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Could Skipping Breakfast Cost Your Patient with Type 2 Diabetes Their Cardiovascular Health? 

May 30, 2020
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Mia Flowers, PharmD. Candidate of Florida Agricultural & Mechanical University School of Pharmacy

Arterial stiffness is a complication of cardiovascular disease; does skipping meals contribute to this condition in patients with type 2 diabetes mellitus?

People with type 2 diabetes mellitus are at increased risk of developing arterial stiffness—a complication of cardiovascular diseases (CVD), which are one of the most common mortalities in these patients. Arterial stiffness is often evaluated by the brachial-ankle pulse wave velocity (baPWV), which can assist in the evaluation of atherosclerotic severity as well as predict and prevent CVD in this patient population. In past cross-sectional studies, researchers found a correlation between inadequate sleep hygiene, inactivity, or low amounts of exercise, and the development of arterial stiffness in people with type 2 diabetes. Other studies identified the common atherosclerotic risk factors as causing an increase in arterial stiffness. Lifestyle modifications were evaluated in this study to understand better how depression, exercise, energy, sleep, and diets involving late-night dinners and lack of breakfast play a role in the development of atherosclerosis. Fluctuating hormones and diminishing cardiovascular health can be controlled by lifestyle modifications that can also potentially lead to arterial stiffness. In the general population, skipping breakfast increases weight, the prevalence of type 2 diabetes, and the risk of atherosclerosis leading to cardiovascular events and cerebrovascular accidents. Lifestyle habits can provoke and/or prevent all these stipulations. This study aims to expound upon the risk of atherosclerosis in patients with diabetes who skip out on their most important meal of the day.  


For this observational prospective cohort study which is taking place in Japan, patients were enrolled at the Diabetes Outpatient Clinic of Juntendo University, Naka Kinen Clinicand Secomedic Hospital. While the study is still ongoing, the finding of this work is the result of an eight-year followup investigation of the relationship between CVD and lifestyle interventions. From June 2013 to January 2014, 736 subjects from the outpatient setting were recruited. The inclusion criteria were pure in that the patients had to have type 2 diabetes. The patients in this study were free of any observable CVD; this CVD was an exclusion factor. Survey questionnaires and baPWVs were taken at baseline, year two, and year five.  Peripheral artery disease was defined as an ankle-brachial score less than or equal to 0.9 at rest, which was another part of the exclusion criteria. Over five years, starting from the baseline, blood sugar readings were recorded once a year at minimum. Other monitoring parameters such as hbA1c, lipid panels, liver, and kidney function were monitored following standard recommendations.  

Statistical analysis entailed two-sided test with a significance level of 5%, mean standard deviation, median, interquartile range, and proportions. Linear mixed-effects model with multivariable was utilized to assess longitudinal baPWV. Within five years, two patients withdrew consent, and bAPWV values increased significantly. The model used to measure this increase adjusted for age and gender found decreased breakfast intake highly correlated with persistent increased bAPWV scores. It was observed that the patients who eat less breakfast have a higher prevalence of other unfavorable lifestyle choices, which can also perpetuate atherosclerosis.  

To conclude, this ongoing follow up of type 2 diabetes patients examined the effects of skipping breakfast singlehandedly and found steadily increased arterial stiffness. Limitations of this study include the single location in Japan, the use of self-reported surveys which could easily contain falsified information, the use of arterial stiffness as an indicator of CVD, the inability to establish a causal relationship between lifestyle factors and stiffness of arteries, the small number of patients who reported eating breakfast less than daily, that the results may not be able to be duplicated in larger populations, and the lack of consideration for other lifestyle factors or medications which could influence a decline in the arterial stiffening. The ongoing study will use the same cohort to observe the onset of cardiovascular disease and its correlation with lifestyle modifications, including breakfast intake. 

Practice Pearls:  

  • A decreased intake of breakfast was independently and actively affiliated with the stiffening of the arteries measured by high brachial-ankle pulse wave velocity. 
  • The inclusion of breakfast in patients with type 2 diabetes’ morning routine could decrease arterial stiffness. 
  • Questioning breakfast intake could be an easy strategy to implement when identifying and aiding in the prevention of cardiovascular disease development.  


MitaT,OsonoiY,OsonoiT, et al. Breakfast skipping is associated with persistently increased arterial stiffness in patients with type 2 diabetes. BMJ Open Diabetes Research and Care2020 


 Mia Flowers, PharmD. Candidate of Florida Agricultural & Mechanical University School of Pharmacy 


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