially protective factors associated with healthful body mass index in adolescents with obese and nonobese parents: a secondary data analysis of the third national health and nutrition examination survey, 1988-1994. J Am Diet Assoc 2006;106(1):55e64. 17. Dhurandhar EJ, Dawson J, Alcorn A, Larsen LH, Thomas EA, Cardel M, et al. The effectiveness of breakfast recommendations on weight loss: a randomized controlled trial. Am J Clin Nutr 2014;100(2):507e13. 18. Betts JA, Richardson JD, Chowdhury EA, Holman GD, Tsintzas K, Thompson D. The causal role of breakfast in energy balance and health: a randomized controlled trial in lean adults. Am J Clin Nutr 2014;100(2):539e47. 19. Sakata K, Matumura Y, Yoshimura N, Tamaki J, Hashimoto T, Oguri S, et al. Relationship between skipping breakfast and cardiovascular disease risk factors in the national nutrition survey data. Nihon Koshu Eisei Zasshi 2001;48(10):837e41. 20. Ruxton C, Kirk T. Breakfast: a review of associations with measures of dietary intake, physiology and biochemistry. Br J Nutr 1997;78(2):199e214. 21. Pedersen TP, Meilstrup C, Holstein BE, Rasmussen M. Fruit and vegetable intake is associated with frequency of breakfast, lunch and evening meal: cross-sectional study of 11-, 13-, and 15-year-olds. Int J Behav Nutr Phys Act 2012;9:9. 22. Timlin MT, Pereira MA. Breakfast frequency and quality in the etiology of adult obesity and chronic diseases. Nutr Rev 2007;65(6):268e81. rez-Rodrigo C. Breakfast 23. Aranceta J, Serra-Majem L, Ribas L, Pe consumption in Spanish children and young people. Public Health Nutr 2001;4(6a):1439e44. 24. Kelishadi R, Ardalan G, Qorbani M, Ataie-Jafari A, Bahreynian M, Taslimi M, et al. Methodology and early findings of the fourth survey of childhood and adolescence surveillance and prevention of adult non-communicable disease in Iran: the CASPIAN-IV study. Int J Prev Med 2013;4(12):1451e60. 25. Knowles K, Paiva L, Sanchez S, Revilla L, Lopez T, Yasuda M, et al. Waist circumference, body mass index, and other measures of adiposity in predicting cardiovascular disease risk factors among peruvian adults. Int J Hypertens 2011;2011:5. http://dx.doi.org/10.4061/2011/931402. Article ID 931402. 26. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114(2 Suppl. 4th Report):555e76.
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27. Shafiee G, Kelishadi R, Qorbani M, Motlagh ME, Taheri M, Ardalan G, et al. Association of breakfast intake with cardiometabolic risk factors. J Pediatr 2013;89:575e82. 28. Keski-Rahkonen A, Kaprio J, Rissanen A, Virkkunen M, Rose RJ. Breakfast skipping and health-compromising behaviors in adolescents and adults. Eur J Clin Nutr 2003;57(7):842e53. 29. Fabritius K, Rasmussen M. Breakfast habits and overweight in Danish schoolchildren. The role of socioeconomic positions. Ugeskrift laeger 2008;170(34):2559. 30. Martin A, Normand S, Sothier M, Peyrat J, Louche-Pelissier C, Laville M. Is advice for breakfast consumption justified? Results from a short-term dietary and metabolic experiment in young healthy men. Br J Nutr 2000;84(03):337e44. 31. Burley V, Leeds A, Blundell J. The effect of high and low-fibre breakfasts on hunger, satiety and food intake in a subsequent meal. Int J Obes 1986;11:87e93. 32. Holt S. The effects of high-carbohydrate vs high-fat breakfasts on feelings of fullness and alertness, and subsequent food intake. Int J Food Sci Nutr 1999;50(1):13e28. 33. Pasman W, Blokdijk V, Bertina F, Hopman W, Hendriks H. Effect of two breakfasts, different in carbohydrate
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Original Research
Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study Z. Ahadi a, M. Qorbani b, R. Kelishadi c, G. Ardalan d, M.E. Motlagh e, H. Asayesh f, M. Zeynali d, M. Chinian g, B. Larijani h, G. Shafiee a, R. Heshmat a,* a
Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran b Department of Public Health, Alborz University of Medical Sciences, Karaj, Iran c Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran d Department of School Health, Bureau of Population, Family and School Health, Ministry of Health and Medical Education, Tehran, Iran e Department of Pediatrics, Ahvaz University of Medical Sciences, Ahvaz, Iran f Department of Medical Emergencies, Qom University of Medical Sciences, Qom, Iran g Bureau of Health and Fitness, Ministry of Education and Training, Tehran, Iran h Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
article info
abstract
Article history:
Objective: The aim of this study is to assess the association between breakfast intake with
Received 31 May 2014
anthropometric measurements and blood pressure among Iranian children and adoles-
Received in revised form
cents. The second goal is to investigate the correction of breakfast consumption with other
8 March 2015
food consumption behaviors.
Accepted 16 March 2015
Research methods & procedures: In this national survey, 13,486 children and adolescents, aged
Available online xxx
6e18 years, were selected by multistage, cluster sampling method from rural and urban areas of 31 provinces of Iran (2011e2012). Physical measurements included height, weight,
Keywords:
waist circumference, and blood pressure. Food habits were assessed by self-reported
Breakfast skipping
questionnaire. Breakfast frequency was defined as skippers (eating breakfast 0e2 days/
Obesity
week), semi-skippers (eating breakfast 3e4 days/week) and non-skippers (eating breakfast
BMI
5e7 days/week). The data were analyzed by the STATA package.
Adolescents
Results: Of the participants, 18.9%, 13.2% and 67.9%, were breakfast skippers, semi-skippers and non-skippers respectively. The prevalence of overweight and obesity among breakfast skippers were higher than non-skippers counterparts (P-value < 0.001). The percentage rates of abdominal obesity among breakfast skippers and non-skippers group were 22.6%
* Corresponding author. # 111, 19th St, North Kargar Ave., Tehran, Iran. Tel.: +98 21 88354327; fax: +98 21 88637563. E-mail address: [email protected] (R. Heshmat). http://dx.doi.org/10.1016/j.puhe.2015.03.019 0033-3506/© 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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(CI 95%: 21e24.3) and 17.9% (CI 95%: 17e18.6), respectively. Blood pressure did not significantly differ between non-skippers students and breakfast skippers (P-value ¼ 0.1). Nonskipping adolescents ate more fresh fruits, dried fruits, vegetables and drank milk more frequently compared with breakfast skipper; while the skippers showed a higher intake of salty snack, soft drinks, packed fruit juice and fast foods (all P-value < 0.001). Conclusion: Regular breakfast consumption is significantly associated with lower body fatness and healthier dietary habits but that further study, using controlled intervention trials, is required to test whether this represents a causal relationship. © 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
Introduction Obesity is now the most prevalent nutritional problem among children and adolescents and its prevalence is increasing. Iran was one of the seven countries with the greatest prevalence rate of childhood obesity in 1998.1 The prevalence of obesity among Iranian adolescent was at 5.1%.2 Obesity is a multifactorial disorder. Low physical activity, genetic, socioeconomic status (SES), life style habits and food behavior are important risk factors in obesity.3 Unhealthy food habit is one of the most important causes of obesity.4 Food habit is as an unhealthy feeding habit. Breakfast is often considered to be the most important meal of the day. However, breakfast skipping is common among children and adolescents.5 It is estimated in children and adolescents that 14e22% skip breakfast.6e10 Children and adolescents who eat breakfast regularly have better memory function, cognitive function and school attendance.11 Several studies have assessed the association between breakfast consumption with health indicators. A large representative study among Hong Kong children showed that breakfast skipping was negatively associated with BMI and percentage of body fat,12 also these results were found in a New Zealand study.13 Breakfast intake has been inversely associated with visceral adiposity.14 The results of NHANES III presented that people who skipped breakfast have higher BMI,10 also breakfast skipping has been related to a higher rate of overweight and obesity.15,16 Although, the significant causal role of breakfast in weight loss was not observed in randomized controlled trials.17,18 A national survey has shown that skipping breakfast is related to higher blood pressure, serum total cholesterol, fasting insulin and LDL cholesterol,8 these results were confirmed by Sakata K's study.19 A number of studies have shown that children who consumed breakfast irregularly had a poor diet quality,20 lower intakes of fruits/vegetables21 and on the other hand had higher intakes of fat and energy.22 An observational study conducted among Spanish children has presented that children who intake breakfast have better diet quality with a higher intakes of fiber, vitamins and minerals.23 There is little information about the association between breakfast consumption with obesity and blood pressure among children and adolescents in the Middle Eastern countries especially Iran. So the primary aim of this study was to test the association between breakfast consumption and BMI and blood pressure among Iranian adolescents. The authors
hypothesized that breakfast skippers would have higher BMI and blood pressure values than breakfast eaters. A secondary aim was to investigate the association of breakfast consumption with food consumption behavior. The authors hypothesize that those who skipped breakfast would have unhealthy food habits, compared with those who had breakfast.
Methods This cross-sectional study was the fourth survey of Childhood and Adolescence Surveillance and PreventIon of Adult Noncommunicable Disease entitled CASPIAN-IV study (2011e2012). This study was performed among children and adolescents aged 6e18 years from elementary, intermediate and high schools of rural and urban areas of the central counties of 31 provinces of Iran. They were selected by multistage, cluster sampling methods (48 clusters of ten students in each province). Stratification was done according to the school grade (elementary, intermediate, high school) and location (urban/rural). The sample size was calculated as 480 students in each province. Thus, a total of 14,880 students were selected from 31 provinces. The population of this study included 13,486 students out of 14,880 invited subjects (participation rate of 90.6%). A detailed description of the protocol has been published previously,24 respectively, after complete explanation of the study objectives and protocols. Information about demographic, food habit, breakfast frequency, and physical measurements were gathered about students.
Physical measurements Height, weight, waist circumference and blood pressure were measured by trained research assistants according to standardized protocols. Weight was measured in light clothing to the nearest 0.1 kg on a digital scale (Seca, Germany), and height was recorded without shoes to the nearest 0.1 cm. As a measure of obesity, body mass index (BMI) was computed as weight in kilograms divided by the square of height in meters. Waist circumference (WC) was measured using a non-elastic tape to the nearest 0.1 cm, at a point midway between the lower border of the rib cage and the iliac crest at the end of normal expiration. The measurements of systolic and diastolic blood pressure (BP) were conducted using a mercury sphygmomanometer
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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(HEM-780-E) on the right arm with a suitable cuff size for each participant in the sitting position. Blood pressure was measured two times at five-minute intervals, and the average was considered as the actual value. Demographic information was collected by trained interviewers. Breakfast frequency was measured by a single item, ‘Usually on how many days of the week do you eat breakfast (drinking more than a cup of tea or milk)? On weekdays and weekends’. Responses raged from I don't eat at all to 6 days. Physical activity was assessed by two questions. 1) During the past week, on how many days were you physically active for overall 30 min per day? Responses options were from 0 to 7 days. 2) How much time do you spend in exercise class regularly in school per week? Responses ranged from 0 to 3 or more hours. Food habits were assessed by self-reported questionnaire that included nine items. Food habits were measured by following questions; ‘how many times do you eat each of these food groups?’. Response options were from daily to never. Cake, cookies, biscuits and chocolate were defined as sweet group; and chips, pretzels as salty snack; and sausage, pizza and hamburger as fast food.
Definition of terms Breakfast frequency was defined as skippers (eating breakfast 0e2 days/week), semi-skippers (eating breakfast 3e4 days/ week) and non-skippers (eating breakfast 5e7 days/week). SES included father's job and education, mother's job and education, owning a private car and computer, type of student's school (private, public) and ownership of house (private, leased and organizational house) variables. SES was categorized into tertiles. The first tertile was defined as a low SES, second tertile as an intermediate and third tertile as a high. BMI was categorized into underweight (BMI< 5th percentile), normal BMI (5th to 85th percentiles), overweight (85e94th BMI percentile); obese (>or ¼ 95th BMI percentile). Abdominal obesity was defined as waist to height ratio more than 0.5.25 BP was categorized into three groups: normal pressure (<90th percentile), pre hypertension (>90th percentile), and hypertension (>95th percentile).26 Physical activity was evaluated through principal component analysis (PCA) methods and was categorized into tertiles. The first tertile was defined as a low, second tertile as a medium and third tertile as a high. Screen time was assessed by asking how long students spent their time on watching TV/ video and on using computer.
Statistical analyses Categorical variables are presented as percentage and 95% confidence interval (CI). Mean of continuous variables were summarized with 95% CI. Comparisons of means were investigated by t-test and ANOVA. The Pearson Chi-square test was used to analyze categorical variables. The logistic regression was conducted to evaluate the association between breakfast frequency and anthropometric indices and blood pressure in different models for adjusting possible confounders. All statistical measures were estimated using survey data analysis methods. Data were analyzed by using
3
STATA package. P-value < 0.05 was considered as statistically significant.
Results The sample consisted of 13,486 adolescents aged 6e18 years (50.76% boys, 49.24% girls). The total data of South Khorasan was not available; hence, data of 30 provinces only was analyzed. Descriptive subject characteristics are shown in Table 1. Of the adolescents, 2537 (18.9%), 1771 (13.2%) and 9119 (67.9%), respectively, were breakfast skippers, semi-skippers and non-skippers. Height, weight, waist circumference (WC) and waist-to-height ratio (WHtR) of boys were significant higher than girls (P-value < 0.001), while BMI was greater in girls (P-value ¼ 0.002). The mean of systolic and diastolic blood pressure (SBP and DBP) were higher in boys compared with girls (P-value < 0.001). The female adolescents included more breakfast skippers than boys (22.5% vs 15.4%). 11.9% of adolescents were obese, the prevalence of obesity being greater among boys (13.6% vs 10.1%). Also, the percentage of abdominal obesity among boys was significant larger than in girls (Pvalue < 0.001). The boys had more high physical activity compared with girls (35.6% vs 22.4%).
Breakfast frequency The subject characteristics based on breakfast frequency are shown in Table 2. Adolescents who skipped breakfast were older (13.1 years, CI 95%:12.9e13.3), whereas those who ate breakfast daily were younger (12.1 years, CI 95%:12e12.3). The mean of weight, BMI, WC and WHtR in non-skipping students were significantly less than breakfast skippers (P-value < 0.001). And the mean of these anthropometric indices were linearly associated with breakfast frequency (P-trend < 0.001). The prevalence of overweight and obesity among breakfast skippers were higher than non-skipping counterparts (P-value < 0.001). Students who ate breakfast regularly had a significantly higher rate of normal weight compared with adolescents who did not eat breakfast (Pvalue < 0.001). The percentage rate of abdominal obesity among breakfast skippers and non-skipping group were 22.6% (CI 95%:21e24.3) and 17.9% (CI 95%:17e18.6), respectively. Which its percentage was respectively, significantly higher among breakfast skippers (P-value < 0.001). Blood pressure was categorized into three groups (normal, prehypertension, and hypertension), which they did not differ significantly between non-skipping students and breakfast skippers (P-value ¼ 0.1). There were significant association between breakfast frequency and physical activity (P-value < 0.001). So that nonskippers were more active than students who eat breakfast. On the other hand, students who intake breakfast regularly had less screen time compared with their breakfast skipping counterparts (P-value < 0.001). The adolescents who consumed breakfast regularly were more likely to live in a high SES region (P-value < 0.001).
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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Table 1 e Subject characteristics based on gender: the CASPIAN-IV Study. Age (Year) Height (cm) Weight (Kg) BMI (Kg/m2) WC (cm) WHtR SBP (mmHg) DBP (mmHg) Father education (%) Illiterate Diploma Bachelor and upper Mother education (%) Illiterate Diploma Bachelor and upper Breakfast eating Skippers Semi-skippers Non-skippers Screen time 4 h/day >4 h/day Weight status Underweight Normal Overweight Obese Abdominal obesity Physical activity Low Medium High SES Low Intermediate High
Boys (N ¼ 6845)
Girls (N ¼ 6641)
12.3 (12.1e12.6)a 148.1 (146.8e149.5) 43.0 (41.9e44.2) 18.7 (18.5e18.9) 67.8 (67.1e68.5) 0.458 (0.456e0.461) 102.7 (102.0e103.5) 65.5 (64.9e66.2)
12.5 145.7 41.7 18.9 66.1 0.454 100.2 64.1
775 (11.7)b 4943 (74.4) 927 (14.0)
696 (10.8) 4845 (75.2) 904 (14.0)
1471 (11.2) 9788 (74.8) 1831 (14.0)
0.2
1191 (17.6) 4982 (73.6) 596 (8.8)
1079 (16.4) 4943 (75.0) 571 (8.7)
2270 (17.0) 9925 (74.3) 1167 (8.7)
0.1
1050 (15.4) 885 (13.0) 4881 (71.6)
1487 (22.5) 886 (13.4) 4238 (64.1)
2537 (18.9) 1771 (13.2) 9119 (67.9)
<0.001
5301 (78.1) 1489 (21.9)
5598 (84.8) 1005 (15.2)
10,899 (81.4) 2494 (18.6)
<0.001
881 (13.0) 4333 (64.1) 627 (9.3) 918 (13.6) 1385 (20.4)
740 4497 660 666 1171
1945 (28.8) 2410 (35.6) 2410 (35.6) 2082 (33.2) 2050 (32.7) 2143 (34.2)
(12.3e12.8) (144.6e146.8) (40.7e42.6) (18.7e19.1) (65.6e66.7) (0.452e0.457) (99.5e100.8) (63.5e64.7)
Total (N ¼ 13,486)
P-value
12.4 (12.2e12.6) 146.9 (146.1e147.8) 42.4 (41.6e43.1) 18.8 (18.7e18.9) 67.0 (66.5e67.4) 0.456 (0.454e0.458) 101.5 (101.0e102.0) 64.8 (64.4e65.3)
<0.001 <0.001 <0.001 0.002 <0.001 0.001 <0.001 <0.001
(12.2) (66.3) (9.7) (11.9) (19.1)
<0.001
2608 (39.6) 2500 (38.0) 1476 (22.4)
4553 (34.1) 4910 (36.8) 3886 (29.1)
<0.001
2065 (33.8) 2050 (33.5) 2000 (32.7)
4147 (33.5) 4100 (33.1) 4143 (33.4)
0.2
(11.3) (68.5) (10.1) (10.1) (17.8)
1621 8830 1287 1584 2556
<0.001
BMI; body mass index, WC; waist circumference, WHtR; Waist-to-Height ratio, SBP; systolic blood pressure, DBP; diastolic blood pressure, SES; socio-economic status. a Mean ± CI 95%. b N (%). P < 0.05 is significant.
The odd ratios of obesity and blood pressure across breakfast frequency The odd ratios for obesity and blood pressure across breakfast consumption categories are shown in Table 3. The risk of abdominal obesity and general obesity among semi-skippers increased from 11% to 17% and 17e27% compare to nonskipping students, respectively. The students who skipped breakfast had a significantly higher risk of abdominal obesity (OR 1.35, CI 95%:1.18e1.53), overweight (OR 1.16, CI 95%:1.01e1.34) and general obesity (OR 1.61, CI 95%:1.39e1.89).
The b-coefficient values for anthropometric measurements and BP by breakfast frequency b-coefficient values for anthropometric measurements and BP by breakfast frequency are shown in Table 4. WC of breakfast skippers was 1.18e2.86 cm greater than non-skipping counterparts (P-value < 0.05). The amount of WHtR among students
skipping breakfast was greater by 0.0065e0.0076 compared with non-skipping group. In the multivariate model (model III), students who skipped breakfast had 0.65 (CI 95%:0.44e0.85) kg/m2 larger than non-skippers, it of semiskippers was 0.35 (CI 95%:0.72e0.57) kg/m2. The systolic and diastolic blood pressure of breakfast skippers was 1.1 (CI 95%:0.42e1.78) and 0.83 (CI 95%:0.21e1.44) mmHg greater than non-skipping students, respectively.
Food habits The students who ate breakfast daily follow a more healthy food pattern compared with breakfast skippers. Non-skipping adolescents ate more fresh fruits, dried fruits, vegetables and drank milk compared with breakfast skippers, while the skippers showed a higher intake of salty snack, soft drinks, packed fruit juice and fast food (all P-value < 0.001) (data not shown).
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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Table 2 e Subject characteristics based on breakfast frequency: the CASPIAN-IV Study. Breakfast frequency Non-skipper (N ¼ 9119)
P-valuec
P-trendd
12.1 (12.0e12.3) 145.7 (144.8e146.7) 40.9 (40.1e41.7) 18.4 (18.3e18.6) 66.2 (65.7e66.7) 0.455 (0.453e0.457) 101.1 (100.6e101.7) 64.6 (64.1e65.1)
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.001
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
(9.1e12.0) (64.5e69.0) (8.7e11.6) (10.9e14.1) (18.2e22.0)
13.0 (12.3e13.7) 67.0 (66.0e67.9) 9.1 (8.5e9.7) 10.8 (10.2e11.4) 17.9 (17.0e18.6)
<0.001
<0.001
<0.001
<0.001
93.0 (91.9e93.9) 3.0 (2.3e3.7) 4.0 (3.2e4.8)
92.5 (91.1e93.6) 3.1 (2.3e4.0) 4.4 (3.4e5.4)
93.3 (92.7e93.8) 3.2 (0.7e1.1) 3.5 (3.1e3.9)
0.1
0.1
41.8 (39.8e43.7) 33.5 (31.6e35.4) 24.7 (22.9e26.3)
38.4 (36.1e40.7) 35.1 (32.8e37.4) 26.5 (24.4e28.5)
31.1 (30.1e32.0) 38.0 (37.0e39.0) 30.9 (29.9e31.8)
<0.001
<0.001
78.3 (76.6e79.9) 21.7 (20.0e23.3)
79.5 (77.5e81.3) 20.5 (18.6e22.4)
82.6 (81.8e83.3) 17.4 (16.6e18.1)
<0.001
<0.001
36.9 (34.9e38.9) 32.8 (30.8e34.7) 30.3 (28.4e32.2)
33.1 (30.8e35.4) 34.8 (32.4e37.1) 32.1 (29.8e34.4)
32.5 (31.5e33.5) 32.8 (31.8e33.8) 34.7 (33.6e35.7)
<0.001
<0.001
Skipper (N ¼ 2537) Age (Year) Height (cm) Weight (Kg) BMI (Kg/m2) WC (cm) WHtR SBP (mmHg) DBP (mmHg) Weight status Underweight Normal Overweight Obese Abdominal obesity BP (mm Hg) Normal Prehypertension Hypertension Physical activity Low Medium High Screen time 4 h/day >4 h/day SES Low Intermediate High
13.1 149.9 46.0 19.8 69.1 0.461 102.2 65.4 10.3 63.6 11.0 15.1 22.6
(12.9e13.3)a (148.8e151.0) (45.0e47.0) (19.5e20.0) (68.4e69.7) (0.458e0.464) (101.6e102.9) (64.8e66.0) (9.1e11.5)b (61.1e65.5) (9.7e12.2) (13.6e16.5) (21.0e24.3)
Semi-skipper (N ¼ 1771) 12.9 149.2 44.7 19.3 67.9 0.456 102.2 65.2 10.6 66.8 10.2 12.5 20.1
(12.7e13.2) (148.0e150.5) (43.5e45.8) (19.0e19.5) (67.2e68.7) (0.452e0.459) (101.4e103.1) (64.5e65.9)
BMI; body mass index, WC; waist circumference, WHtR; Waist-to-Height ratio, SBP; Systolic blood pressure, DBP; Diastolic blood pressure, BP; Blood Pressure. SES; Socio-economic status. a P-values are resulted from analysis of variance (ANOVA). b P-values are for trend analysis. c Mean ± CI 95%. d % (CI 95%). P < 0.05 is significant.
Discussion The present study corroborated the association between breakfast frequency with overweight and obesity in a large representative sample of Iranian children and adolescents. The results showed skipping breakfast was associated with a greater risk of general and abdominal obesity. And the association between breakfast skipping with general and abdominal obesity remained significant after adjusting for known confounders. This study revealed that adolescents who skipped breakfast were older, had less physical activity, spent more screen time and were from lower SES regions. In the present study, an inverse association was found between breakfast intake with general and abdominal obesity. The results of this study are consistent with previous studies.12,27e29 Skipping breakfast may lead to reduced satiety later during the day with increased eating snacks.30 In contrast, eating breakfast may affect appetite control, energy intake and quality of diet (i.e. increased fiber intake and decreased saturated fat intake).31e33 So these mechanisms may lead to a lower BMI among breakfast consumers. A casual role of breakfast intake in weight loss was assessed by some
randomized clinical trials. Emily J Dhurandhar et al. investigated the effectiveness of breakfast intake on weight loss among healthy overweight and obese adults and the results of their study showed that eating or skipping breakfast did not effect weight loss.17 In another randomized clinical trial, the effect of breakfast intake on energy balance was assessed and it's results presented regular breakfast intake was causally associated with higher physical activity thermogenesis that suggested breakfast eaters spontaneously participant in physical activity.18 In this study, significantly non-skipper breakfast had more physical activity that breakfast skipper. Contrary to the hypothesis, skipping breakfast was not associated with elevated blood pressure. The results of present study showed that adolescents who skipped breakfast did not had higher SBP and DBP compared with breakfast eaters and the breakfast skipping did not lead to elevated blood pressure. The results of the study were supported by other studies.27,34 Breakfast intake is known to be a key factor of weight control;31 but, its effect on BP level is not known. The results of present study were in agreement with previous studies,21,35,36 and supported this hypothesis that breakfast skippers had unhealthy food patterns compared with breakfast consumers. These results indicated that
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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Table 3 e Odds ratios (CI 95%) for anthropometric indices and BP across breakfast frequency: the CASPIAN-IV Study.
Table 4 e b-coefficients (CI 95%) for anthropometric indices and BP across breakfast frequency: the CASPIANIV Study.
Breakfast frequency
Breakfast frequency
Non-skipper Abdominal obesity Model Ia Model IIb Model IIIc Overweight Model I Model II Model III General obesity Model I Model II Model III Elevated SBP Model I Model II Model III Model IVd Elevated DBP Model I Model II Model III Model IVd Elevated BP Model I Model II Model III Model IVd
Semi-skipper
Skipper
1 1 1
1.15 (1.01e1.31)* 1.11 (1.01e1.32)* 1.17 (1.02e1.36)*
1.34 (1.20e1.50)* 1.36 (1.22e1.53)* 1.35 (1.18e1.53)*
1 1 1
1.12 (0.94e1.33) 1.08 (0.91e1.28) 1.14 (0.94e1.37)
1.22 (1.06e1.41)* 1.16 (1.01e1.34)* 1.11 (0.95e1.30)
1 1 1
1.17 (1.00e1.30)* 1.21 (1.03e1.41)* 1.27 (1.07e1.51)*
1.46 (1.27e1.67)* 1.56 (1.36e1.79)* 1.61 (1.39e1.89)*
1 1 1 1
1.46 1.30 1.41 1.31
(9.17e2.34) (0.81e2.09) (0.84e2.35) (0.78e2.22)
1.36 1.31 1.53 1.41
(0.89e2.08) (0.85e2.01) (0.97e2.40) (0.89e2.24)
1 1 1 1
1.22 1.13 1.17 1.14
(0.89e1.68) (0.83e1.54) (0.83e1.65) (0.80e1.62)
1.17 1.11 1.24 1.19
(0.88e1.56) (0.83e1.49) (0.91e1.69) (0.87e1.63)
1 1 1 1
1.24 1.14 1.18 1.15
(0.93e1.66) (0.85e1.51) (0.86e1.62) (0.83e1.58)
1.13 1.06 1.16 1.11
(0.87e1.45) (0.82e1.37) (0.88e1.53) (0.84e1.46)
SBP; systolic blood pressure, DBP; diastolic blood pressure, BP; blood pressure, *P < 0.05. a Without adjusted (crude models). b Adjusted for age and sex. c Additionally adjusted for family history of chronic diseases, screen time, physical activity, socio-economic status. d Additionally adjusted for BMI in all abnormalities except for obesity.
breakfast skippers consumed more frequent salty snacks, soft drinks, packed fruit juice and fast food and less frequent fruits/vegetables and milk compared with non-skippers. Previous studies showed that breakfast eating was associated with higher intakes of calcium, cobalamin, folic acid and vitamin C,36 and lower intake of cholesterol, total fat and fiber,36,37 as well as lower daily intakes of energy36 and sugar.38 In particular, breakfast skippers appeared to follow unhealthier food habits. Also, breakfast skippers appeared to have unhealthier habits included more consumption of outmeals and variable hours for dinner.35 Maybe these differences in the food habits explain in some way why adolescents who omit breakfast have higher intakes of energy and higher anthropometric measurements.
Strengths and limitations The limitation was cross-sectional design of present study, which the authors could not distinguish whether breakfast skipping lead to higher anthropometric indices and an
Non-skipper WC Model Model Model WHtR Model
Ia IIb IIIc
1 1 1
I
1
Model II
1
Model III
1
BMI Model Model Model SBP Model Model Model DBP Model Model Model
I II III
1 1 1
I II III
1 1 1
I II III
1 1 1
Semi-skipper 1.72 (1.05e2.39)* 0.29 (0.24e0.84) 0.40 (0.16e0.97) 0.0009 (0.0025e0.0044) 0.0020 (0.0014e0.0054) 0.0023 (0.0013e0.0061) 0.80 (0.55e1.05)* 0.32 (0.11e0.53)* 0.35 (0.72e0.57)*
Skipper 2.86 (2.22e3.49)* 1.23 (0.71e1.74)* 1.18 (0.63e1.73)* 0.0065 (0.0032e0.0097)* 0.0081 (0.0048e0.1130)* 0.0076 (0.0041e0.0111)* 1.30 (1.07e1.53)* 0.69 (0.49e0.88)* 0.65 (0.44e0.85)*
1.10 (0.42e1.78)* 1.07 (0.27e1.87)* 0.02 (0.73e0.69) 0.01 (0.63e0.61) 0.14 (0.61e0.90) 0.09 (0.56e0.76) 0.64 (0.01e1.31) 0.01 (0.61e0.65) 0.11 (0.58e0.81)
0.83 (0.21e1.44)* 0.19 (0.39e0.78) 0.37 (0.26e1.02)
WC; waist circumference, WHtR; Waist-to-Height ratio, BMI; body mass index, SBP; Systolic Blood Pressure, DBP; Diastolic Blood Pressure, BP; Blood Pressure, *P < 0.05. a Without adjusted (crude models). b Adjusted for age and sex. c Additionally adjusted for family history of chronic diseases, screen time, physical activity, socio-economic status.
unhealthier food habits. Also, self-reported data were another limitation of the study and it is possible some students have miss reported. A large national representative sample of Iranian children and adolescents is the main strengths of present study as well as measuring of SES and lifestyle habits in this study and added to model to reduce confounders' effects.
Conclusion Regular breakfast consumption is significantly associated with lower body fatness and healthier dietary habits but that further study, using controlled intervention trials, is required to test whether this represents a causal relationship.
Author statements Acknowledgments This nationwide survey was performed among Iranian children and adolescents with corporation of Ministry of Education and Training, the Training, the Ministry of Health and Medical education, Child Health Promotion Research Center, Isfahan University of Medical Sciences, and Endocrinology
Please cite this article in press as: Ahadi Z, et al., Association between breakfast intake with anthropometric measurements, blood pressure and food consumption behaviors among Iranian children and adolescents: the CASPIAN-IV study, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.03.019
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and Metabolism Research center of Tehran University of Medical Sciences.
Ethical approval Study protocols were reviewed and approved by ethical committees and other relevant national regulatory organizations. A written informed consent and verbal consent was obtained from the parents and students; respectively, after complete explanation of the study objectives and protocols. Information about demographic, food habit, breakfast frequency, and physical measurements were gathered about students.
Funding None declared.
Competing interests None declared.
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