Skipping Breakfast and Its Long-Term Health Impact on CVD

Do you promote eating breakfast with your patients? What are the risks for skipping breakfast? 

Multiple studies have explored the relationship between eating breakfast and the incidence of CVD. Comparing patients who skipped breakfast to those who ate breakfast, those who skipped were at a higher risk for coronary heart disease. Other studies found similar claims, plus incidence of stroke and hypertension. But what about regarding CVD mortality?

The study wanted to determine the effect of skipping breakfast and its association with cardiovascular and all-cause mortality. 6,550 patients between 40 to 75 years of age were included in this prospective study. Data was extracted from the National Health and Nutrition Examination Survey (NHANES) III. Patients were followed until the last known date alive or censored from the NHANES III mortality file, with a follow-up period of 17 to 23 years. At baseline, patients were asked “How often do you eat breakfast?” Breakfast eating frequency was broken down into four groups, “never,” “rarely,” “some days,” and “every day.” Basic covariate information was gathered during interviews via questionnaires. Height, weight, and blood pressure were measured. Status of hypertension, diabetes, and dyslipidemia were recorded.

Baseline characteristics between the groups were compared via linear and logistic regression for continuous and categorical variables respectively. Cox proportional hazards regression models were used to assess for association between breakfast consumption frequency and cardiovascular and all-cause mortality. A separate model was used to adjust for covariates, BMI, hypertension, diabetes, and dyslipidemia. 

Of the 6,550 patients, 336 never consumed breakfast (5.1%), 713 rarely consumed breakfast (10.9%), 1,639 consumed breakfast some days (25%), and 3,862 consumed breakfast every day (59%). The follow-up was represented by 112,148 person-years, 619 deaths occurred due to CVD (total of 2,318 deaths). Baseline demographics showed patients who never consumed breakfast were more likely to be “non-Hispanic black, former smokers, heavy drinkers, unmarried, physically inactive, and with less family income, lower total energy intake, and poorer dietary quality.” These patients were also more likely to have obesity and higher total blood cholesterol level. These patients are at higher risk for death from CVD. After adjustment in patients who never consumed breakfast for age, sex, and race/ethnicity, they had a 75% higher risk of all-cause mortality and 2.58-fold higher risk of cardiovascular mortality.

Lastly, the researchers further assessed breakfast eating in association with heart disease-specific and stroke-specific mortality. Similarly, patients who never consume breakfast had a higher risk of heart disease-specific and stroke-specific mortality (HR: 2.34; HR: 3.53). After full-adjustment, as previously done, the association became non-significant between skipping breakfast and heart disease-specific mortality (HR: 1.59); however, stroke-specific-specific mortality persisted as significant (HR: 3.39).

All in all, the authors determined that skipping breakfast is significantly associated with an increased risk of cardiovascular mortality, specifically for stroke-specific mortality. This data further supports the importance of eating breakfast to promote cardiovascular health and to prevent future outcomes. Having a large nationally representative sample, the authors believe their data is generalizable to the general United States population. The study had a long-term follow-up period giving comprehensive data and they were able to control potential confounding effects. However, in the study, the authors didn’t provide specifics regarding what the patients were ingesting, only the frequency with which they ate breakfast. Different breakfast options will affect mortality risk. Also, patients were asked at baseline their frequency of eating breakfast; there was no notation if their habits changed throughout the study. Regardless, the association found by the authors should further be researched, specifically, the mechanisms of the association, to better identify targeted interventions.

Practice Pearls:

• Skipping breakfast poorly effects appetite regulation, most likely leading to overindulgence in the evening and poor glycemic response.
• In patients with diabetes, who are already at risk for cardiovascular mortality, they should be advised to eat breakfast to support cardiovascular health.
• Furthermore, a proper breakfast should be discussed and individualized to a patient with diabetes to ensure they have options.

Reference:

Rong, Shuang, et al. Association of Skipping Breakfast With Cardiovascular and All-Cause Mortality. Journal of the American College of Cardiology. 2019 January 8.

Emma Kammerer, L|E|C|O|M Bradenton School of Pharmacy, PharmD Candidate