- Email: [email protected]
Hearty Breakfast for Healthier Arteries∗
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 70, NO. 15, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacc.2017.08.054
EDITORIAL COMMENT
Hearty Breakfast for Healthier Arteries* Prakash Deedwania, MD,a Tushar Acharya, MDb
B
reakfast is the first meal of the day, and it is
disease. In the Health Professionals Follow-up Study,
generally believed to be the most important
men who skipped breakfast had a 27% higher risk of
meal because it provides balanced and nutri-
CHD (2). In a population-based study from Japan,
tious food rich in fiber, vitamins, and other essential
Kubota et al. (3) demonstrated that stroke and hem-
nutrients. Consumption of a hearty breakfast that
orrhagic stroke risk increased by 18% and 36%,
provides at least 20% of the daily energy intake is
respectively, in breakfast skippers without an in-
generally associated with less frequent nibbling of
crease in CHD risk. The authors explain that the
unhealthy food later in the day.
Japanese have more stroke, especially hemorrhagic
During the past decade, a number of studies have
stroke, and less CHD compared with the West due to
shown that skipping breakfast is associated with
more prevalent hypertension and less prevalent hy-
adverse cardiometabolic perturbations that can lead
percholesterolemia. This geographic/genetic varia-
to the development of metabolic syndrome and
tion may explain the differential involvement of
diabetes, and eventually increase the risk of coronary
vascular beds. Skipping breakfast via overactivity in
heart disease (CHD) and stroke (1–8). The paper by
the hypothalamic–pituitary–adrenal axis from pro-
Uzhova et al. (9) in this issue of the Journal provides a
longed fasting leads to elevated blood pressure (4)—
new insight into the chain of events by demonstrating
which in turn causes more strokes. Having breakfast
a higher prevalence of subclinical atherosclerosis
conversely decreases systolic and diastolic blood
in breakfast skippers.
pressure (5).
SEE PAGE 1833
Dietary patterns have changed significantly over the last few decades such that an estimated 20% to 30% of
There is considerable evidence for ill effects of
adults skip breakfast (6). These trends mirror the in-
altered eating patterns and skipping breakfast in
crease in obesity and associated cardiometabolic de-
the published reports (1–8). For example, young
rangements. It is less clear whether skipping breakfast
breakfast skippers in the NHANES (National Health
causes more people to be obese or if the obese skip
and Nutrition Examination Survey) (1999 to 2002)
breakfast with the misguided goal of losing weight.
were found to have 30% to 40% more obesity, higher
This “chicken or egg” situation notwithstanding, it is
blood pressure, cholesterol, low-density lipoprotein
apparent that the relationship is complex.
cholesterol, and insulin levels, and lower HDL-C
There are multiple possible mechanisms to explain
high-density lipoprotein cholesterol compared with
how alterations in dietary habits such as skipping
those that regularly consumed cereal breakfast (1).
breakfast can have an impact on cardiometabolic
This accumulation of risk factors when persistent can
health. The adverse effects of skipping breakfast begin
certainly manifest as clinical cardiovascular (CV)
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-
*Editorials published in the Journal of the American College of Cardiology
density lipoprotein cholesterol was lower in “seldom
reflect the views of the authors and do not necessarily represent the
breakfast eaters” compared with their peers, and the
views of JACC or the American College of Cardiology. From the aUniversity of California, San Francisco, Fresno, California; and b
Advanced Cardiovascular Imaging, National Heart, Lung, and Blood
risk of metabolic syndrome was significantly greater (7). Breakfast skippers end up eating more unbalanced
Institute, Washington, DC. Both authors have reported that they have no
meals later in the day and tend to consume more fatty
relationships relevant to the contents of this paper to disclose.
foods at night, thus effectively increasing the overall
1844
Deedwania and Acharya
JACC VOL. 70, NO. 15, 2017 OCTOBER 10, 2017:1843–5
Hearty Breakfast for Healthier Arteries
energy intake through unhealthy foods (2). They are
quarter was on the cardioprotective Mediterranean
also more likely to make other poor lifestyle choices
diet (14).
such as smoking, alcohol consumption, and less
Disentangling the effect of breakfast from other
frequent exercise (8). Additionally, skipping breakfast
dietary and nondietary predictors, and establishing
and eating at odd hours of night can cause neurohor-
SBF as an independent marker of atherosclerosis is a
monal imbalances and alter circadian rhythms (10).
daunting task. Apart from dietary differences, the
Peripheral circadian clocks are entrained by food
SBF group had significantly more males, smokers,
intake, and polymorphisms in circadian regulation
and obese, hypertensive, dyslipidemic, and diabetic
genes such as CLOCK and BMAL1 are implicated in the
individuals, making the comparisons groups quite
development of metabolic syndrome, diabetes, and
dissimilar. Statistical adjustment to tease out the
hypertension (11).
effects of predictors independent of confounders in
There is a significant lag-time between the onset
significantly
disparate
groups
may
be
difficult.
of metabolic derangements leading to CV risk factors
However, epidemiological studies controlling for
and subsequent clinical CV events such as heart at-
most variables might be somewhat impractical. It is
tacks and strokes. What happens in the interim, in
also important to keep in mind that this cross-
the form of subclinical atherosclerosis, is an impor-
sectional study evaluates for an association and not
tant link in this chain of events. The paper by
causality.
Uzhova et al. (9) provides clinically important in-
The important message of this study, as pointed
formation by demonstrating evidence of subclinical
out by the authors, is that skipping breakfast serves
atherosclerosis in breakfast skippers.
as a marker of poor dietary and lifestyle choices that
This study is unique in that it evaluates the asso-
are
linked to
subclinical atherosclerosis. These
ciation of eating patterns, especially breakfast intake,
dietary choices are generally made relatively early in
with the objective evidence of subclinical athero-
life and, if they remain unchanged, can lead to
sclerosis such as carotid, iliofemoral, and descending
clinical CV disease later on. Modification of dietary
aorta plaque and coronary artery calcium (CAC)
patterns with healthy eating and specifically not
evaluated by well-established imaging techniques
skipping breakfast can reduce the burden of athero-
such as vascular ultrasound and cardiac computed
sclerotic CV disease.
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
CLINICAL IMPLICATIONS 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.
lunch. Additionally, they made poor dietary choices with excessive consumption of red and processed
ADDRESS
meat, appetizers, sweetened beverages, and alcohol,
Deedwania, University of California, San Francisco, UCSF
FOR
CORRESPONDENCE:
and lower intake of fruits, vegetables, and fiber.
Fresno, Division of Cardiology Academic Offices, 2335
Almost one-half of the SBF group consumed an
East Kashian Lane, Suite 460, Fresno, California 93701.
atherogenic social–business diet (13), and only a
E-mail: [email protected].
Dr. Prakash
Deedwania and Acharya
JACC VOL. 70, NO. 15, 2017 OCTOBER 10, 2017:1843–5
Hearty Breakfast for Healthier Arteries
REFERENCES 1. Deshmukh-Taskar P, Nicklas TA, Radcliffe JD, O’Neil CE, Liu Y. The relationship of breakfast skipping and type of breakfast consumed with overweight/obesity, abdominal obesity, other cardiometabolic risk factors and the metabolic syndrome in young adults: the National Health and Nutrition Examination Survey (NHANES): 1999-2006. Public Health Nutr 2013;16:2073–82.
measures of arterial stiffness in healthy humans. Am J Clin Nutr 2009;90:298–303. 6. St-Onge MP, Ard J, Baskin ML, et al., American Heart Association Obesity Committee of the Council on Lifestyle and Cardiometabolic Health, Council on Cardiovascular Disease in the
2. Cahill LE, Chiuve SE, Mekary RA, et al. Prospective study of breakfast eating and incident coronary heart disease in a cohort of male US health professionals. Circulation 2013;128:337–43.
Young, Council on Clinical Cardiology; and Stroke Council. Meal timing and frequency: implications for cardiovascular disease prevention: a scientific statement from the American Heart Association. Circulation 2017;135: e96–121.
3. Kubota Y, Iso H, Sawada N, Tsugane S, JPHC Study Group. Association of breakfast intake with
7. Shafiee G, Kelishadi R, Qorbani M, et al. Association of breakfast intake with car-
incident stroke and coronary heart disease: the Japan Public Health Center-Based Study. Stroke 2016;47:477–81.
diometabolic risk factors. J Pediatr (Rio J) 2013; 89:575–82.
4. Witbracht M, Keim NL, Forester S, Widaman A, Laugero K. Female breakfast skippers display a disrupted cortisol rhythm and elevated blood pressure. Physiol Behav 2015; 140:215–21. 5. Ahuja KD, Robertson IK, Ball MJ. Acute effects of food on postprandial blood pressure and
8. Timlin MT, Pereira MA. Breakfast frequency and quality in the etiology of adult obesity and chronic diseases. Nutr Rev 2007;65 Pt 1: 268–81. 9. Uzhova I, Fuster V, Fernández-Ortiz A, et al. The importance of breakfast in atherosclerosis disease: insights from the PESA study. J Am Coll Cardiol 2017;70:1833–42.
10. Dallmann R, Viola AU, Tarokh L, Cajochen C, Brown SA. The human circadian metabolome. Proc Natl Acad Sci U S A 2012;109:2625–9. 11. Gnocchi D, Pedrelli M, Hurt-Camejo E, Parini P. Lipids around the clock: focus on circadian rhythms and lipid metabolism. Biology (Basel) 2015;4:104–32. 12. Fernández-Friera L, Peñalvo JL, FernándezOrtiz A, et al. Prevalence, vascular distribution, and multiterritorial extent of subclinical atherosclerosis in a middle-aged cohort: the PESA (Progression of Early Subclinical Atherosclerosis) study. Circulation 2015;131:2104–13. 13. Peñalvo JL, Fernández-Friera L, LópezMelgar B, et al. Association between a socialbusiness eating pattern and early asymptomatic atherosclerosis. J Am Coll Cardiol 2016;68:805–14. 14. Estruch R, Ros E, Salas-Salvadó J, et al., PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279–90.
KEY WORDS skipping breakfast, subclinical atherosclerosis
1845
VOL. 70, NO. 15, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacc.2017.08.054
EDITORIAL COMMENT
Hearty Breakfast for Healthier Arteries* Prakash Deedwania, MD,a Tushar Acharya, MDb
B
reakfast is the first meal of the day, and it is
disease. In the Health Professionals Follow-up Study,
generally believed to be the most important
men who skipped breakfast had a 27% higher risk of
meal because it provides balanced and nutri-
CHD (2). In a population-based study from Japan,
tious food rich in fiber, vitamins, and other essential
Kubota et al. (3) demonstrated that stroke and hem-
nutrients. Consumption of a hearty breakfast that
orrhagic stroke risk increased by 18% and 36%,
provides at least 20% of the daily energy intake is
respectively, in breakfast skippers without an in-
generally associated with less frequent nibbling of
crease in CHD risk. The authors explain that the
unhealthy food later in the day.
Japanese have more stroke, especially hemorrhagic
During the past decade, a number of studies have
stroke, and less CHD compared with the West due to
shown that skipping breakfast is associated with
more prevalent hypertension and less prevalent hy-
adverse cardiometabolic perturbations that can lead
percholesterolemia. This geographic/genetic varia-
to the development of metabolic syndrome and
tion may explain the differential involvement of
diabetes, and eventually increase the risk of coronary
vascular beds. Skipping breakfast via overactivity in
heart disease (CHD) and stroke (1–8). The paper by
the hypothalamic–pituitary–adrenal axis from pro-
Uzhova et al. (9) in this issue of the Journal provides a
longed fasting leads to elevated blood pressure (4)—
new insight into the chain of events by demonstrating
which in turn causes more strokes. Having breakfast
a higher prevalence of subclinical atherosclerosis
conversely decreases systolic and diastolic blood
in breakfast skippers.
pressure (5).
SEE PAGE 1833
Dietary patterns have changed significantly over the last few decades such that an estimated 20% to 30% of
There is considerable evidence for ill effects of
adults skip breakfast (6). These trends mirror the in-
altered eating patterns and skipping breakfast in
crease in obesity and associated cardiometabolic de-
the published reports (1–8). For example, young
rangements. It is less clear whether skipping breakfast
breakfast skippers in the NHANES (National Health
causes more people to be obese or if the obese skip
and Nutrition Examination Survey) (1999 to 2002)
breakfast with the misguided goal of losing weight.
were found to have 30% to 40% more obesity, higher
This “chicken or egg” situation notwithstanding, it is
blood pressure, cholesterol, low-density lipoprotein
apparent that the relationship is complex.
cholesterol, and insulin levels, and lower HDL-C
There are multiple possible mechanisms to explain
high-density lipoprotein cholesterol compared with
how alterations in dietary habits such as skipping
those that regularly consumed cereal breakfast (1).
breakfast can have an impact on cardiometabolic
This accumulation of risk factors when persistent can
health. The adverse effects of skipping breakfast begin
certainly manifest as clinical cardiovascular (CV)
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-
*Editorials published in the Journal of the American College of Cardiology
density lipoprotein cholesterol was lower in “seldom
reflect the views of the authors and do not necessarily represent the
breakfast eaters” compared with their peers, and the
views of JACC or the American College of Cardiology. From the aUniversity of California, San Francisco, Fresno, California; and b
Advanced Cardiovascular Imaging, National Heart, Lung, and Blood
risk of metabolic syndrome was significantly greater (7). Breakfast skippers end up eating more unbalanced
Institute, Washington, DC. Both authors have reported that they have no
meals later in the day and tend to consume more fatty
relationships relevant to the contents of this paper to disclose.
foods at night, thus effectively increasing the overall
1844
Deedwania and Acharya
JACC VOL. 70, NO. 15, 2017 OCTOBER 10, 2017:1843–5
Hearty Breakfast for Healthier Arteries
energy intake through unhealthy foods (2). They are
quarter was on the cardioprotective Mediterranean
also more likely to make other poor lifestyle choices
diet (14).
such as smoking, alcohol consumption, and less
Disentangling the effect of breakfast from other
frequent exercise (8). Additionally, skipping breakfast
dietary and nondietary predictors, and establishing
and eating at odd hours of night can cause neurohor-
SBF as an independent marker of atherosclerosis is a
monal imbalances and alter circadian rhythms (10).
daunting task. Apart from dietary differences, the
Peripheral circadian clocks are entrained by food
SBF group had significantly more males, smokers,
intake, and polymorphisms in circadian regulation
and obese, hypertensive, dyslipidemic, and diabetic
genes such as CLOCK and BMAL1 are implicated in the
individuals, making the comparisons groups quite
development of metabolic syndrome, diabetes, and
dissimilar. Statistical adjustment to tease out the
hypertension (11).
effects of predictors independent of confounders in
There is a significant lag-time between the onset
significantly
disparate
groups
may
be
difficult.
of metabolic derangements leading to CV risk factors
However, epidemiological studies controlling for
and subsequent clinical CV events such as heart at-
most variables might be somewhat impractical. It is
tacks and strokes. What happens in the interim, in
also important to keep in mind that this cross-
the form of subclinical atherosclerosis, is an impor-
sectional study evaluates for an association and not
tant link in this chain of events. The paper by
causality.
Uzhova et al. (9) provides clinically important in-
The important message of this study, as pointed
formation by demonstrating evidence of subclinical
out by the authors, is that skipping breakfast serves
atherosclerosis in breakfast skippers.
as a marker of poor dietary and lifestyle choices that
This study is unique in that it evaluates the asso-
are
linked to
subclinical atherosclerosis. These
ciation of eating patterns, especially breakfast intake,
dietary choices are generally made relatively early in
with the objective evidence of subclinical athero-
life and, if they remain unchanged, can lead to
sclerosis such as carotid, iliofemoral, and descending
clinical CV disease later on. Modification of dietary
aorta plaque and coronary artery calcium (CAC)
patterns with healthy eating and specifically not
evaluated by well-established imaging techniques
skipping breakfast can reduce the burden of athero-
such as vascular ultrasound and cardiac computed
sclerotic CV disease.
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
CLINICAL IMPLICATIONS 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.
lunch. Additionally, they made poor dietary choices with excessive consumption of red and processed
ADDRESS
meat, appetizers, sweetened beverages, and alcohol,
Deedwania, University of California, San Francisco, UCSF
FOR
CORRESPONDENCE:
and lower intake of fruits, vegetables, and fiber.
Fresno, Division of Cardiology Academic Offices, 2335
Almost one-half of the SBF group consumed an
East Kashian Lane, Suite 460, Fresno, California 93701.
atherogenic social–business diet (13), and only a
E-mail: [email protected].
Dr. Prakash
Deedwania and Acharya
JACC VOL. 70, NO. 15, 2017 OCTOBER 10, 2017:1843–5
Hearty Breakfast for Healthier Arteries
REFERENCES 1. Deshmukh-Taskar P, Nicklas TA, Radcliffe JD, O’Neil CE, Liu Y. The relationship of breakfast skipping and type of breakfast consumed with overweight/obesity, abdominal obesity, other cardiometabolic risk factors and the metabolic syndrome in young adults: the National Health and Nutrition Examination Survey (NHANES): 1999-2006. Public Health Nutr 2013;16:2073–82.
measures of arterial stiffness in healthy humans. Am J Clin Nutr 2009;90:298–303. 6. St-Onge MP, Ard J, Baskin ML, et al., American Heart Association Obesity Committee of the Council on Lifestyle and Cardiometabolic Health, Council on Cardiovascular Disease in the
2. Cahill LE, Chiuve SE, Mekary RA, et al. Prospective study of breakfast eating and incident coronary heart disease in a cohort of male US health professionals. Circulation 2013;128:337–43.
Young, Council on Clinical Cardiology; and Stroke Council. Meal timing and frequency: implications for cardiovascular disease prevention: a scientific statement from the American Heart Association. Circulation 2017;135: e96–121.
3. Kubota Y, Iso H, Sawada N, Tsugane S, JPHC Study Group. Association of breakfast intake with
7. Shafiee G, Kelishadi R, Qorbani M, et al. Association of breakfast intake with car-
incident stroke and coronary heart disease: the Japan Public Health Center-Based Study. Stroke 2016;47:477–81.
diometabolic risk factors. J Pediatr (Rio J) 2013; 89:575–82.
4. Witbracht M, Keim NL, Forester S, Widaman A, Laugero K. Female breakfast skippers display a disrupted cortisol rhythm and elevated blood pressure. Physiol Behav 2015; 140:215–21. 5. Ahuja KD, Robertson IK, Ball MJ. Acute effects of food on postprandial blood pressure and
8. Timlin MT, Pereira MA. Breakfast frequency and quality in the etiology of adult obesity and chronic diseases. Nutr Rev 2007;65 Pt 1: 268–81. 9. Uzhova I, Fuster V, Fernández-Ortiz A, et al. The importance of breakfast in atherosclerosis disease: insights from the PESA study. J Am Coll Cardiol 2017;70:1833–42.
10. Dallmann R, Viola AU, Tarokh L, Cajochen C, Brown SA. The human circadian metabolome. Proc Natl Acad Sci U S A 2012;109:2625–9. 11. Gnocchi D, Pedrelli M, Hurt-Camejo E, Parini P. Lipids around the clock: focus on circadian rhythms and lipid metabolism. Biology (Basel) 2015;4:104–32. 12. Fernández-Friera L, Peñalvo JL, FernándezOrtiz A, et al. Prevalence, vascular distribution, and multiterritorial extent of subclinical atherosclerosis in a middle-aged cohort: the PESA (Progression of Early Subclinical Atherosclerosis) study. Circulation 2015;131:2104–13. 13. Peñalvo JL, Fernández-Friera L, LópezMelgar B, et al. Association between a socialbusiness eating pattern and early asymptomatic atherosclerosis. J Am Coll Cardiol 2016;68:805–14. 14. Estruch R, Ros E, Salas-Salvadó J, et al., PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279–90.
KEY WORDS skipping breakfast, subclinical atherosclerosis
1845