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REVIEW ARTICLE

published: 08 August 2013


HUMAN NEUROSCIENCE doi: 10.3389/fnhum.2013.00425

The effects of breakfast on behavior and academic


performance in children and adolescents
Katie Adolphus*, Clare L. Lawton and Louise Dye
Human Appetite Research Unit, Institute of Psychological Sciences, University of Leeds, Leeds, UK

Edited by: Breakfast consumption is associated with positive outcomes for diet quality, micronutrient
Michael Smith, Northumbria intake, weight status and lifestyle factors. Breakfast has been suggested to positively
University, UK
affect learning in children in terms of behavior, cognitive, and school performance.
Reviewed by:
However, these assertions are largely based on evidence which demonstrates acute
Margaret Anne Defeyter, Northumbria
University, UK effects of breakfast on cognitive performance. Less research which examines the
Wendy Hazel Oddy, Telethon Institute effects of breakfast on the ecologically valid outcomes of academic performance or
for Child Health Research, Australia in-class behavior is available. The literature was searched for articles published between
*Correspondence: 19502013 indexed in Ovid MEDLINE, Pubmed, Web of Science, the Cochrane Library,
Katie Adolphus, Human Appetite
EMBASE databases, and PsychINFO. Thirty-six articles examining the effects of breakfast
Research Unit, Institute of
Psychological Sciences, University on in-class behavior and academic performance in children and adolescents were
Road, University of Leeds, Leeds, included. The effects of breakfast in different populations were considered, including
LS2 9JT, UK undernourished or well-nourished children and adolescents from differing socio-economic
e-mail: pskad@leeds.ac.uk
status (SES) backgrounds. The habitual and acute effects of breakfast and the effects
of school breakfast programs (SBPs) were considered. The evidence indicated a mainly
positive effect of breakfast on on-task behavior in the classroom. There was suggestive
evidence that habitual breakfast (frequency and quality) and SBPs have a positive
effect on childrens academic performance with clearest effects on mathematic and
arithmetic grades in undernourished children. Increased frequency of habitual breakfast
was consistently positively associated with academic performance. Some evidence
suggested that quality of habitual breakfast, in terms of providing a greater variety
of food groups and adequate energy, was positively related to school performance.
However, these associations can be attributed, in part, to confounders such as SES
and to methodological weaknesses such as the subjective nature of the observations of
behavior in class.

Keywords: breakfast, behavior, academic performance, children, adolescents, learning

INTRODUCTION learning in children in terms of behavior, cognitive, and school


Breakfast is widely acknowledged to be the most important meal performance (Hoyland et al., 2009).
of the day. Children who habitually consume breakfast are more The assumptions about the benefit of breakfast for childrens
likely to have favorable nutrient intakes including higher intake learning are largely based on evidence which demonstrates acute
of dietary fiber, total carbohydrate and lower total fat and choles- effects of breakfast on childrens cognitive performance from lab-
terol (Deshmukh-Taskar et al., 2010). Breakfast also makes a oratory based experimental studies. Although the evidence is
large contribution to daily micronutrient intake (Balvin Frantzen quite mixed, studies generally demonstrate that eating breakfast
et al., 2013). Iron, B vitamins (folate, thiamine, riboflavin, niacin, has a positive effect on childrens cognitive performance, partic-
vitamin B6 , and vitamin B12 ) and Vitamin D are approxi- ularly in the domains of memory and attention (Wesnes et al.,
mately 2060% higher in children who regularly eat breakfast 2003, 2012; Widenhorn-Muller et al., 2008; Cooper et al., 2011;
compared with breakfast skippers (Gibson, 2003). Consuming Pivik et al., 2012). Additionally, the positive effects of breakfast are
breakfast can also contribute to maintaining a body mass index more demonstrable in children who are considered undernour-
(BMI) within the normal range. Two systematic reviews report ished, typically defined as one standard deviation below normal
that children and adolescents who habitually consume breakfast height or weight for age using the US National Center for Health
[including ready-to-eat-cereal (RTEC)] have reduced likelihood Statistics (NCHS) reference (Pollitt et al., 1996; Cueto et al.,
of being overweight (Szajewska and Ruszczynski, 2010; de la 1998). More recent evidence compares breakfast meals that dif-
Hunty et al., 2013). Breakfast consumption is also associated fer in Glycaemic Load (GL), Glycaemic Index (GI) or both. This
with other healthy lifestyle factors. Children who do not con- evidence generally suggests that a lower postprandial glycaemic
sume breakfast are more likely to be less physically active and response is beneficial to childrens cognitive performance (Benton
have a lower cardio respiratory fitness level (Sandercock et al., and Jarvis, 2007; Ingwersen et al., 2007; Micha et al., 2011; Cooper
2010). Moreover, there is evidence that breakfast positively affects et al., 2012) however the evidence is equivocal (Brindal et al.,

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Adolphus et al. Breakfast, behavior, and academic performance

2012). Moreover, it remains unclear whether this effect is specif- morning. Nevertheless, breakfast is the most frequently skipped
ically due to GI or GL, or both, or to other effects unrelated to meal. Between 2030% of children and adolescents skip breakfast
glycaemic response. in the developed world (Deshmukh-Taskar et al., 2010; Corder
Studies rarely investigate the acute effects of breakfast on et al., 2011).
behavior in the classroom and there remains a lack of research Despite intense public and scientific interest and a widely
in this area. This may be, in part, attributed to the complicated promoted consensus that breakfast improves concentration and
nature of the measures used to assess behavior in class and the alertness, Hoyland et al. (2009) were only able to identify 45
need to develop standardized, validated, and comparable coding studies on the effects of breakfast on objectively measured cog-
systems to measure behavior. Similarly, few studies examine the nitive performance in the period of 19502008 in their system-
effects of breakfast on tangible academic outcomes such as school atic review. They concluded that breakfast consumption is more
grades or standardized achievement tests relative to cognitive out- beneficial than skipping breakfast to cognitive outcomes, effects
comes. Whilst crude measures of academic performance may not which were more apparent in children who are considered under-
provide the most sensitive indicator of the effects of breakfast, nourished. They did not consider ecologically valid outcomes of
direct measures of academic performance are ecologically valid, behavior (in-class or at school) and academic performance. This
have most relevance to pupils, parents, teachers, and educational article complements the Hoyland et al. (2009) review by consider-
policy makers and as a result may produce most impact. ing the evidence on the effect of breakfast on behavior (in-class or
Cognitive, behavioral, and academic outcomes are not indepen- at school) and academic performance in children and considers
dent. Changes in cognitive performance are likely to be reflected by the methodological challenges in isolating the effects of breakfast
changes in behavior. An increase in attention following breakfast, from other factors. Findings will be discussed dependent on out-
compared with no breakfast, may be reflected by an increase in come measure and study design with effects evaluated based on
on-task behavior during lessons. Similarly, changes in cognitive breakfast manipulation where possible. The effects of breakfast
performance may also impact school performance and academic in different populations will be considered, including children,
outcomes in a cumulative manner. The beneficial effects of eating adolescents who are undernourished or well-nourished and from
breakfast on cognitive performance are expected to be short term differing socio-economic status (SES) backgrounds. The habitual
and specific to the morning on which breakfast is eaten and to and acute effects of breakfast will be considered along with the
selective cognitive functions. These immediate or acute effects effects of school breakfast programs (SBPs).
might translate to benefits in academic performance with habitual
or regular breakfast consumption, but this has not been evaluated METHODS
in most studies. Short term changes in cognitive function during The literature was searched for original articles and reviews
lessons (e.g., memory and attention) may therefore translate, with published between 19502013 on databases: Ovid MEDLINE,
habitual breakfast consumption, to meaningful changes in school Pubmed, Web of Science, the Cochrane Library, EMBASE
performance by an increased ability to attend to and remember databases and PsychINFO. The search was conducted using the
information during lessons. In class behavior also has important key words breakfast or school breakfast combined with chil-
implications for school performance. This is because a prerequi- dren or adolescents combined with behavio$, on-task,
site for academic learning is the ability to stay on task and sustain off-task, concentration, attention, school performance,
attention in class. Greater attention in class and engagement in academic performance, scholastic performance, academic
learning activities (referred to as on-task behavior) are likely achievement, school grades, school achievement, and edu-
to be associated with a more productive learning environment cational achievement using the Boolean operator and. The $
which may impact academic outcomes in the long term. symbol was used for truncation to ensure the search included
Children may be particularly vulnerable to the nutritional all keywords associated with behavior (behavior, behaviour,
effects of breakfast on brain activity and associated cognitive, behavioural, behavioral). Studies are limited to these out-
behavioral, and academic outcomes. Children have a higher brain comes in children and adolescents (<18 years). The reference
glucose metabolism compared with adults. Positron Emission lists of existing reviews and identified articles were examined
Tomography studies indicate that cerebral metabolic rate of glu- individually to supplement the electronic search. The presenta-
cose utilization is approximately twice as high in children aged tion of the results are organized by two main outcomes: In-class
410 years compared with adults. This higher rate of glucose uti- behavior/behavior at school and academic performance with cor-
lization gradually declines from age 10 and usually reaches adult responding summary tables which detail design, sample, break-
levels by the age of 1618 years (Chugani, 1998). Average cere- fast intervention/dietary assessment, assessment of outcomes and
bral blood flow and cerebral oxygen utilization is 1.8 and 1.3 reported results for each article. A total of 36 studies are included.
times higher in children aged 311 years compared with adults, Fourteen studies included behavior measures, seventeen stud-
respectively (Kennedy and Sokoloff, 1957; Chiron et al., 1992). ies included academic performance measures, and five studies
Moreover, the longer overnight fasting period, due to higher examined both behavior and academic performance.
sleep demands during childhood and adolescence compared with
adults, can deplete glycogen stores overnight (Thorleifsdottir RESULTS
et al., 2002). To maintain this higher metabolic rate, a continuous IN-CLASS BEHAVIOR AND BEHAVIOR AT SCHOOL
supply of energy derived from glucose is needed, hence breakfast Nineteen studies employed behavioral measures to examine the
consumption may be vital in providing adequate energy for the effects of breakfast on behavior at school, either by use of

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Adolphus et al. Breakfast, behavior, and academic performance

classroom observations or rating scales usually completed by advantage of breakfast on on-task behavior (Chang et al., 1996;
teachers (Table 1). Four studies included both classroom obser- Benton and Jarvis, 2007; Benton et al., 2007).
vations and rating scales (Kaplan et al., 1986; Milich and Pelham, Benton et al. (2007) observed classroom behavior and reaction
1986; Rosen et al., 1988; Richter et al., 1997). to frustration following three isocaloric breakfast meals of high,
medium or low GL in a sample of young children (mean age: 6
Observations of behavior in the classroom years 10 months) from a school in an economically disadvantaged
Direct measures of classroom behavior were utilized in 11 studies. area. Children spent significantly more time on-task following
Although there are inconsistent findings, the evidence indicated a low GL breakfast meal compared with medium and high GL
a mainly positive effect of breakfast on on-task behavior in the breakfast meals. This effect was specific to the first 10 min of the
classroom in children. Seven of the eleven studies demonstrated observation. Children also displayed fewer signs of frustration
a positive effect of breakfast on on-task behavior. This was appar- during a video game observation, but again, effects were short
ent in children who were either well-nourished, undernourished lived and specific to the initial observation period. No signifi-
and/or from low SES or deprived backgrounds. Two studies car- cant effects were found for distracted behavior. Although meals
ried out in undernourished samples (Chang et al., 1996; Richter aimed to be isocaloric, actual intake across conditions was vari-
et al., 1997) and three studies in children from low SES back- able and the macronutrient content differed between conditions.
grounds (Bro et al., 1994, 1996; Benton et al., 2007) demonstrated Consequently, the difference in classroom behavior may be due to
positive effects on on-task behavior following breakfast. One differences in macronutrient content rather than GL. Four studies
study reported a negative effect of a SBP on behavior in under- failed to find a similar advantage for on-task behavior in chil-
nourished children (Cueto and Chinen, 2008) and three studies dren with Attention Deficit Disorder with hyperactivity (ADD-H)
in children with behavioral problems demonstrated no effect of or behavioral problems (Kaplan et al., 1986; Milich and Pelham,
breakfast composition on behavior (Kaplan et al., 1986; Milich 1986; Wender and Solanto, 1991) or in primary school chil-
and Pelham, 1986; Wender and Solanto, 1991). Most studies dren without behavioral problems (Rosen et al., 1988) following
included small samples of the order of 1030 children which, breakfast meals that differed in sugar content.
although limited in terms of power and generalizability to the Mixed results were reported when comparing the effects of
larger population, are more feasible and appropriate given the breakfast vs. no breakfast in undernourished children. Chang
nature of the data and extensive coding methods required. et al. (1996) examined the effects of breakfast on classroom
behavior in 57 undernourished (< 1 SD weight-for-age of
Intervention studies. Four intervention studies demonstrated a the NCHS reference) and 56 adequately nourished children in
positive effect of SBPs on on-task behavior in undernourished Jamaican rural schools. A significant increase in on-task behav-
and low SES children. Richter et al. (1997) reported a signifi- ior was observed following a 520 Kcal breakfast, which was
cant positive change in behavior from pre to post intervention seen only in the well-equipped school. In the three less well-
in undernourished children aged 8 years. Following a 6-week SBP equipped schools, behavior deteriorated following breakfast with
providing approximately 267 Kcal per day at breakfast, children an observed increase in off-task behavior (talking, movement).
in the intervention group displayed significantly less off-task and The well-equipped school had separate classrooms for each class
out of seat behavior and significantly more class participation and each child had their own desk, an environment probably
(Richter et al., 1997). Concomitant teacher ratings of hyperactiv- more conducive to positive in-class behavior. The deterioration
ity also declined significantly in the intervention group, however of behavior following breakfast in the less well-equipped schools
teachers reported no change in attention. This effect has also been could reflect greater difficulties in accurately observing whether
demonstrated in adolescents. Two studies in small samples of ado- children are on-task or off-task when they do not have their own
lescents aged 1419 years showed an increase in on-task behavior desk or are in overcrowded classrooms. In developed high income
in the classroom following an unstandardized teacher led SBP in countries where school infrastructure is more standardized and
vocational schools in USA (Bro et al., 1994, 1996). More recent where classrooms are not overcrowded, this possibly spurious
evidence failed to show the same benefit in undernourished chil- effect is less likely to occur (Murphy et al., 2011; Ni Mhurchu
dren ( 2 SD height-for-age of the NCHS reference) aged et al., 2013). However, negative effects on behavior have also been
11 years. Cueto and Chinen (2008) observed a reduction in on- reported in UK primary and secondary school children within
task behavior following a 3-year SBP measured using time per day deprived areas following a SBP (Shemilt et al., 2004). Therefore,
spent in the classroom as an indirect proxy measure. The design other factors, including the breakfast club environment, delivery,
of the intervention required teachers to dedicate time to providing and staff engagement with the SBP may have also influenced the
the breakfast mid-morning. This unexpected negative impact on impact of breakfast on behavior, as well as school structure. For
on-task behavior is unlikely to occur when breakfast is delivered example, activities during the breakfast club and general atmo-
before school by non-teaching staff and when direct measures of sphere may promote negative and excitable behavior. Nutritional
classroom behavior are employed. status did not influence the results of Chang et als study, however,
the degree of undernourishment was mild. It is possible that pos-
Acute experimental studies. Seven studies employed a within- itive effects may be more demonstrable in children who are more
subjects acute experimental design to examine the effects of severely undernourished. In addition, an appropriate environ-
breakfast on classroom behavior across the morning. The find- ment in terms of classroom structure and equipment is needed
ings were inconsistent, with three of the seven studies showing an to accurately observe the effects of breakfast.

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Table 1 | Tabulation of studies investigating the effects of breakfast on behavior at school in children and adolescents.

Authors, year Design Sample BF intervention/assessment Assessment of behavior Reported results


of BF
Adolphus et al.

Kaplan et al. RM randomized acute Behavior treatment center Behavior problems: In-class observation, +3060 min No significant difference in
(1986) experimental study. (USA). n = 9 aged 913 years. 1. High sugar BF post ingestion. behavior due to high or low
Double blind. Behavior problems: n = 5 2. Low sugar aspartame Behavior coded: on-task during sugar BF.
ADD-H: n = 4. sweetened BF 30 min observation.
ADD-H group: Good inter-rater reliability.
1. High sugar BF + Conners Teacher Rating Scale
Methylphenidate hyperactivity index.

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2. Low sugar aspartame
sweetened BF +
Methylphenidate
3. High sugar BF + placebo
4. Low sugar aspartame
sweetened BF + placebo
BF of either high or low sugar,
not matched for energy.
Stratified by behavior
problems/ADD-H

Milich and RM randomized acute Behavior treatment center Two conditions: Drink at 0800 h Three observations in two No significant effects of
Pelham (1986) experimental study. (USA). n = 16, male children 1. High sugar: 50 g sugar drink settings. treatment on behavior in both
Double blind. mean age 69 years, 2. Low sugar: 0 g sugar drink + 1. In-class observation via one settings.
diagnosed ADD-H. 175 mg aspartame way mirror. Behavior coded:
on-task, class points, questions

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correct, and questions
attempted for set tasks.
2. Structured recreational
observation (1). Behavior
coded: rule adhering, positive
peer interaction,
noncompliance, negative
verbalization.
3. Structured recreational
observation (2). Behavior
coded: Positive/negative/neutral
interaction.
Good inter-rater reliability.
Conners Teacher Rating Scale
inattention/over-activity and
aggression scales.

(Continued)

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Breakfast, behavior, and academic performance
Table 1 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of behavior Reported results


of BF
Adolphus et al.

Rosen et al. RM acute experimental Two schools (USA). n = 45. Three conditions: Standard BF In-class and free play observation No significant effects of sugar
(1988) study. Double blind. Preschool: N = 30, mean and 113 g drink of differing +30 min post BF. on behavior in both settings.
age: 5 years 4 months. sugar content: 1. Preschool: Free play Significant increase in
Male: 66%, Female: 33% 1. High sugar: 50 g sugar drink + observation. Behavior coded: Conners Teacher Rating Scale
Primary school: n = 15, mean BF (489 Kcal/90.8 g CHO) Fidget, activity change, hyperactivity index in high
age: 7 years 2 months. Male: 2. Low sugar: 6.25 g sugar movement, vocalization, sugar condition compared

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40%, female: 60% drink + BF (314 Kcal/47 g CHO) aggression. with low sugar condition.
Middle-High SES. 3. Control: 0 g sugar drink 2. Primary school. In-class
sweetened with aspartame observation. Behavior coded:
(291 Kcal/41 g CHO) Fidget, on-task.
Standard BF: 198 g oats, 170 g Time sampling. Good inter-rater
whole milk, bread (1 slice), reliability.
1 tsp margarine, 1 tsp grape Conners Teacher Rating Scale
jelly (287 Kcal) 10-item hyperactivity index
Global rating scale completed
by teachers.

Richter et al. SBP evaluation. Pre-post Two primary schools (South Two conditions: Video recorded in-class Significant decrease in
(1997) test design. 6-week Africa). n = 108. 1. SBP: 30 g Cornflakes, 100 ml observation following habituation. off-task and out of seat
intervention. Male: 50%, Female: 50% semi-skimmed milk, banana Behavior coded: on-task, off-task, behavior in SBP group from
Control: n = 55 (267.4 Kcal/1117.8 K) passive-active, positive, or pre- post intervention. No
well-nourished children mean 2. Control: No SBP negative peer interaction, class change in control group.
age SD: 8.3 0.8. participation, out of seat, request Significant increase in activity

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Intervention: n = 53 attention, unclear/out of view. and class participation in SBP
undernourished children Time sampling. group from pre-post
mean age SD: 10.5 1.9. ADD-H Comprehensive Teachers intervention. No change in
Rating Scale 24-item. Teacher control group. Significant
completed four subscales for decline in on-task behavior in
classroom behavior: attention, control group from pre-post
hyperactivity, social skills, and test. No change in SBP
oppositional behavior. group. No significant change
in request attention, negative
peer interaction, and passive
behavior. Hyperactivity
subscale scores declined
significantly in intervention
group from pre-post test.

(Continued)

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Breakfast, behavior, and academic performance
Table 1 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of behavior Reported results


of BF
Adolphus et al.

Chang et al. RM randomized acute Four primary schools Two conditions: In-class observation at Significant school
(1996) experimental study. (Jamaica). n = 113, Male: 1. In-class BF before school: 68 g 09001130 h. Two mock treatment interaction for
50%, Female: 50% bread, 28 g cheese, 227 g classroom situations: active teaching on-task, talks,
Undernourished (< 1 SD chocolate milk (520 Kcal) 1. Active teaching (2 30 min) and gross motor behavior and
weight-for-age NCHS): 2. Low energy control: 68 g 2. Set task (2 30 min) for set task on-task behavior.
n = 57, mean age SD: orange (18 Kcal) Behavior coded: On-task, talking Significant increase in on-task

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9.68 0.42. to peers, gross motor, class behavior and decrease in
Nourished: n = 56, mean participation. gross motor behavior
age SD: 9.18 0.77. Time sampling. Acceptable-good following BF during active
inter-rater reliability. teaching in well-equipped
school. Significant increase in
talking to peers during active
teaching and decrease in
on-task behavior during set
task in poorly equipped
schools following BF. No
significant effects of
nutritional group and
treatment.

Bro et al. (1994) SBP evaluation. Pre-post Vocational secondary school Two conditions: In-class observation conducted by Increase in on-task behavior
test. 20-day intervention. (USA) n = 10 males aged 1. Teacher led in-class SBP teacher. post SBP compared to
1418 years. High rate of Nutritionally balanced Behavior coded: on-task. baseline.

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off-task behavior at baseline. 2. No SBP Time sampling. Good inter-rater
Low SES. reliability.

Bro et al. (1996) SBP evaluation. Pre-post Vocational and learning center Two conditions: In-class observation conducted by Increase in on-task behavior
test. 9-day intervention. (USA): n = 18, aged 1519 1. Teacher led in-class SBP. Fruit teacher in academic and at follow up compared with
years 17 males, 1 female. juice, milk, English muffins, vocational setting. Behavior baseline in both vocational
Low SES. blueberry muffins, bagels, coded: on-task. and academic setting.
cream cheese, eggs, toast, hot Time sampling. Acceptable Decrease in subjective
cakes Inter-rater reliability in both ratings of ability to stay
2. No SBP settings. on-task at follow up. High
Subjective ratings of ability to stay rate of off-task behavior at
on task. baseline.

(Continued)

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Breakfast, behavior, and academic performance
Table 1 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of behavior Reported results


of BF
Adolphus et al.

Benton et al. RM randomized acute Primary school children (UK). Three conditions, 4-week SBP. Two observations. Meal time interaction for
(2007) experimental study. n = 19, Mean age: 6 years, Isocaloric BF at 08150845 h of 1. Video recorded in-class time on-task in first 10 min of
10 months. differing GL observation at 10301100 h class observation.
Low SES school. 1. High GL: Cornflakes, (+135 min post BF) during Significantly more time spent
semi-skimmed milk, sugar, independent quiet work. Time on-task after consuming low
waffle, syrup (305 Kcal/39 GL) sampling. Behavior coded: GL BF compared with med

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2. Medium GL: Scrambled egg, on-task, looking around room, GL BF and high GL BF. No
bread, jam, spread, yoghurt talking to peers, fidgeting, significant effect of BF on
(284 Kcal/14.8 GL) negatively interacting with other behavior. GL of BF
3. Low GL: Ham, cheese, linseed peers, out of seat. negatively predicted
bread, spread (299 Kcal/5.9 GL) 2. Reaction to frustration performance on video game
measured by response to on first test occasion
difficult video game. Behavior (behavior better after low GL
coded: concentrating, fidgeting, BF).
physical signs of frustration,
negative verbal comments.

Cueto and Chinen SBP evaluation. 11 Primary schools (Peru) Two conditions: Behavior coded: Average time/day Reduction in time spent in
(2008) intervention schools, 9 n = 590. 1. Free Mid-morning SBP: BF spent in classroom with teacher classroom indicative of
control schools. Multiple SBP: n = 300, mean age during school break time at as proxy measure for on-task on-task behavior in
and full grade schools. SD: 11.87 1.77. 10001100 h. Milk-like beverage behavior. intervention schools.
3-year intervention. Male: 51.7%, Female: 48.3% and 6 biscuits (600 Kcal/60% Increased time spent in
Control: n = 290 mean age RDA vitamins and minerals recess following SBP.

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SD: 11.87 1.90. 100% RDA for Iron)
Male: 49.7%, Female: 50.3%. 2. Control: No BF/BF at home
6669% 1st grade children
2 SD height-for-age NCHS
reference.

Wender and RM randomized acute Lab based (USA). n = 26. Two conditions. Isocaloric BF and Video recorded playroom No effects of BF on
Solanto (1991) experimental study. Controls: No ADD-H n = 9, drink (226 g) at 0900 h observation at 1000, 1100, 1200, aggression.
Double blind. mean age SD: 6.7 0.7. 1. High sugar: Bread (1 slice), 1300 h (+60, +120, +180 min
ADD-H: n = 17, butter (5 g), and 35 g sugar post BF and +30 min post lunch).
mean age SD: 6.9 0.6. drink (275 Kcals) Behavior coded: Aggression,
2. Low sugar: Bread (2 slices) hitting, kicking throwing.
butter (15 g), and 0 g sugar drink Time sampling. Good periodic
sweetened 175 mg aspartame inter-rater reliability.
or saccharine. (275 Kcals)

(Continued)

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Breakfast, behavior, and academic performance
Table 1 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of behavior Reported results


of BF
Adolphus et al.

Benton and Jarvis RM, randomized acute Primary school children (UK). Mid-morning snack, 1045 h after In-class observation at Size of BF snack interaction
(2007) experimental study. n = 20. Mean age: 9 years 4 self-reported BF: 11151215 h (+30 min post for on-task behavior. Children
months. 1. Muesli bar 25 g (226 Kcal/35 g mid-morning snack). who consumed <150 Kcal BF
Male: 50%, CHO) Behavior coded: on-task, spent significantly more time
Female: 50%. 2. No snack distracted, disruptive, interacting on-task when a snack was
Children classified depending on with teacher, out of chair. eaten. BF snack interaction

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energy content of BF: Categories collapsed into on-task for off-task behavior. Children
1. <150 Kcal (Mean SE: or off-task behavior. consuming <150 Kcal BF
61.2 18.5 Kcal) Time sampling. spent significantly more time
2. 151230 Kcal (Mean SE: off-task when no snack
209.7 8.3 Kcal) consumed compared with
3. >230 Kcal (Mean SE: 151230 Kcal and >230 Kcal
270.3 64.8 Kcal) BF. Children who consumed
<150 Kcal BF spent
significantly less time off-task
when a snack was eaten.

Wahlstrom and SBP evaluation. Primary schools (USA) Two conditions: Interviews with teachers and Teachers perceived positive
Begalle (1999) 6 intervention schools. n = 2901 children age 614 1. Intervention: Free SBP questionnaires completed by impact of SBP on social
3 control schools 3-year years. Proportion of children Unstandardized. Average daily teachers. behavior and readiness to
intervention. eligible for FSM or reduced participation rate: 68.997.5% Behavior assessed: Readiness to learn compared with pre
priced meals: 20.477.3%. 2. Control: No SBP learn and social behavior. intervention. Teacher
Number of discipline referrals. reported increase attention

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and concentration following
SBP. Decrease in discipline
referrals following SBP.

Overby and Cross-sectional survey Four secondary schools Questionnaire, 1 item to measure Self-reported behavior. 4-item Frequent breakfast
Hoigaard (2012) study. (Norway). n = 475, mean age BF. BF intake classified as: questionnaire to measure consumption significantly
(SD) 14.6 0.56, Male: 1. Often: BF >5 days/week disruptive behavior in class. associated with decreased
49.7%, Female: 50.3%. 2. Never/seldom: BF 5 days/per Score range: 420. Higher scores odds of behavior problems
week indicating poorer behavior. Total (AOR: 0.29 95% CI:
scores dichotomized into two 0.150.55) compared with
categories: never/seldom consumption
No behavioral problems: 411 following adjustment for
Behavioral problems: 1220 gender and BMI.

(Continued)

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Breakfast, behavior, and academic performance
Table 1 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of behavior Reported results


of BF
Adolphus et al.

Murphy et al. SBP evaluation. Pre-post Three primary schools (USA) Free SBP. Considered nutritionally Conners Teacher Rating Scale Significantly greater
(1998) test. 4-month intervention. n = 133 mean age SD: balanced including milk, RTEC, hyperactivity index 10-item. decreases in hyperactivity
10.3 1.6 years. bread, muffin, fruit, juice. scores in children who
Male: 44%, Female: 56%. Stratified by SBP participation: increased participation in SBP
Proportion of children eligible 1. Often: 80% attendance post intervention compared
for FSM or reduced priced 2. Sometimes: 2079% with children who had not

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meals: >70%. attendance changed SBP participation.
3. Rarely: <20% attendance

Ni Mhurchu et al. Cluster RCT, stepped Primary schools (New Two conditions: The Strength and Difficulties No significant effect of SBP
(2013) wedge (sequential roll-out Zealand) n = 424 children 1. Free SBP: School run. Questionnaire completed by on behavior vs. control.
of intervention over 1 year aged 513 years. Non-standardized. School teachers. 25 items related to five Proportion of children eating
period). SBP evaluation. 14 Male: 47%, Female: 53%. selected food: Low sugar dimensions: hyperactivity/ BF everyday did not change.
primary schools. 1 year Low SES schools. RTEC, low-fat milk, bread, inattention, emotional symptoms, Decrease in proportion of
intervention. spreads (honey, jam, and conduct problems, peer children eating BF at home,
margarine), chocolate flavored relationship problems, and increase in proportion of
milk powder, and sugar pro-social behavior. children eating BF at school.
2. Control: No SBP PISA Student Engagement
Questionnaire to measure
self-report belonging and
relationships with other students.

Murphy et al. Clustered RCT with a Primary schools (UK). Two conditions: The Strength and Difficulties No difference in classroom

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(2011) repeated cross-sectional n = 4350 baseline, n = 4472 1. Intervention: SBP, Non- sugar Questionnaire completed by behavior in intervention vs.
design. 56 control schools, follow-up aged 911 years. coated RTEC, milk, bread, fruit. teachers. Classroom behavior control schools.
55 intervention schools. Teacher completed behavior Considered nutritionally rated. Hyperactivity/inattention
SBP evaluation. 1 year assessment on sub-sample balanced scale used as potential
intervention. of 5 pupils in 2 year groups. 2. Control: No SBP, wait listed relationship with on-task behavior.
Control: n = 473 Intervention: control
n = 485.

(Continued)

August 2013 | Volume 7 | Article 425 | 9


Breakfast, behavior, and academic performance
Table 1 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of behavior Reported results


of BF
Adolphus et al.

Shemilt et al. Clustered RCT with Primary and secondary Two conditions: The Strength and Difficulties Significantly higher proportion
(2004) observational analysis due schools (UK) n = 6042 1. Funding for free SBP Questionnaire. Teachers of primary school BF club
to contamination between Control: n = 2369, mean 2. Control: No funding for SBP completed questionnaire for attendees had
treatment arms. 3-month age SD: 10.13 3.93. For analysis of behavior, children primary school children. borderline/abnormal conduct
follow up (CT testing Male: 52%, Female: 48%. classified as: Self-report version for secondary and total difficulties scores
outcomes) and 1 year Intervention: n = 3673, mean 1. Non-attendees: Never attended school children. 25-item related to compared to non-attendees

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follow up (behavioral age SD: 9.59 2.96 Male: 2. Attendees: Attended at least five dimensions: following adjustment for
outcomes). 49%, Female: 51%. once hyperactivity/inattention, confounders. Significantly
emotional symptoms, conduct higher proportion of
problems, peer relationship secondary school BF club
problems, and pro-social behavior. attendees had
Score dichotomized into normal or borderline/abnormal
borderline/abnormal for each pro-social scores compared
dimension. with non-attendees following
adjustment for confounders.
Adjusted for school type,
gender, FSM status.

OSullivan et al. Cross-sectional survey School children (Australia) Three-day food diary. BF intake Child Behavior Checklist Increase in BF quality
(2009) study. The Western n = 836, aged 1315 years, classified based on 5 core food completed by parents (higher associated with decrease in
Australian Pregnancy Male: 50.7% Female: 49.3% groups defined by AGHE: Bread score indicates poor behavior), internalizing behavior score
cohort study. Majority well-nourished, and cereals, vegetables, fruit, 118-item. and a decrease in
5.7% underweight. dairy, and dairy alternatives, meat, Internalizing behavior: Somatic externalizing behavior scores.

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and meat alternatives. complaints, withdrawal, Increase in BF quality
1. No food or drink/water only anxious/depressed associated with decrease in
2. Non nutritious food and drink Externalizing behavior: total child behavior score.
3. Food from 1 AGHE core food Aggression, delinquency Stepwise decrease in total
group Total behavior: Internalizing score with increasing
4. Food from 2 AGHE core food subscale, externalizing subscale, breakfast quality. Adjusted
group social thought, and attention for: PA, sedentary behavior,
5. Food from 3 AGHE core food problems. weight status, family income,
group maternal education, maternal
age of conception, family
structure, family functioning.

(Continued)

August 2013 | Volume 7 | Article 425 | 10


Breakfast, behavior, and academic performance
Table 1 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of behavior Reported results


of BF
Adolphus et al.

Miller et al. (2012) Prospective cohort study. Preschool- primary school Parental questionnaire, 1 item to Internalizing and externalizing No significant association
Part of ECLS-K national children (USA) n = 21400 at assess family BF frequency. BF subscales of the Social Rating between frequency of family
study. Data collection in baseline, n = 9700 at final classified as frequency/week Scale adapted from Social Skills BF and behavior. Fixed
five waves: 1999 follow up, aged 515 years (07) Rating System. effects model results used as
(preschool), 2000 (grade 1), (mean 6.09 years) Externalizing subscale behavior provides most unbiased
2002 (grade 3), 2004 Male: 51%, Female: 49%. coded: arguing, fighting, angry, estimates: account for all

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(grade 5), 2007 (grade 8). impulsivity, disturbed activities, controls and eliminates
talked during quiet study. between-subject variation.
Internalizing subscale behavior Extensive controls: Gender,
coded: anxious, lonely, sad, low ethnicity, family SES, parental
self-esteem. education, family income,
Teachers rated behavior until parental job prestige, family
grade 5. Children completed structure, area of residence,
scales at grade 8. Acceptable to language, maternal
good reliability on both scales. employment during
preschool, birth weight,
teaching quality, school
quality, region of residence,
parental working hours,
single parent family.

ADD-H, attention deficit disorder-hyperactivity; AGHE, australian guide to health eating; BMI, body mass index; BF, breakfast; CHO, carbohydrate; CT, cognitive testing; ECLS-K, early childhood longitudinal study
kindergarten cohort; FSM, free school meals; GI, glycaemic index; GL, glycaemic load; IG, independent groups; Kcal, kilocalorie; NCHS, national center for health statistics; PA, physical activity; PISA, programme

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for international student assessment; RCT, randomized control trial; RDA, recommended daily allowance; RM, repeated measures; RTEC, ready to eat cereal; SBP, school breakfast program; SD, standard deviation;
SES, socio-economic status.

August 2013 | Volume 7 | Article 425 | 11


Breakfast, behavior, and academic performance
Adolphus et al. Breakfast, behavior, and academic performance

One study examined the effects of breakfast size with or inattention, emotional symptoms, conduct and peer relation-
without a mid-morning snack (Benton and Jarvis, 2007). The ship problems, and pro-social behavior in children. However,
results indicated that children who consumed a small breakfast in both trials, SBP attendance was low and variable, limiting
(<150 Kcal) spent significantly more time on-task when a mid- the potential impact on behavior. The barriers to participation
morning snack was also eaten. This effect was not evident in chil- in SBPs include a lack of parental support, a lack of teaching
dren who consumed more energy at breakfast (151230 Kcal and support, social stigma, busy morning schedules, transport issues
>230 Kcal). Correspondingly, children who consumed <150 Kcal preventing children from getting to school early and breakfast
at breakfast spent significantly more time off-task when no snack clubs causing children to arrive late to the first lesson (Reddan
was eaten compared with children who consumed more energy et al., 2002; McDonnell et al., 2004; Greves et al., 2007; Lambert
at breakfast. This suggests a mid-morning snack is only beneficial et al., 2007).Furthermore, the proportion of children eating
for children who have skipped or eaten very little for breakfast and breakfast everyday remained unchanged whilst the proportion
corrects the energy deficiency. of children eating breakfast at home decreased, suggestive of a
shift in consumption from at-home to at-school, rather than a
Rating scales and questionnaires change/increase in consumption. This may account for the lack of
Twelve studies utilized teacher completed rating scales to assess observed effects on behavior. Shemilt et al. (2004) indicated a neg-
childrens behavior at school following breakfast. These studies ative impact of a SBP on behavior in both primary and secondary
usually employed global scales to assess a range of behavioral school children within deprived areas. Although this study aimed
domains including: attention, disruptive behavior, hyperactivity, to employ a RCT design, contamination between treatment arms
pro-social behavior, and aggression. The majority used standard- necessitated a longitudinal observational analysis of behavioral
ized, established measures of behavior comparable across studies. outcomes and SBP attendance, rather than the planned inten-
Measures included the Strength and Difficulties Questionnaire tion to treat analysis. Results at 1 year follow up indicated that
(SDQ), Social Skills Rating System (SSRS), Child Behavior children who attended the breakfast club had a higher incidence
Checklist (CBCL) Conners Teacher Rating Scale (CTRS), and of borderline or abnormal conduct, pro-social, and total difficul-
The Attention Deficit DisorderHyperactivity Comprehensive ties compared to children who did not attend the breakfast club
Teachers Rating Scale (ACTeRS). Of the 12 studies that utilized (Shemilt et al., 2004). Teachers also indicated that children were
rating scales and questionnaires, only two studies used unstan- more energetic, less well-behaved and were difficult to control in
dardized questionnaires and interviews with teachers to measure the classroom as a result of attending the breakfast club. Parallel
behavior (Wahlstrom and Begalle, 1999; Overby and Hoigaard, qualitative data from teachers, breakfast club staff and researchers
2012). Six of the twelve studies demonstrated a positive effect of who observed the breakfast club suggested that childrens behav-
breakfast on behavior at school, which was mainly hyperactivity ior deteriorated during the breakfast club as a result of inadequate
and disruptive behavior. supervision and training, and a lack of teaching staff who seemed
to be regarded with more authority by children. Observations
Intervention studies. Six intervention studies reported mixed of the breakfast club indicated behavior was often boisterous or
evidence for the effects of SBPs on behavior at school. Two stud- disruptive and there was a general lively atmosphere. This sug-
ies in low SES and undernourished children aged 810 years gests that factors associated with the delivery of the SBP had more
reported beneficial effects on hyperactivity (Richter et al., 1997; impact on behavioral outcomes than the subtle nutritional effects
Murphy et al., 1998). In a longitudinal analysis of a 4-month of breakfast in this study. In addition, this study epitomizes the
SBP, Murphy et al. (1998) found significantly greater decreases difficulties in isolating the independent effects of breakfast.
in CTRS hyperactivity scores in children who increased partici-
pation in the SBP compared with children whose participation Acute experimental studies. Three acute experimental studies
was unchanged. Similarly, results from a 6-week SBP in under- examined the effects of breakfast meals that differed in sugar
nourished children indicated a significant decline in ACTeRS content on CTRS hyperactivity, inattention/over-activity and
hyperactivity scores following the SBP, but no change in attention, aggression subscales. Both Milich and Pelham (1986) and Kaplan
social skills and oppositional behavior during lessons (Richter et al. (1986) showed no effect of the sugar content of breakfast
et al., 1997). Wahlstrom and Begalle (1999) reported an increase and behavior in children with ADD-H or behavioral problems.
in social behavior and readiness to learn from interviews with However, Rosen et al. (1988) observed a small significant increase
teachers following a 3-year SBP. Their results also indicated a in hyperactivity scores following a breakfast with high sugar
decrease in overall discipline referrals following the SBP. Whilst content compared with low sugar in children without behavior
this evidence indicates an apparent benefit of SBPs on school problems (Rosen et al., 1988).
behavior, methodological shortcomings, including a lack of ran-
domization and the inclusion of an appropriate control group, Cross-sectional studies. Two cross-sectional studies in well-
cannot preclude the effects of confounding factors. nourished adolescent populations reported a significant asso-
Three recent robust randomized control trials (RCT) that ciation between habitual breakfast consumption and behavior.
address the above inadequacies failed to find a similar benefit for Overby and Hoigaard (2012) found that frequency of break-
school behavior measured by the SDQ following a 1 year inter- fast was significantly associated with less self-reported disruptive
vention. Both Ni Mhurchu et al. (2013) and Murphy et al. (2011) behavior during lessons in adolescents (mean age 14.6 years).
reported no significant effects of a 1 year SBP on hyperactivity, Adolescents who habitually consumed breakfast (>5 days/per

Frontiers in Human Neuroscience www.frontiersin.org August 2013 | Volume 7 | Article 425 | 12


Adolphus et al. Breakfast, behavior, and academic performance

week) had significantly reduced likelihood of disruptive behavior only (Rahmani et al., 2011). Although it was not clear if the sam-
[Odds Ratio (OR): 0.29, 95% CI: 0.150.55] compared with those ple included undernourished children, the effect coincided with
who ate breakfast less frequently (5 times per week). A simi- a significant increase in weight of the girls following the inter-
lar association was also evident between breakfast quality based vention in schools which received the intervention compared to
on the number of food groups within the breakfast meal and control schools. Supportive evidence from Kleinman et al. (2002)
CBCL scores (higher score indicates poor behavior) in adolescents found that following a 6-month SBP, children who had improved
(OSullivan et al., 2009). Higher breakfast quality scores were their nutritional status from at risk (energy and/or >2 nutrients
most strongly associated with lower CBLC externalizing behavior <50% RDA) to adequate significantly increased their mathe-
scores (which indicates aggression and delinquency). The results matics grades. Murphy et al. (1998) reported that following a
indicated a stepwise decrease in total scores on the CBCL with 4-month SBP, children who increased participation were signifi-
increasing breakfast quality, indicative of a possible dose-response cantly more likely to increase their mathematics grades compared
relationship. to those who had decreased or maintained participation.

Prospective cohort studies. Although there is some associative Cross-sectional studies. Seven cross-sectional studies demon-
evidence of a relationship between habitual breakfast consump- strated a consistent positive association between habitual break-
tion and behavior in adolescents, the same relationship was not fast and school grades in adolescents.
apparent in a well-controlled prospective cohort study. Miller Frequency of breakfast consumption was associated with
et al. (2012) reported no association between frequency of break- school performance in five studies. Breakfast skipping (eating
fast and negative behavior (e.g., arguing, fighting, angry, and breakfast <5 days/week) was associated with lower average annual
disruptive) in 21,400 school children aged 515 years following school grades in a sample of 605 Dutch adolescents aged 1118
a 10 years follow up and adjustment for extensive confounders. years who were in higher educational streams (Boschloo et al.,
2012). This association was evident in both sexes and indepen-
ACADEMIC PERFORMANCE dent of age. Additionally, breakfast skipping was associated with
Twenty-two studies employed academic performance measures more self-reported attention problems, which partially mediated
to investigate the effects of breakfast on academic outcomes this relationship. A larger cohort of nearly 6500 Korean adoles-
(Table 2). The academic performance outcomes employed by cents of similar age range (1017 years) demonstrated a similar
studies included either school grades or standardized achieve- association across all ages. However, the association was stronger
ment tests. Twenty-one studies demonstrated that habitual break- in younger children (1011 and 1314 years) than older chil-
fast (frequency and quality) and SBPs have a positive effect on dren (1617 years) (Kim et al., 2003). Effects were seen in both
children and adolescents academic performance. genders, except for in 1011 year olds, where the significant asso-
ciation between regular breakfast intake and school performance
Average school grades was only apparent in boys.
Ten studies examined the effects of breakfast on average school This association is also evident in undernourished adolescents
grades. The majority produced a composite score from school (Gajre et al., 2008). Gajre et al. (2008) demonstrated that eat-
reported grades across a range of subjects, usually considered ing breakfast >4 days/week significantly predicted total average
core subjects. Two studies relied on self-reported school grades grades in a sample of children aged 1113 years, a third of whom
(Lien, 2007) or self-reported subjective ratings of school perfor- were undernourished. Analysis of individual subject domains
mance (So, 2013). Seven of the ten studies were in 1218 year olds, indicated that regular breakfast eaters had significantly higher
reflecting the schooling system in which grading is more common grades for science and English, but not mathematics compared
in older pupils. Only three studies were carried out in primary to children who never ate breakfast (Gajre et al., 2008).
school children aged 711 years (Murphy et al., 1998; Kleinman Lien (2007) demonstrated, in a large sample of adolescents
et al., 2002; Rahmani et al., 2011). One study included children aged 1516 years, that those who never ate breakfast were twice
of low SES (Murphy et al., 1998) and two studies included under- as likely to have lower self-reported school grades compared
nourished children (Kleinman et al., 2002; Gajre et al., 2008). All with those who consumed breakfast every day (7 days/week).
10 studies identified demonstrated that habitual breakfast (fre- This finding was consistent in boys and girls. Moreover, the
quency and quality) and SBPs have a positive effect on children odds of having lower self-reported school grades decreased with
and adolescents school performance, with three studies observ- successive quintiles of breakfast eating frequency suggestive of
ing clearest effects on mathematics grades (Murphy et al., 1998; a dose-response relationship. Recent evidence from an inter-
Kleinman et al., 2002; Morales et al., 2008). net based study demonstrated a similar relationship between
habitual breakfast and self-rated academic performance in over
Intervention studies. Three intervention studies demonstrated 75,500 adolescents aged 1218 years (So, 2013). Regular break-
positive effects of SBPs on school grades, particularly mathe- fast eaters (7 days/week) had increased likelihood of rating their
matics grades in both well-nourished, undernourished and low school performance as higher compared with breakfast skippers
SES children aged 710 years. Effects were demonstrable after (0 day/week).
an intervention period of 36 months. A significant increase in Two studies demonstrated a consistent association between
school grades was apparent following an intervention providing breakfast composition derived from energy and food groups pro-
250 ml 2.5% fat milk at breakfast, which was apparent in girls vided and school grades in adolescents aged 1217 years. Morales

Frontiers in Human Neuroscience www.frontiersin.org August 2013 | Volume 7 | Article 425 | 13


Table 2 | Tabulation of studies investigating the effects of breakfast on academic performance in children and adolescents.

Authors, year Design Sample BF intervention/assessment Assessment of school Reported results


of BF performance
Adolphus et al.

Lien (2007) Cross-sectional survey School children (Norway) Questionnaire, 1-item to assess Self-reported most recent grade Increased odds of having low
study. n = 7305 aged 1516 years. BF frequency. BF intake classified for: school grades (3) in children
Male: 49.4%, Female: 50.6%. as: 1. Mathematics who seldom/never ate BF
1. Seldom/never 2. Norwegian compared with everyday
2. 12 days/week 3. English consumption in boys and girls
3. 34 days/week 4. Social Science (AOR: 2.0, 95% CI: 1.33.1

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4. 56 days/week Grade scale: 1 (lowest) to 6 and AOR: 2.0 95% CI:
5. Everyday (highest). 1.33.01, respectively).
Total average grade calculated Adjusted for: parental
and dichotomized as: 3 or >3. education, family structure,
immigrant status, smoking,
dieting, soft drink
consumption.

So (2013) Cross-sectional survey School children (Korea) Internet questionnaire, 1-item to Self-reported academic BF eaters (7 days/week) had
study. Korea Youth Risk n = 75643 mean age SD: assess BF frequency. BF performance rating for previous increased likelihood of rating
Behavior Web-based 15.10 1.75. classified as frequency/week 12 months: higher school performance
survey. Male: 51%, Female: 49%. (07) 1. Very high compared with BF skippers
2. High (0 day/week). AOR males: 1.7,
3. Average 95% CI: 1.571.83; AOR
4. Low females: 1.92, 95% CI:
5. Very low 1.762.97. Adjusted for: age,
Dichotomized into two groups: BMI, smoking, alcohol,

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1. <Average academic parental education, family
performance SES, PA (vigorous and
2. Average academic moderate), muscular
performance strength, mental stress.

Murphy et al. SBP evaluation. Pre-post Three primary schools (USA) Free SBP. Considered nutritionally School reported grades for: Higher mathematics grades
(1998) test. 4-month intervention. n = 133 mean age SD balanced including milk, RTEC, 1. Mathematics post intervention in children
10.3 1.6 years. bread, muffin, fruit, juice. 2. Reading who regularly participate in
Male: 44%, Female: 56%. Stratified by SBP participation: 3. Science SBP compared to those who
Proportion of children eligible 1. Often: 80% attendance 4. Social studies rarely or sometimes
for FSM or reduced priced 2. Sometimes: 2079% Letter grade converted into participate. Children who
meals: >70%. attendance numeric value: A = 4, B = 3, increased their SBP
3. Rarely: <20% attendance C = 2, D = 1, F = 0. participation were
significantly more likely to
increase mathematics grades
compared to those who had
decreased or unchanged
participation. No effects of
SBP on other grades.

(Continued)

August 2013 | Volume 7 | Article 425 | 14


Breakfast, behavior, and academic performance
Table 2 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of school Reported results


of BF performance
Adolphus et al.

Kleinman et al. SBP evaluation. Pre-post Primary schools (USA) n = 97 Two conditions, SBP. School grades obtained from Significant increase in
(2002) test. 6-month intervention. aged 912 years. 1. Free SBP for 6 months school records: mathematics grades in
Nutritionally at risk (energy 2. No SBP 1. Mathematics children who improved
and/or >2 nutrients <50% 2. Reading nutritionally status from at
RDA): n = 29. 3. Science risk to adequate post
Adequate: n = 68. 4. Social Studies intervention.
Letter grade converted into

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numeric value: A = 4, B = 3,
C = 2, D = 1, F = 0.

Rahmani et al. SBP outcome evaluation, Four primary schools (Iran) Two conditions: Average grade point. Girls had significantly higher
(2011) IG. 2 intervention schools, n = 469 1. School feeding program: 250 ml average grade point following
2 control schools. 3-month Male: 49% mean age SD: 2.5% fat milk at 0930 h intervention compared with
intervention. 7.9 0.8 years. 2. Control: No milk control. Girls were
Female: 51%, mean age significantly higher in weight
SD: 7.5 0.9 years. Medium following intervention
SES. compared with control.

Gajre et al. (2008) Cross-sectional survey School children (India) Questionnaire to assess BF End of year grades for: Regular BF group had
study. n = 379 aged 1113 years. eating frequency and type. BF 1. Mathematics significantly higher marks for
Male: 55% defined as first eating occasion 2. Sciences science, English and total
Female: 45% during the morning before school. 3. English grade compared to no BF
Underweight: 20.8% BF intake classified as: Total average grade and individual group.

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Stunted: 38.5% 1. Regular: >4 days/week subject grades used in analysis. Regular BF significantly
NCHS reference. 2. Irregular: Skipping BF 23 predicted total average grade.
days/week Regular BF and education of
3. Never mother predicted English
Composition of breakfast not grades. Regular breakfast,
reported type of family and height for
age significantly predicted
science grades. No
association between BF and
mathematics grades.

(Continued)

August 2013 | Volume 7 | Article 425 | 15


Breakfast, behavior, and academic performance
Table 2 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of school Reported results


of BF performance
Adolphus et al.

Morales et al. Cross-sectional survey School children (Spain) Seven-day food diary (Mon-Sun) Average end of course grades: Full and good quality BF
(2008) study. n = 467 aged 1217 years. and FFQ. BF intake classified as: 1. Language groups associated with
Male: 42%, Female:58%. 1. Full BF: >25% of TE, includes 2. Mathematics higher total, mathematics,
4 foods groups of dairy, 3. Chemistry chemistry, and social science
cereals, fruit, fat 4. Biology grades compared with no BF.
2. Good quality: 3 food groups of 5. Social Sciences Physical education, biology,

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dairy, cereals, and fruit 6. Physical education and languages grades were
3. Better options: Missing one Total average grade calculated. highest in no BF group
food group compared with full and food
4. Poor quality: Missing two food quality BF groups.
groups
5. No BF

Boschloo et al. Cross-sectional survey School children (Netherlands) Questionnaire, 1-item to assess Average end of year school BF skipping significantly
(2012) study. n = 605 aged 1118 years. BF frequency on school days. BF grades: associated with lower school
Male: 44%, Female: 56%. classified as: 1. Dutch performance and more
All children in advanced 1. BF eaters: 5 days/week 2. Mathematics self-reported attention
educational tracks in 2. BF skippers: <5 days/week 3. English as a foreign language problems. Attention problems
secondary schools. Grade range: 1(very bad) to 10 partially mediated the
(outstanding) relationship between BF
Attention problems: Attention skipping and school
Problems Scale from the Dutch performance. Adjusted for:
Youth Self Report. age, sex, educational track,

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parental education.

Kim et al. (2003) Cross-sectional survey School children (Korea) FFQ and dietary behavior Average grade from last school Regular BF associated with
study. n = 6463 aged 1011, 1314, questionnaire. BF intake classified semester. Scores range from 15 higher average grade in 1011
1617 years. as: obtained from school records years old boys, higher
Male: 53%, Female: 47%. 1. Regular BF 1. Korean average grade in 1314 years
2. No regular BF 2. Mathematics old boys and girls and higher
3. Social Studies average grade 1617 years
4. Science old boys and girls. Adjusted
5. Physical education for: parental education,
6. Music physical fitness, physical
7. Art status.
8. Practical course
9. Ethics
10. English (grade 8 and 11)

(Continued)

August 2013 | Volume 7 | Article 425 | 16


Breakfast, behavior, and academic performance
Table 2 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of school Reported results


of BF performance
Adolphus et al.

Herrero Lozano Cross-sectional survey School children (Spain) Recall BF of previous day (1 day Average end of year grade. Significantly higher average
and Fillat study. n = 141 aged 1213 years. only). BF intake classified as: grades obtained in good
Ballesteros Male: 49.6%, Female: 50.4%. 1. Good quality: 3 food groups of quality BF groups compared
(2006) dairy, cereals and fruit with poor quality. Average
2. Improvable quality: Missing grade increased when good
one of the food groups quality snack was eaten in

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3. Insufficient quality: Missing poor and insufficient BF
two food groups quality groups.
4. Poor quality: No BF
Contribution of a mid-morning
snack to BF considered

Cueto and Chinen SBP evaluation. 11 Primary schools (Peru) Two conditions: Unstandardized tests developed Higher arithmetic and reading
(2008) intervention schools, 9 n = 590. 1. Free Mid-morning SBP: BF to account for variability in scores in multiple grade
control schools. Multiple SBP: n = 300, mean age during school break time at curriculum: intervention schools
and full grade schools. SD: 11.87 1.77. 10001100 h. Milk-like beverage 1. Arithmetic compared to control post
3-year intervention. Male: 51.7%, Female: 48.3% and 6 biscuits (600 Kcal/60% 2. Reading comprehension intervention. No significant
Control: n = 290 mean age RDA vitamins and minerals effect of SBP in full grade
SD: 11.87 1.90. 100% RDA for iron) schools.
Male: 49.7%, Female: 50.3% 2. Control: No BF/BF at home
6669% 1st grade children
2 SD height-for-age NCHS.

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Acham et al. Cross-sectional survey School children (Uganda) Questionnaire, 1-item to assess Unstandardized tests: Developed Boys who had consumed BF
(2012) study. n = 645 aged 915 years. BF frequency. to account for variability in school and mid-day meal were
Male: 46%, Female: 54% BF intake classified as: environment. significantly more likely to
Underweight: 13% 1. BF 1. English score 120 than those who
Stunted: 8.7%. 2. BF and/or mid-day meal 2. Mathematics only had one meal (OR: 1.99
3. No BF or mid-day meal 3. Life Skills 95% CI: 1.03.9). No
4. Oral comprehension association between BF
Maximum score of 400. Cut-off of alone and test scores.
<120 used to define poor Adjusted for household size,
performance. mothers education, land
68.4% scored <120. quantity owned, school
attendance, gender head of
household, feeding habits,
age, household wealth.

(Continued)

August 2013 | Volume 7 | Article 425 | 17


Breakfast, behavior, and academic performance
Table 2 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of school Reported results


of BF performance
Adolphus et al.

Powell et al. SBP evaluation. RCT. 1 16 Primary schools. (Jamaica) Two conditions: The Wide Range Achievement Significant positive effect of
(1998) school year intervention. n = 810 children aged 711 1. Intervention: Free SBP. Cheese Test: BF on Arithmetic. Grade
years. sandwich/spiced bun and 1. Reading Treatment interaction
Undernourished (< 1 SD cheese, flavored milk 2. Spelling indicated the positive effect
weight-for-age NCHS): 405 (576703 Kcal/27.1 g 3. Arithmetic on arithmetic scores was
Nourished: 405. PRO). Served before school mainly demonstrated in

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2. Control: orange (18 Kcal/0.4 g younger children. No effects
PRO) of BF on spelling and reading.
No differential effects by
nutritional group.

Simeon (1998) SBP evaluation. 1 school School based (Jamaica) Three condition. BF at 0900 h. 1 The Wide Range Achievement Syrup drink and no BF groups
Study 1 semester intervention. n = 115.1213 years school semester intervention. Test: combined to form one control
Rural schools, low ability 1. School BF: 100 ml milk 1. Spelling group as no significant
children, low attendance at (130 Kcal), cake (250 Kcal), or 2. Arithmetic differences found on all
school meat filled pasty (599 Kcal) 3. Reading (not used in analysis) outcomes. Children receiving
Undernourished: 50%. 2. Syrup drink (31 Kcal) school BF performed better
3. No BF on arithmetic test relative to
control group post
intervention.

Wahlstrom and SBP evaluation. 6 Primary schools (USA) Two conditions: School achievement tests, Within school effects
Begalle (1999) intervention schools, 3 n = 2901 children age 614 1. Intervention: Free SBP Incomparable across schools. (pre-post intervention) show

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control schools. 3-year years. Proportion of children Unstandardized. Average daily 1. Mathematics general increase in scores for
intervention. eligible for FSM or reduced participation rate: 68.997.5% 2. Reading reading and mathematics.
priced meals: 20.477.3% 2. Control: No SBP

Jacoby et al. SBP evaluation. RCT. 10 Primary school (Peru) Two conditions, SBP. Achievement test for: No effects of SBP on any
(1996) 1 month intervention. n = 352. 1. Intervention: SBP: 600 Kcal, 1. Reading comprehension achievement tests.
Intervention: n = 201, mean 60% RDA various vitamins and 2. Vocabulary Significant weight
age SD: 136.2 18 months minerals and 100% RDA iron 3. Mathematics treatment interaction children
Male: 46%, Female: 54% 2. Control: No SBP in intervention schools of
Control: n = 151, mean age higher weight increase
SD: 138.9 20 months. vocabulary scores.
Male:53%, Female 47%
Normal weight and
underweight and stunted
children.

(Continued)

August 2013 | Volume 7 | Article 425 | 18


Breakfast, behavior, and academic performance
Table 2 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of school Reported results


of BF performance
Adolphus et al.

Meyers et al. SBP evaluation. pre-post 16 Primary schools (USA) SBP. Stratified by SBP The Comprehension Test of Basic Lower total scores at
(1989) test. 3-month intervention. n = 1023 children aged 812 participation Skills. baseline in non-attendees.
(grades 36) 1. Non attendees: <60% 1. Language Greater increase in total and
Male: 51%, Female: 49% attendance 2. Reading language scores in attendees
Low income. 2. Attendees: 60% attendance 3. Mathematics compared with
non-attendees. SBP

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attendance positively
associated with total scores
at follow up.

Ni Mhurchu et al. Cluster RCT, stepped Primary schools (New Two conditions: Standardized school achievement No significant effects on
(2013) wedge (sequential roll-out Zealand) n = 424 school 1. Free SBP: Non-standardized. tests: achievement tests, self-report
of intervention over 1 year children aged 513 years. School selected food: Low 1. Literacy reading ability and
period). SBP evaluation. 14 Male: 47%, Female: 53%. sugar RTEC, low-fat milk, 2. Numeracy attendance. Proportion of
primary schools. 1 year Low SES schools. bread, spreads (honey, jam, Self-report assessment of reading children eating BF everyday
intervention. margarine), chocolate flavored ability using questionnaire. Scores did not change. Decrease in
milk powder, and sugar from 1 (not very well) to 5 (very proportion of children eating
2. Control: No SBP well). BF at home, increase in
proportion of children eating
BF at school.

Edwards et al. Cross-sectional survey School children (USA) Adapted questions from Youth MAP tests. Standardized Higher mean mathematics
(2011) study. n = 800 aged 1113 years. Risk Behavior Surveillance survey. computer tests for MAP scores associated with

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n = 694 complete data on BF intake classified as 1. Mathematics eating BF 5 days/week
gender 1. BF 5 days/week 2. Reading compared with <5
Male: 48%, Female: 52% 2. BF < 5 days/week days/week. Regression
13.5% eligible for FSM. analysis indicated BF intake
was significantly associated
with mean MAP
mathematics scores. No
association between BF and
MAP reading scores:
Adjusted for: FSM status.

(Continued)

August 2013 | Volume 7 | Article 425 | 19


Breakfast, behavior, and academic performance
Table 2 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of school Reported results


of BF performance
Adolphus et al.

Lopez-Sobaler Cross-sectional survey School children (Spain) Weighed 7-day food diary. Spanish SAT-1 test. Three Higher reasoning SAT-1
et al. (2003) study. n = 180 aged 913 years. Definition of BF: Cut-off of 20% sub-batteries: scores obtained by AB group
Male: 57%, Female: 43%. of daily energy requirement. BF 1. Verbal compared with IB group.
intake classified as: 2. Reasoning Higher total SAT-1 scores
1. AB: 20% of daily energy 3. Calculation obtained by AB group
requirement Direct scores, centile scores, and compared with IB group.

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2. IB: <20% of daily energy IQ score obtained. Better quality breakfast
requirement significantly predicated better
reasoning and total scores.

ODea and Cross-sectional survey School Children (Australia) Questionnaire and interview with Standardized school achievement Nutritional quality of BF
Mugridge (2012) study. n = 824 grades 37 (aged dietitian. BF defined as solid or tests, NAPLAN test scores for: significantly predicted literacy
813 years). liquid eaten before 1000 h on day 1. Literacy scores. Non-significant
Male: 49%, Female: 51% of testing. BF intake classified as: 2. Numeracy association between BF and
n = 755 parents. 0. No food/drink numeracy scores. Few
1. Non-nutrient liquid children skipped BF. Adjusted
2. Confectionary/snack food for: age, gender, SES,
3. Grain/cereal or fruit/vegetable maternal education.
4. Grain/cereal + vitamin C
5. Protein + vitamin C
6. Grain/cereal + protein or
Grain/cereal + calcium
7. Grain/cereal + protein +

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vitamin C or Protein +
calcium + vitamin C
8. Grain/cereal + protein +
calcium
9. Grain/cereal + protein +
calcium + vitamin C
10. Grain/cereal + protein +
Vitamin C + calcium including
low-fat option

(Continued)

August 2013 | Volume 7 | Article 425 | 20


Breakfast, behavior, and academic performance
Table 2 | Continued

Authors, year Design Sample BF intervention/assessment Assessment of school Reported results


of BF performance
Adolphus et al.

Miller et al. (2012) Prospective cohort study. Preschool-primary school Parental questionnaire, 1 item to Standardized achievement tests No significant association
Part of ECLS-K national children (USA) n = 21400 at assess family BF frequency. BF 1. Reading between frequency of family
study. Data collection in baseline, n = 9700 at final classified as frequency/week 2. Mathematics BF and test scores. Fixed
five waves: 1999 follow up, aged 515 years (07) 3. Science (grades 3, 5, 6) effects model results used as
(preschool), 2000 (grade 1), (mean 6.09 years) provides most unbiased
2002 (grade 3), 2004 Male: 51%, Female: 49%. estimates: accounts for all

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(grade 5), 2007 (grade 8). controls and eliminates
between subject variations.
Extensive controls. Adjusted
for: Gender, ethnicity, family
SES, parental education,
family income, parental job
prestige, family structure,
area of residence, language,
maternal employment during
preschool, birth weight,
teaching quality, school
quality, region of residence,
parental working hours,
single parent family.

AD, adequate breakfast; AOR, adjusted odds ratio; BF, breakfast; BMI, body mass index; CI, confidence intervals; CT, cognitive testing; ECLS-K, early childhood longitudinal studykindergarten cohort; FFQ, food

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frequency questionnaire; FSM, free school meals; GI, glycaemic index; GL, glycaemic load; IB, inadequate breakfast; IG, independent groups; IQ, intelligence quotient; Kcal, kilocalorie; KJ, kilo joules; MAP,
measure of academic progress; NAPLAN, the national assessment program literacy and numeracy; NCHS, national center for health statistics; OR, odds ratios; PRO, protein; PA, physical activity; RCT, randomized
control trial; RDA, recommended daily allowance; RM, repeated measures; RTEC, ready to eat cereal; SAT, scholastic aptitude test; SBP, school breakfast program; SD, standard deviation; SES, socio-economic
status.

August 2013 | Volume 7 | Article 425 | 21


Breakfast, behavior, and academic performance
Adolphus et al. Breakfast, behavior, and academic performance

et al. (2008) found that adolescents who habitually ate breakfast Two studies found positive effects on arithmetic test scores
that provided >25% of total estimated energy needs and included from the WRAT following a relatively large breakfast meal (>500
four or more foods groups from dairy, cereals, fruit, and fat were Kcal) compared with a low energy control in undernourished
more likely to achieve higher grades than those consuming no and well-nourished children (Powell et al., 1998; Simeon, 1998).
breakfast or breakfast lacking the specified food groups. Analysis Cueto and Chinen (2008) examined the effects of a mid-morning
of individual subject domains indicated that mathematics, chem- SBP providing 600 Kcal and 60% of the daily requirements for
istry and social science grades were highest in full (>25% of several vitamins and minerals and 100% of the daily requirement
total energy needs and 4 food groups) and good (<25% energy for iron in a large sample of children, two thirds of whom were
and three food groups) quality breakfast groups compared with undernourished ( 2 SD height-for-age of the NCHS refer-
no breakfast. Physical education, biology and languages grades ence). Higher arithmetic and reading scores were demonstrated
were highest in the no breakfast group compared with full and following the SBP in intervention schools compared to con-
good quality breakfast groups. Supportive findings from Herrero trol schools, particularly in schools which tended to have higher
Lozano and Fillat Ballesteros (2006) indicated that higher aver- levels of poverty, undernourished children and lower achieve-
age grades were obtained in adolescents who habitually consumed ment. Comparable results were reported by Jacoby et al. (1996)
a breakfast containing three food groups from dairy, cereals and following the same breakfast intervention for 1 month in chil-
fruit compared with those consuming no breakfast or breakfast dren where the majority were below height-for-age but relatively
providing one of the specified food groups. The contribution of a overweight (due to increased body water and weight-for-height
mid-morning snack to breakfast quality was also considered in the classification). Children in intervention schools of higher weight
analysis, which indicated a positive association between a mid- (and therefore likely to be undernourished) increased vocabu-
morning snack and school grades specific to children who had lary scores post intervention. No effects were observed in normal
consumed no breakfast. weight children who were therefore likely to be well nourished.
In children aged 812 years from low SES backgrounds,
Standardized achievement tests Meyers et al. (1989) reported greater increases in language and
Age specific standardized achievement tests are routinely admin- total test scores in SBP attendees compared with non-attendees.
istered by schools in developed countries for monitoring and Wahlstrom and Begalle (1999) also demonstrated an increase in
provide an overall indication of intellectual level. Various sub- scores for reading and mathematics from pre to post interven-
tests are included, usually literacy/reading, numeracy/arithmetic tion. However, both studies were not well-controlled. A recent
and reasoning. Standardized achievement tests employed by large RCT in pupils from low SES schools in New Zealand failed
studies include the Wide Range Achievement test (WRAT), to show any benefit of a 1 year SBP on school achievement tests
the National Assessment ProgramLiteracy and Numeracy for literacy and numeracy and self-reported reading ability (Ni
(NAPLAN), Measure of Academic Progress (MAP), Scholastic Mhurchu et al., 2013).
Aptitude Test (SAT), and Assessment Tool for Teaching and
Learning (asTTle). Twelve studies used standardized achievement Cross-sectional studies. Four cross-sectional studies demon-
tests to measure school performance. Two studies conducted strated a consistent positive association between habitual
in developing countries used unstandardized achievement tests breakfast consumption and achievement test scores in children,
developed for the purpose of the research to account for variabil- including undernourished children.
ity in curriculum and school environment (Cueto and Chinen, Frequency of breakfast consumption was associated with
2008; Acham et al., 2012). Studies were generally conducted in achievement scores in two studies. Acham et al. (2012) demon-
children aged 613 years with 10 of the 12 studies in children strated in well-nourished and undernourished 915 year olds
younger than 13 years. Evidence indicated a positive effect of SBPs predominantly considered low ability, that those who had con-
on test scores, with clearest effects on arithmetic scores in both sumed breakfast and a mid-day meal were almost twice as likely
well-nourished and undernourished samples. Evidence also indi- to score highly on achievement tests compared to those who only
cated a positive association between habitual breakfast frequency had one meal. This association was specific to boys, and consum-
and quality, and test scores. ing breakfast alone was not associated with school performance
(Acham et al., 2012). This gender difference is not consistent
Intervention studies. Six of the seven intervention studies across studies with evidence demonstrating increased odds of
demonstrated positive effects of SBPs on standardized achieve- having lower self-reported school grades when skipping breakfast
ment tests in children aged 414 years, with clearest effects on compared with habitually consuming breakfast in both genders
arithmetic scores in undernourished children. Four of the seven (Lien, 2007). Edwards et al. (2011) indicated that higher mean
studies demonstrated a benefit of breakfast on arithmetic scores mathematics MAP scores were associated with habitually eating
(Powell et al., 1998; Simeon, 1998; Wahlstrom and Begalle, 1999; breakfast (5 days/week) compared with less frequent consump-
Cueto and Chinen, 2008). Four of the studies were carried out in tion (<5 days/week). No association was found between breakfast
samples which included undernourished children (Jacoby et al., frequency and reading MAP scores.
1996; Powell et al., 1998; Simeon, 1998; Cueto and Chinen, 2008) Two studies demonstrated an association between breakfast
and two studies included low SES samples (Meyers et al., 1989; composition (energy, food group, and micronutrient content)
Ni Mhurchu et al., 2013). Effects were demonstrable after an and achievement scores in children aged 813 years. Habitually
intervention period of at least 1 month and up to 3 years. consuming a breakfast providing 20% of total energy needs

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Adolphus et al. Breakfast, behavior, and academic performance

was associated with poorer total SAT performance, particularly Most of the studies focus primarily on on-task and off-task behav-
logical reasoning in 911 year olds (Lopez-Sobaler et al., 2003). ior within the classroom. Other behavioral domains measured
However, SES was not controlled. ODea and Mugridge (2012) less frequently include: being distracted, disruptive behavior,
demonstrated a significant association between habitual breakfast positively, or negatively interacting with peers, interacting with
quality according to food groups (carbohydrate and protein) and teacher, and reaction to frustration. One study did not directly
micronutrients (vitamin C and calcium) and NAPLAN literacy observe classroom behavior and measured overall time spent in
scores in children aged 813 years. No significant association was the classroom as a proxy measure for on-task behavior, which is
found between breakfast quality and numeracy scores. an inadequate assessment of behavior (Cueto and Chinen, 2008).
The measures used to code classroom behavior are often non-
Prospective cohort studies. Miller et al. (2012) demonstrated, validated, unstandardized coding methods developed for the pur-
in a large cohort of 21,400 school children aged 515 years, a pose of the research, and often inter-rater reliability is unspecified
non-significant association between breakfast eating frequency or merely recorded as acceptable. Overall, the general theme is the
and scores on standardized achievement tests for reading, math- subjective nature of these studies and reliance on interpretation of
ematics and science following adjustment for an extensive set of behavior. There is a lack of studies that use systematic, validated,
confounders. This was specific to breakfast that was eaten with the and reliable coding systems to measure classroom behavior. Two
family rather than total breakfast intake. recent studies have demonstrated effects on on-task behavior fol-
lowing school lunch manipulations using a validated observation
DISCUSSION protocol (Golley et al., 2010; Storey et al., 2011). Future studies
THE EFFECTS OF BREAKFAST ON BEHAVIOR investigating the effects of breakfast on behavior should adopt val-
Overview of findings idated and reliable, focused coding schemes to measure classroom
This review identified 19 studies that examined the effects of behavior. Given the subjective nature of the methods to assess
breakfast on behavior in children and adolescents of which 11 behavior, observers should also be blind to treatment condition.
studies demonstrated a positive effect of breakfast on behav-
ior. The evidence suggests a mainly positive effect of breakfast Observational methods: Real-time vs. Recorded observations.
on on-task behavior in the classroom. This effect was appar- Several issues concern the observational methods used to assess
ent in children irrespective of whether they were well-nourished behavior. Real-time classroom observations carried out by teach-
and undernourished or from low SES or deprived backgrounds. ers or researchers were common. Only four studies utilized video
However, most of the research on the impact of breakfast on recorded classroom observations likely to produce more accurate
behavior has taken the form of SBP evaluations, which lack sci- and ecologically valid behavioral measures and offer the possi-
entific rigor. Three RCTs have not found similar benefits for bility of post hoc verification by independent observers (Milich
behavior using standardized measures following a 1 year SBP, and Pelham, 1986; Wender and Solanto, 1991; Richter et al.,
although, participation in the SBP was consistently low in some 1997; Benton et al., 2007). Video recorded classroom obser-
trials, which is likely to account for the lack of effects. In order for vations are therefore a more accurate and reliable behavioral
SBPs to impact on behavioral outcomes, the barriers to participa- measure. During real-time classroom observations, the researcher
tion need to be addressed. Studies in children with pre-existing is required to observe multiple pupils within the lesson. The
behavior problems (e.g., ADD-H) demonstrated no benefit of dual processing of watching and recording in the classroom is
breakfast of differing sugar content. Findings for other behavioral a complex task. The use of a video recorded classroom obser-
outcomes including off-task behavior, distractibility, hyperactiv- vation may have the advantage of increased accuracy via the
ity, and disruptive behavior are inconsistent. The frequent null ability to replay, review, and control observer fatigue (Haidet
findings reported suggest the effects of breakfast may be specific et al., 2009). Secondly, due to the reactive nature of the obser-
to selective behavioral domains. vation process, the Hawthorne effect may be present, such that
The increase in on-task behavior following breakfast may indi- children and teachers change their behavior because they are
cate that children who eat breakfast are more able to concentrate, under observation (Roethlisberger and Lombard, 1977). Not
pay attention and are more alert at school. This is supported by having observers present during the observation or utilizing
evidence that demonstrates positive effects of breakfast on cog- video recorded observation methods may limit this anticipated
nitive performance including attention and memory (Hoyland behavior change. Finally, the habituation period, where cam-
et al., 2009). Similarly, more on-task behavior in the classroom eras/observers are introduced, is often not reported. This habitua-
may be associated with improvements in academic performance tion period may allow children to become familiar to the presence
supported by the positive association between habitual break- of observers/cameras in order to reduce reactive behavior change.
fast intake and academic performance (Boschloo et al., 2012; So, Future studies should consider, when possible, a video recorded
2013). Moreover, an improvement in classroom behavior has the observation to yield a more accurate, reliable observation whilst
potential to reduce disruption and produce a more productive maintaining ethical safeguards.
learning environment.
Design. Various breakfast manipulations are employed. There
Methodological issues are few direct comparisons of breakfasts varying in composition
Behavioral measures. Classroom behavior was typically mea- precluding conclusions about the effects of breakfast composi-
sured by coding observed behavior into predefined domains. tion on behavior. Additionally, many studies lack randomization

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Adolphus et al. Breakfast, behavior, and academic performance

and the inclusion of an appropriate comparable control group. including undernourished children demonstrated consistent pos-
Most studies are based on small samples and limited to chil- itive effects of breakfast on school performance (Jacoby et al.,
dren aged <13 years, with fewer studies in adolescents. Metabolic 1996; Powell et al., 1998; Simeon, 1998; Cueto and Chinen, 2008).
and behavioral effects of breakfast may be different in older chil- This is suggestive of a possible mechanism by which breakfast may
dren aged >13 years. Classroom behavior is dynamic and can improve school performance. The observed increase in school
be different across year groups and ages. Previous research has performance may be facilitated by correction of nutritional defi-
found differences in behavior between older and younger chil- ciencies due to the fortification of many breakfast products, par-
dren in the classroom following school lunch manipulations, ticularly with iron and iodine which have largely been implicated
where younger children tend to be more distracted when work- in improving cognitive function which may influence school per-
ing alone with the reverse true for older children and adolescents formance (Tiwari et al., 1996; Grantham-McGregor and Ani,
(Golley et al., 2010; Storey et al., 2011). The influence of gen- 2001; Falkingham et al., 2010). Whilst nutritional influences
der on behavior is also not considered by most studies. For may have contributed toward the improved school performance,
example, Chang et al. (1996) demonstrated that girls talked school attendance also increased in many studies following which
and displayed more movement compared with boys in a set may account for most of the improvement in school grades
task classroom situation. Further research in this field should (Hoyland et al., 2009; Defeyter et al., 2010).
include larger samples providing sufficient power and also include
older children >13 years and consider the effects of gender on Methodological issues
behavior. Influence of confounders. Research on breakfast and educational
outcomes is a particularly difficult area given the potential for
THE EFFECT OF BREAKFAST ON ACADEMIC PERFORMANCE confounding. The majority of studies that employ academic out-
Overview of findings comes are cross-sectional, so adjustment of potential confounders
This review identified 21 studies that demonstrated suggestive is critical. Adequate control for confounders varied within the
evidence that habitual breakfast (frequency and quality) and studies identified. An important potential confound is SES. It
SBPs are associated with children and adolescents academic per- is likely that children and adolescents who eat breakfast differ
formance. This effect was apparent in both well-nourished or from those who do not eat breakfast in ways that also influence
undernourished samples and/or children from low SES back- educational outcomes. There is a consistent evidence that SES is
grounds. Increased frequency of habitual breakfast was consis- associated with breakfast eating, with children from higher SES
tently positively associated with improved school performance. backgrounds more likely to regularly eat breakfast than children
Some evidence suggested that increased quality of habitual break- from lower SES backgrounds, an effect which is consistent across
fast in terms of providing a greater variety of food groups (34) gender and age (Delva et al., 2006; Moore et al., 2007; Doku
and adequate energy (>2025% of total estimated energy needs) et al., 2011; Hallstrm et al., 2011, 2012; Overby et al., 2011).
is positively related to school performance. Similarly, there is well established consistent evidence that SES is a
Evidence suggested a positive effect of SBPs on arithmetic test central determinant of academic performance and cognitive abil-
scores and mathematic grades. Three studies demonstrated clear- ity (Brooks-Gunn and Duncan, 1997; McLoyd, 1998; McCulloch
est effects on mathematic grades (Murphy et al., 1998; Kleinman and Joshi, 2001; Machin and Vignoles, 2004). However, some
et al., 2002; Morales et al., 2008) and four studies demon- studies failed to adequately adjust for SES in their analysis or
strated a benefit of breakfast on arithmetic scores (Powell et al., used various proxy measures of SES which may be inadequate.
1998; Simeon, 1998; Wahlstrom and Begalle, 1999; Cueto and If SES is not accounted for in the analysis, it is likely associa-
Chinen, 2008; Edwards et al., 2011). However, some of the evi- tions observed are because children select into both high breakfast
dence was inconsistent (Gajre et al., 2008; ODea and Mugridge, consumption frequency and higher school grades as a result
2012). Gajre et al. (2008) found that regular breakfast eaters (>4 of SES. Further work investigating the effects of breakfast on
days per week) had significantly higher marks for science and school performance should carefully consider the role of con-
English compared to those who never eat breakfast, but there founding, and apply adequate controls in the analysis, particularly
was no difference in mathematics marks. However, total marks, for SES.
which included mathematics, were significantly higher in the
regular breakfast group compared with the no breakfast group. Academic performance measures. Studies employed a wide range
Similarly, the majority of studies employing composite measures of outcomes as academic performance indicators, either by use
of school grades across subject domains show a positive asso- of average school grades or standardized achievement tests. Two
ciation which, may be related to increased power afforded by studies relied on self-reported school grades (Lien, 2007) or self-
composite measures. reported subjective ratings of school performance (So, 2013)
Some evidence suggested that effects may be more apparent which are open to socially desirable and inaccurate reporting.
in undernourished children who improved their nutritional sta- Moreover, direct measures of academic performance, although
tus from at risk to adequate following a SBP (Kleinman et al., ecologically valid are however, crude measures that may be insen-
2002). Cueto and Chinen (2008) reported that positive effects on sitive to the effects of breakfast. Although many confounders are
achievement test scores following a SBP, particularly in schools controlled for in the studies reviewed, it may be inappropriate to
which tended to have more undernourished children and lower use broad measures of scholastic achievement such as end of year
achievement. In support, studies that were carried out in samples grades since many other factors interplay to determine grades.

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Adolphus et al. Breakfast, behavior, and academic performance

There are multiple, modifiable, and unmodifiable, determinants yes/no) are often used which may yield an inadequate assess-
of academic performance that may act over and above the subtle ment of habitual intake. Additionally there is a lack of validation
nutritional effects of breakfast. studies examining the accuracy of brief dietary assessment or
measures of specific meals compared with other methods which
Design. The evidence is based on studies investigating the effects tend to examine total diet. Different measurement periods are
of either habitual breakfast consumption or SBPs on academic used to define habitual breakfast and studies do not differentiate
performance. The majority of studies on habitual breakfast intake between weekday and weekend breakfast consumption, despite
are cross-sectional. The dominance of cross-sectional evidence, the importance for school performance where weekday (school-
although offering a unique opportunity to establish the effects of days) breakfast meals may be more important. Measures focus
habitual breakfast on academic performance, provides no indica- on either frequency or composition and it is rare both to be
tion of causality or temporality. Only one well controlled prospec- considered. Self-report measures also have limitations because
tive cohort study has been published to date (Miller et al., 2012). breakfast is often subjectively defined and interpreted by the
This study focused on breakfast that was eaten with the family respondent, allowing for bias, inaccurate recall, and misreporting.
rather than total breakfast intake, however this may still be reflec- Furthermore, all food and drink consumed as part of breakfast
tive of habitual breakfast consumption particularly in younger may not be considered. For example, food consumed on the way
children who are more likely to have family meals (Fulkerson to school or food that is not traditionally consumed for breakfast
et al., 2006) and since most regular breakfast eaters have breakfast may be excluded.
at home (Hoyland et al., 2012). The majority of studies on habitual breakfast intake are based
SBP intervention studies also present difficulties in attributing on adolescent samples aged 1218 years. Accurate nutritional
the direct effects of the breakfast meal or the regime of providing assessment in adolescents is problematic and challenging com-
a free school breakfast in a breakfast club environment to aca- pared with younger children, who are more likely to eat breakfast
demic outcomes (Defeyter et al., 2010). Many studies lack details at home (Hoyland et al., 2012). There is an overall trend of
of the composition and amount of food provided and consumed, increased inaccuracy and underreporting of food intake with
precluding conclusions regarding breakfast type. SBPs are often age (Livingstone et al., 2004). Validation studies show dietary
associated with increased attendance (Jacoby et al., 1996; Simeon, records provide unbiased and accurate estimates of diet in normal
1998; Kleinman et al., 2002) punctuality (Murphy et al., 1998), weight children up until the age of 9 years whereas adolescents
readiness to learn (Wahlstrom and Begalle, 1999), decreased and older children are more likely to underreport dietary energy
dropout rates (Cueto and Chinen, 2008) better behavior in the intake by approximately 20% (Livingstone et al., 1992; Bandini
classroom (Bro et al., 1994; Richter et al., 1997) and increased et al., 1997). Adolescence is a period of rapid growth, increasing
pro-social behavior (Shemilt et al., 2004), all of which are likely to body image concerns, changing eating habits, increased inde-
impact school performance concurrently. The positive effects of pendence over diet, greater peer influence and decreased coop-
SBPs on other outcomes that will also influence academic perfor- eration with authority, all of which may decrease compliance
mance make it difficult to attribute the effects either to the break- and reporting accuracy in this population (Livingstone et al.,
fast meal or as an artifact of increased attendance and punctuality. 2004).
Furthermore, the intervention duration is particularly important Further work should consider, both frequency and composi-
in relation to academic performance because it is likely that a sta- tion of breakfast as well as differentiating between weekday and
ble period of operation is needed to impact both breakfast eating weekend breakfast when measuring habitual breakfast intake. A
behavior and academic outcomes. Two studies following a 1 year longer measurement period to define habitual breakfast (e.g., at
SBP reported no increase in the total number of children eating least 7 days) is needed to adequately measure breakfast intake and
breakfast (Murphy et al., 2011; Ni Mhurchu et al., 2013). Clearly, a dichotomous classification system to define habitual breakfast is
the increase in school performance reported in studies that do insufficient.
not impact breakfast eating behavior is likely to be an artifact of
other outcomes. SUMMARY OF THE EFFECT OF BREAKFAST ON BEHAVIOR AND
ACADEMIC PERFORMANCE
Dietary assessment. Studies that examine the effects of habitual Overall, the evidence suggests beneficial effects of breakfast for
breakfast consumption on scholastic outcomes also have lim- on-task behavior in the classroom, mainly in younger children
itations in terms of how breakfast is measured and defined. <13 years. This effect was apparent in children who were well-
Varying definitions of breakfast and classifications of habit- nourished, undernourished and/or from deprived or low SES
ual consumption are used. Often dichotomous classifications backgrounds. For school performance outcomes, evidence sug-
using different cut-offs (e.g., 5 days/week, <5 days/week) to gests a positive association between habitual breakfast frequency
define habitual breakfast consumption are employed preclud- and quality on school grades or achievement test scores. Similarly,
ing comparisons between these categories. This crude indication evidence from SBPs suggest a positive effect on school perfor-
of habitual consumption is unlikely to reflect true intake of mance, particularly mathematics grades and arithmetic scores
breakfast. and in undernourished children and/or children from deprived
Measurements of habitual breakfast intake are normally brief or low SES backgrounds. The positive effects of breakfast on
dietary assessments, given their use in situations for to measure academic performance appear clearer than those on behavior,
specific aspects of diet. One item questionnaires (e.g., breakfast probably due to the difficulties surrounding accurate measures

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Adolphus et al. Breakfast, behavior, and academic performance

of behavior which are inherently subjective in nature. These ACKNOWLEDGMENTS


outcomes are ecologically valid, have more relevance to pupils, Katie Adolphus was supported by an Economic and Social
parents, teachers, and educational policy makers and as a result Research Council (ESRC) research studentship and funding from
may produce most impact. The Schools Partnership Trust Academies (SPTA).

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