Skipping Breakfast Linked to Increased Atherosclerosis

Liam Davenport

October 05, 2017

MADRID, SPAIN — Going without breakfast in the morning is associated with a substantially increased risk of developing subclinical atherosclerosis, a new observational study shows[1].

The findings provide support for previous reports suggesting dietary patterns can affect rates of cardiovascular events, the researchers say.

 In an analysis of an ongoing cohort study, they found that not eating breakfast in the morning was associated an approximately 75% increased risk of subclinical atherosclerosis, while the risk of generalized atherosclerosis was more than doubled.

The research, which was published in the October 10, 2017 issue of the Journal of the American College of Cardiology, also showed that even people who ate a low-energy breakfast also had an increased risk of atherosclerosis vs those who started their day with a heartier meal.

Study coauthor Dr José L Peñalvo (Tufts University, Boston, MA) told theheart.org | Medscape Cardiology that the message from the study is simple: "The better your breakfast, the more protected you are against developing plaque."

Moreover, it is a positive message that doesn't lay blame on individuals and their behavior and is something that is both easily identified and easily changed, he said.  

Peñalvo added that skipping breakfast is a behavior that tends to cluster with other behaviors. "If you eat in the morning, you're not going to be as hungry midmorning, and you're not going to go to the vending machine and get a snack, and so on and so forth," he said.

Subclinical Atherosclerosis

Dr Valentin Fuster (Mount Sinai, New York), editor-in-chief of JACC and a coauthor on the paper, describes the findings on a JACC audio summary accompanying the publication. He points out that eating patterns are highly dependent on cultural, social, and psychological determinants that inform people's daily routines.

Breakfast consumption is associated with factors such as satisfaction, early daily energy intake, metabolic efficiency, and early appetite regulation, he noted. "Although there are some studies linking skipping breakfast with coronary heart disease, to the best of our knowledge, no studies have been investigating the association of breakfast with the presence of subclinical atherosclerotic disease, as addressed by imaging."

For this investigation, the researchers conducted a cross-sectional analysis of Progression of Early Subclinical Atherosclerosis (PESA), an ongoing observational, prospective cohort study of 4082 employees at the headquarters of a multinational bank in Madrid, Spain.

They included male and female volunteers aged 40 to 54 years who were free of any cardiovascular events at baseline, examining lifestyle and multivascular imaging data alongside clinical covariates in a total of 4052 study participants.

The individuals' usual diet was estimated using a questionnaire developed and validated for a previous Spanish population study, which asks about foods consumed in the past 15 days, taking into account eating occasions.

Drawing on  other previously published work, the researchers defined three patterns of breakfast consumption:

  • Skipping breakfast, in which <5% of the total daily energy intake occurred in the morning. This was taken as a proxy for having only a coffee with or without milk or another nonalcoholic beverage.

  • Low-energy breakfast, in which between 5% and 20% of total daily energy intake occurred in the morning. This would equate to having a coffee and a pastry or toast.

  • High-energy breakfast, in which >20% of the total daily energy intake occurred in the morning.

The team found that 2.9% of participants were skipping breakfast, 69.4% had a low-energy breakfast, and 27.7% had a high-energy breakfast.

Compared with other groups, breakfast skippers were more likely to be male and current smokers. They were also more likely to have changed their diet in the past year to lose weight and to consume the highest percentage of calories at lunch.

Low-energy breakfast consumers were more likely than those who ate a high energy breakfast to be male and smokers, to have a lower educational level, and also to consume a larger proportion of calories at lunch.

Both breakfast skippers and low-energy breakfast eaters had a higher animal protein and dietary cholesterol intake than those who ate a high-energy breakfast.

High-energy breakfast eaters, conversely, had significantly higher intakes of carbohydrates and dietary fiber and tended to eat more fruit and vegetables, as well as whole grains and high-fat dairy. Fuster noted breakfasts consumed by the high-energy breakfast eaters tended to include items considered part of the Mediterranean diet.

Using 2D ultrasound, they scanned for the presence of focal atherosclerotic disease in both carotid arteries, the infrarenal abdominal aorta, and both iliofemoral arteries. Coronary artery calcium (CAC) was assessed using noncontrast 16-slice CT scanning, and a CAC score was calculated.

They defined subclinical atherosclerosis as the presence of plaque in one of the five arterial sites or the presence of calcium in the coronary arteries (CAC >0). Noncoronary atherosclerosis was defined as the presence of plaque in one the five sites excluding CAC. If atherosclerosis was detected in any four of these six measures, it was considered generalized atherosclerosis.

The overall prevalence of subclinical, noncoronary, and generalized atherosclerosis was 62.5%, 60.3% and 13.4%, respectively. A CAC score >0 was calculated in 18.1% of the overall population.

Multivariate analysis taking into account age, sex, waist circumference, hypertension, dyslipidemia, diabetes, smoking, and red meat, alcohol, and salt intake indicated that breakfast skippers were significantly more likely than those who ate a high-energy breakfast to have subclinical atherosclerosis.

Specifically, they were more likely to have plaques in the abdominal aorta, at an odds ratio of 1.79 (95% CI 1.16–2.77), in the carotid artery, at an odds ratio of 1.76 (95% CI 1.17–2.65) and in the iliofemoral artery, at an odds ratio of 1.71 (95% CI 1.11–2.64).

Breakfast skippers were also significantly more likely than those consuming a high-energy breakfast to have noncoronary atherosclerosis, at an odds ratio of 1.55 (95% CI 0.97–2.46), and generalized atherosclerosis, at an odds ratio of 2.57 (95% CI 1.54–4.31).

Compared with high-energy breakfast consumers, those who ate a low-energy breakfast also had a higher risk of carotid atherosclerotic plaques, at an odds ratio of 1.21 (95% CI 1.03–1.43), and of iliofemoral plaques, at an odds ratio of 1.17 (95% CI 1.00–1.37).

Skipping breakfast, Fuster concludes, "is associated with an increased odds of prevalent noncoronary and generalized atherosclerosis, independently of the presence of conventional cardiovascular risk factors."

Complex Relationship

An accompanying editorial[2] points out that, while previous studies have suggested that skipping breakfast is linked to "adverse cardiometabolic perturbations," the current analysis "provides a new insight into the chain of events by demonstrating a higher prevalence of subclinical atherosclerosis."

Authors Dr Prakash Deedwania (University of California, San Francisco, CA) and Dr Tushar Acharya (National Heart, Lung, and Blood Institute, Washington, DC) note that changes in dietary patterns mean that up to 30% of adults now skip breakfast.

"These trends mirror the increase in obesity and associated cardiometabolic derangements," they write. "It is less clear whether skipping breakfast causes more people to be obese or if the obese skip breakfast with the misguided goal of losing weight."

"This 'chicken-or-egg' situation notwithstanding, it is apparent that the relationship is complex," they note.

The authors say that given the "urgent need" for public-health measures to "curb the global epidemic of obesity," results from this and other studies suggest that "it seems prudent to pay attention to diet and educate the public to implement simple lifestyle changes that include emphasis on a regular, hearty, and nutritious breakfast."

Speaking to theheart.org | Medscape Cardiology, Deedwania emphasized that, while the relationship between skipping breakfast and atherosclerosis may be complex and a causal link cannot be established, "for practical advice it doesn't really matter what is causing it; what matters is it's a significant and strong association.

"Our forefathers always tell us to have a healthy breakfast, and now this study has clearly shown that it's not just an old man's advice, it's good health advice that, if you have a heartier breakfast, you will have healthier arteries," he added.

Recalling the old adage to breakfast like a king, lunch like a prince, and dine like a pauper, Deedwania said, "Even though this is an old saying, it emphasizes how our eating habits should be. This study and others that we reported in the editorial clearly have proven the fact that breakfast is the most important meal of the day and that we should pay attention."

Deedwania also noted that the importance of a good breakfast is that it means that, at least once a day, people are consuming nutritious foods.

"Nobody eating breakfast is going to have a steak," he added. "People are going to have cereal, people are going to have fruit, etc, so your nutritional value of a heartier breakfast is much better for your health than other meals in the day."

The PESA is cofunded equally by the Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC) and Banco Santander. The study also receives funding from the Institute of Health Carlos III and the European Regional Development Fund. The CNIC is supported by the Ministry of Economy, Industry, and Competitiveness and the Pro-CNIC Foundation and is a Severo Ochoa Center of Excellence. Peñalvo is currently an employee at Merck. Disclosures for the coauthors are listed in the paper. The editorialists report they have no relevant financial relationships.

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