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Journal of Human Nutrition and Dietetics

PUBLIC HEALTH NUTRITION AND EPIDEMIOLOGY
Body mass, frequency of eating and breakfast consumption in 9–13-year-olds
T. Coppinger,* Y. M. Jeanes,  J. Hardwick  & S. Reeves 
*Recreation & Leisure, Cork Institute of Technology, Bishopstown, Cork, Ireland  Life Sciences, Roehampton University, Roehampton, London, UK

Keywords body mass, breakfast, children, eating frequency. Correspondence T. Coppinger, Recreation & Leisure, Cork Institute of Technology, Bishopstown, Cork, Ireland. Tel.: +44 (0) 208 392 3328 Fax: +44 (0) 208 392 3610 E-mail: tara.coppinger@cit.ie doi:10.1111/j.1365-277X.2011.01184.x

Abstract Background: Unhealthy eating patterns in childhood can lead to adverse health conditions, particularly obesity. However, debate remains around the precise eating behaviours that lead to these conditions. The present study aimed to address this lack of evidence by reporting on the eating frequency, breakfast consumption and body mass index (BMI, kg m–2) of youth in the UK. Methods: A total of 264 (133 boys and 131 girls) participants, aged 10– 13 years, completed self-report measures of dietary intake via 3-day food/drink diaries (Friday to Sunday). Trained researchers recorded height and weight to calculate the BMI. Diaries were analysed using dietplan 6 nutritional analysis software (Forestfield Software, Horsham, UK) and multivariate linear regression was used to examine any association between breakfast consumption, frequency of eating and BMI. Results: No relationship existed between BMI Z-score, eating frequency and breakfast consumption. However, frequent breakfast consumers had significantly lower mean (SD) BMI Z-scores [0.18 (1.06) versus 0.57 (1.23)] and higher intakes of iron, calcium and vitamin E than those who did not eat breakfast regularly. Those aged ‡11 years consumed breakfast less frequently [0.92 (0.20)] and were less likely to eat regularly [4.6 (1.4)] than those aged £10 years. Conclusions: Older boys were the least likely to eat regularly and the least likely to consume breakfast. Promoting the importance of regular eating, particularly breakfast consumption to these boys, may be essential to ensure healthier, long-term eating patterns. Furthermore, the lower breakfast intakes in 11–13-year-olds and higher BMI Z-scores of those who did not eat breakfast regularly should be monitored.

Introduction Although it is widely recognised that unhealthy eating patterns in childhood can lead to adverse health conditions, particularly obesity (McNaughton et al., 2008), debate still remains around the precise eating behaviours that lead to these conditions (Patro & Szajewska, 2010). Breakfast consumption, in particular, has received much attention in recent years, with evidence showing greater fibre, calcium and lower saturated fat intakes (Song et al., 2006; Timlin et al., 2008) in children who consume

breakfast regularly. Improvements in cognitive function and academic performance have also been reported (Hoyland et al., 2009) and some studies also suggest children who eat breakfast regularly maintain healthier weights and undertake more healthful food choices (Rampersaud, 2008). Yet, research within this field remains inconclusive (Walker et al., 1982; Resnicow, 1991; Abalkhail & Shawky, 2002), particularly with regard to the relationship between meal frequency, breakfast consumption and BMI (kg m–2) in youth (Timlin et al., 2008; Patro & Szajewska, 2010). Some cross-sectional studies (Gibson &
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ª 2011 The Authors Journal of Human Nutrition and Dietetics ª 2011 The British Dietetic Association Ltd. 2012 J Hum Nutr Diet, 25, pp. 43–49

Parametric data ª 2011 The Authors Journal of Human Nutrition and Dietetics ª 2011 The British Dietetic Association Ltd.. their study only included data on school day breakfast patterns. overweight and obesity of participants.. Birmingham. whereas others (Toschke et al.1 kg and 0. Only one recent study (Macdiarmid et al. Koletzko & Toschke. The Roehampton University Ethics Committee approved the study.. (iii) gender make-up of school. Materials and methods Study population and design A detailed outline of the study design has been reported previously (Coppinger et al. which ranged from mid–high socio-economic backgrounds. Coppinger et al. is the most important factor in the inverse obesity relationship. Finnerty et al. who were aged 10–13 years [mean (SD). pp. As a result of absenteeism. 1997). the findings should not be applied to a British setting where children exhibit different behavioural eating patterns. such as ‘What did you have for breakfast?’ and ‘Did you have any snacks today?’ To determine the frequency of eating. 2003) have shown an inverse relationship between body weight and breakfast consumption. Much of the current research also originates from the USA. To allow for international comparisons. Children were asked to record everything they ate and drank over the 3 days. (2010) found that participants who always ate breakfast were less likely to be obese and exhibit positive health behaviours than those who sometimes did. generally smaller and less structured). and not regular breakfast eating. Statistical analysis Preliminary analysis of the variables using a Kolmogorov– Smirnov test of normality revealed that the meal and snacking pattern data were normally distributed. Height and weight Omron M5-1 Intellisense (Kyoto. and found that meal and snack frequency did not differ by age or BMI group.1 cm. breakfast consumption and BMI. Children aged 9–13 years can reliably report food intake and the 3-day food/drink diary was a valid tool to measure this behaviour (Rockett & Colditz.. 1995). 264 (133 boys.. the permission of the Head teacher was received from each of the participating schools. respectively. a one-stage cluster sampling method was used to select schools and overcome the constraints of time and costs associated with a dispersed population. and this method of choice also helped minimise interference with the school day in the present study.. and all children were asked to remove their shoes and any other heavy outer garments before measurement. These clusters included: (i) type of school. 1995. hence. 315 (162 boys and 153 girls) children were recruited in 2007. Keski-Rahkonen et al. one of the main eating occasions of the day) and ‘snacks’. Breakfast consumption and frequency of eating Dietary intake (including meal frequency and breakfast consumption) was assessed via 3-day food/drink diaries (Friday–Sunday). where the number of eating occasions of each participant was recorded. Redmond. Of the available research from the UK.e. UK).1) years] and in full-time education in three primary and six secondary schools. 2010. 131 girls) children completed all aspects of the study. Japan) weighing scales and a Leicester (Crawlea Medical. an eating frequency chart was created for each participant (using the Microsoft Excel software package. each child gave informed consent. normal weight. UK) freestanding stadiometer were used to measure participants’ height and weight. including portion sizes. (ii) school geographical location. Horsham. (iv) secondary school feeding system (as a result of an associated longitudinal study that was also taking place). Sandercock et al. refer to other eating episodes (i. Sjoberg et al. In brief. 2009. 2010) report instead that a higher meal frequency. Furthermore. Because Gatenby (1997) noted that ‘meals’ are generally described in a colloquial sense (i. 11. USA). 43–49 . Measurements were recorded to the nearest 0. Albertson et al. However. Microsoft Corp. Pan & Cole’s (2007) Microsoft Excel add-in ‘imsgrowth’ package was also used to calculate graded levels of thinness. and (v) school classification.. De Castro (1991) reported greater variation in food intake over the weekend compared to weekdays. 2010). 2009) has reported on weekend eating patterns and the frequency of eating. which was carried out by trained researchers in a private area in the participating schools. the diary contained prompts. drop-out and apparatus-related issues. 25.4 (1. 2012 J Hum Nutr Diet.Eating and breakfast consumption in 9–13-year-olds T. 2003. including loss/incomplete diary comple44 tion. in south-west London. 2002. breakfast consumption and BMI in youth. The present study aimed to address this need by investigating any relationship that may exist between the frequency of eating. In total.. WA. O’Sullivan. Much remains to be learned about any relationship between meal pattern and BMI. The diaries were analysed using dietplan 6 nutritional analysis software (Forestfield Software.e. BMI (kg m–2) and BMI Z-score were then calculated using equations based on UK reference data (Cole et al. Hackett et al. (2009) reported breakfast consumption (ready to eat cereal) to be associated with lower BMI and total and low-density lipoprotein cholesterol levels. and parental consent was obtained before a child’s participation in the study..

76) 0. P < 0. Nine.08]. Chicago. )3).97)] and girls [0.07) )0. pp.1 (2.001). mean (SD) BMI Z-scores for both genders were within the ‘normal’ weight category (Table 1) and an independent-samples t-test found no significant difference between boys [0. eating frequency and breakfast consumption were investigated using 45 17. This difference remained even when physical activity (steps taken per day) and energy intake (kJ day)1) were added as possible covariates. Analysis of the percentage of energy gained from the macronutrients. Frequency of eating The mean (SD) number of eating occasions per day was 4. IL. frequency of eating and BMI. P = 0.09)] than those aged ‡11 years [0.5 (3. 43–49 .31) 6192 (1849) ª 2011 The Authors Journal of Human Nutrition and Dietetics ª 2011 The British Dietetic Association Ltd.001) and vitamin E (t262 = )2. Body mass index Using UK reference data (Cole et al. mean (SD) Group 1 9–10-year-old boys (n = 30) Group 2 11–13-year-old boys (n = 103) Group 3 9–10-year-old girls (n = 42) Group 4 11–13-year-old girls (n = 89) BMI (Z-score).036) (Table 2). P < 0. sugar and saturated fat in the snacks and meals of all participants showed no differences between those that ate breakfast regularly and those who did not. 7% of participants (three boys. t262 = 3. There was no relationship between BMI Z-score and eating frequency (P > 0.. Coppinger et al. 2000). version 17.77. No significant differences were found between the genders but when an analysis was undertaken via age group.78. P = 0. 76% (109 boys. six girls) (BMI International Grade 2). Pearson’s correlations were also used to investigate bivariate relationships between BMI Z-scores. 13% (15 boys. 1).14 (0.001). P = 0.10.001) (Table 2).3 (2. mean (SD) boys) was significantly greater than Group 3 (9–10 year old girls) (Table 1).001]. Multivariable linear regression was used to examine any association between breakfast consumption.91) 6740 (2041) 19. Breakfast consumption Eighty-four percent (n = 223) of the participants ate breakfast every day over the measurement period. group 2: boys aged 11–13 years.65. age and eating frequency and independent samples t-tests were used to examine differences between genders against a range of variables. these children also had higher intakes of iron (t262 = )4.134. energy intake and the different micronutrients.20).98 (0.to 10-year-old boys ate the most often [5. Post hoc comparisons indicated that the mean BMI Z-score for Group 2 (11–13 year old Table 1 Mean body mass index (BMI). 25. Z-score and energy intake per day (SD) BMI (kg m–2).21.47.260 = 3.03). those aged £10 years consumed breakfast more frequently [0. Results Table 1 shows the descriptive characteristics of the participants by age group. Associations between BMI Z-score. mean (SD) Energy intake (kJ day)1). 14 girls) were identified as being underweight (BMI International Grades )1.36 (0. n = 264.30. Further analysis of breakfast consumption revealed that those who ate breakfast every day were less likely to have a mid-morning snack and less likely to miss other meals or snacks throughout the day (Fig.24 (1.6 (1.T. No significant differences were found between the other groups.92 (0.5) amongst all participants and the relationship between age and frequency of eating showed a weak negative correlation (r = )0. P < 0. P = 0. 94 girls) as having a normal weight (BMI International Grade 0). P < 0. t262 = 1. USA) and the results displayed as the mean (SD). A one-way anova investigated the impact of age and gender on BMI Z-scores and found a statistically significant difference in BMI Z-scores for the four groups (F3.8) times] and 11–13 year old boys. the least often [4.05). 1995)..12 (1. the data were also divided into four groups (group 1: boys aged 9–10 years.1 (1.2 (1. calcium (t262 = )4. To allow analysis by age-group. Eating and breakfast consumption in 9–13-year-olds analyses were undertaken accordingly using the spss statistical package. P = 0. 17 girls) as being overweight (BMI International Grade 1) and 4% as obese (five boys. frequency of breakfast consumption.20).. The mean BMI Z-scores for these participants was also significantly lower than irregular breakfast consumers (t262 = 2. group 3: girls aged 9– 10 years and group 4: girls aged 11–13 years) and analysis of variance (anova) tests were used to investigate differences. including BMI Z-score.4) times].7 (1. )2.00) 6803 (2050) 17.86) 0. When international grades were used for comparison (Cole et al.05 (0. Although the energy intake of those who ate breakfast every day was higher than those who did not eat breakfast everyday (t262 = )3.21.021).94) 0.78) 7297 (1753) 19.45 (1. 2012 J Hum Nutr Diet.0 (SPSS Inc.

69) (2.05) and five subjects (two boys. P < 0. Coppinger et al. 43–49 .91 6. Targeting older children. as well as cross-sectional (Timlin et al.260 = 2. P = 0. such as smoking. Post hoc comparisons indicated that the mean (SD) score for the normal weight group [6795 (1983) kJ day)1] was higher than that of the obese group [5121 (1815) kJ day)1].28) (2.02].. multiple linear regression and no significant association was found. 2003). Dietary intake To validate intake. The impact of BMI on total energy intake for the four groups was investigated in accordance with BMI International Grade and a statistically significant difference was found (F3.001 day day day day ommended.Eating and breakfast consumption in 9–13-year-olds Table 2 Results of independent t-tests on body mass index (BMI). iron and vitamin E. P < 0. P = 0. higher serum cholesterol levels. irregular intake of lunch and dinner (Sjoberg et al.f. when specifically looking at the frequency of breakfast consumption and BMI Z-score. P T. However. the 3 day food/drink diary was was cross-validated with a Fruit and Vegetables Screening Measure (Prochaska & Sallis. 2006) continues to warrant support. P < 0.99. 2008). 2008) with a disposable camera..10. stressing the importance of regular breakfast consumption in youth to prevent a heightened risk of obesity (Miech et al. particularly breakfast consumption.16 6. three girls) were randomly selected to take photographs of all their food and drink (Ovaskainen et al. This supports the findings reported elsewhere. insulin resistance. Barton et al. P < 0. aiming to investigate any relationship that may exist between these variables and to contribute to the lack of research that is currently available from the UK. 2008) and longitudinal research (Berkey et al.21.06) 5632 (1916) 6828 (1933) 4.21.47 8. The older groups of boys and girls consumed only 73% and 80% of the EAR respectively. t262 = 2. those that consumed breakfast regularly had significantly lower BMI Z-scores than those who did not. during the transition into adolescence on the importance of regular eating.05 t262 = 3. and assess for reporting error.50) (207) (259) t262 = 2. The relationship between BMI/BMI Z-score and eating frequency showed no association.. Thus. Other work has shown infrequent breakfast eating to be related to negative health and lifestyle factors.22 508 688 (2.18 (1.78. particularly boys. Z-scores. 2012 J Hum Nutr Diet.57 (1. This behaviour should also be monitored because knowledge of long-term (longitudinal) breakfast habits may provide potential behaviour targets for intervention programmes (Alexy et al.001 t262 = 4. available in reviews (Patro & Szajewska. highlighting the need to regularly consume breakfast to promote healthy growth and development. older boys were the least likely to eat regularly and consume breakfast. energy intake and breakfast consumption Variable BMI (kg m–2) Z-score Total energy intake/day (kJ day)1) Total intake Vitamin E Iron Calcium Group Breakfast Not every Every day Breakfast Not every Every day Breakfast Not every Every day Not every Every day Not every Every day n Mean (SD) td.. No significant differences (P > 0. lower dietary induced thermogenesis and poorer Percentage of missed eating occasions 80 70 60 50 40 30 20 10 0 Morning Snack Lunch Afternoon Snack Dinner Breakfast eaten every day Breakfast not eaten every day Percentage Other snacks Eating occasion Figure 1 Percentage of regular and nonregular breakfast consumers who regularly missed another snack or meal over the period of the present study.23) 0.65. All four groups failed to reach the estimated average requirement (EAR) of energy for their age in the UK. breakfast consumption and BMI of 10–13-year-olds.001 t262 = 2.. More frequent breakfast consumers were also found to have higher intakes of calcium. pp. 2003. An independent-samples t-test found a greater total energy intake for boys [6912 (1991) kJ day)1] compared to girls [6368 (1924) kJ day)1.03).43. 2010) and should identify whether there are causal links between breakfast consumption and future chronic disease.. This nonsignificant relationship remained when physical activity (steps taken per day) was added to the model. 25. day 41 223 41 223 41 223 41 223 41 223 0. Discussion The present study examined the frequency of eating. Although the majority of youth in the present study ate frequently (approximately five times a day).001 t262 = 4.20) (2. P < 0. 2004) (r = 0. 2010). may be essential to ensure healthier long-term eating patterns (Timlin et al. P < 0..05) in energy intake were found.. 2005)..27. although the younger boys and girls had total intakes of 89% and 93% of that rec46 ª 2011 The Authors Journal of Human Nutrition and Dietetics ª 2011 The British Dietetic Association Ltd.

B. There are some limitations to the present study. 105. & Kersting. Eldridge. Coppinger et al.... 2005) and crosssectional (Berg-Kelly. source of funding and authorship The authors declare that they have no conflicts of interest. 1–8.A. those aged £10 years consumed breakfast more often than those aged ‡11 years. Nicklas et al. The self-reporting nature of dietary intake may too have played a role. any true relationship between breakfast. R. Unfortunately. TC assisted with the design. YJ assisted in the design and execution of the study. Conflict of interests... 25.L..M. Affenito. 519–528. Thompson. Although this goes against the findings in other observational studies (Skinner et al. The findings from large epidemiological (Affenito et al.. Affenito. studies on dietary habits in free-living populations most often rely on self-report (Livingstone et al. Holschuh. 1985. Although representing only a small significant difference. and body mass index of children as they age through adolescence. although we took a number of steps to try and reduce its effects. Diet. SR assisted in the design of the study and the statistical analysis.. Albertson. (2005) Breakfast consumption by African-American and white adolescent girls correlates positively with calcium and fiber intake and negatively with body mass index. M. Eldridge. Alexy.L. Although issues related to under-reporting cannot be ignored. Prompts were used in the diary to act as reminders for participants and food photographs and foods were cross-validated with a validated fruit and vegetable screening questionnaire. until such data become available. 1999). 1996.. iron deficiency anemia and awareness of being anemic among Saudi school students. It is important to note that an analysis of the percentage of energy gained from the macronutrients. GranthamMcGregor. A. & Barton. with the youngest male participants (9–10 year old boys) eating the most often. 1995. these boys may be placing themselves at risk of eating only at times of considerable hunger.. Public Health Nutr. M. J.. There was also a significant negative correlation between age and frequency of eating. Bauserman. Siega-Riz et al.. R. may be essential to ensure healthier eating patterns. S. B. future research should consider investigating why these boys’ behaviours were different. S. particularly breakfast consumption to these boys. No statistical differences were found between the energy intakes of the different methods used for validation. B. 2003. Because the oldest boys (11–13 year olds) were the least likely to eat regularly and had the lowest breakfast consumption intakes.A. 2005). D. U. there are few prospective studies confirming such relationships (Szajewska & Ruszczynski. 2010) also demonstrate them to have insufficient fruit and vegetable intakes and higher than recommended intakes of saturated fat.. 2004).. 43–49 47 ... S. 18. observational findings do not allow us to evaluate whether low frequency breakfast consumers have a direct causal relationship to becoming overweight/obese over time. Int.A. 109. blood lipids.. Barton. It is also possible that measurement error in the potential confounding variables may have biased associations towards the null (i.H. Berkey et al. Nutr. (2005) The relationship ª 2011 The Authors Journal of Human Nutrition and Dietetics ª 2011 The British Dietetic Association Ltd.T. All authors critically reviewed the manuscript and approved the final version submitted for publication... sugar and saturated fat in the snacks and meals of all participants showed no differences between those that ate breakfast regularly and those who did not. Assoc... particularly breakfast consumption. It could be just as likely that children who were overweight/obese were missing breakfast in an attempt to lose or manage their weight. promoting the importance of regular eating. & Franko. execution.e. 2005. because those who ate breakfast in the present study were also less likely to miss other meals or snacks throughout the day (aside from mid-morning snacks). (2010) Breakfast trends in children and adolescents: frequency and quality. 938–945. JH helped create the database and performed statistical analysis. Assoc. 1998) studies that suggest food habits. Affenito. 2000) that report healthier diet profiles in those who eat breakfast regularly. Food Sci. A. Older boys (11–13 years) ate the least frequently. D. change during maturation implies that such changes may also be a factor among the participants of different ages who were involved in the present study. 1557–1565. Striegel-Moore. Thompson. Eating and breakfast consumption in 9–13-year-olds performance levels at school (Ruxton et al.R. eating frequency and BMI may have been underestimated). J. Diet.G. & Barton. S. The cross-sectional. 53. Furthermore.G. A grant from Roehampton University supported the study. Siega-Riz et al. Thus. Am. (2002) Prevalence of daily breakfast intake. increasing their chances of consuming higher fat foods at these times (Lozano et al. & Shawky.L. N. J. Barton et al. 1998. D. and write up of the manuscript. (2009) The relationship of ready-to-eat cereal consumption to nutrient intake.G. 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