Skipping Breakfast Is Associated With an Increased Long-term Cardiovascular Mortality in Metabolic Dysfunction-associated Fatty Liver Disease (MAFLD) but not MAFLD-free Individuals

Jiarong Xie; Hangkai Huang; Yishu Chen; Lei Xu; Chengfu Xu


Aliment Pharmacol Ther. 2022;55(2):212-224. 

In This Article

Abstract and Introduction


Background: Balancing calorie control to prevent cardiovascular diseases (CVDs) by skipping breakfast while guarding against its potential risks is a challenge.

Aims: To explore the association between skipping breakfast and cardiovascular mortality in individuals with metabolic dysfunction-associated fatty liver disease (MAFLD).

Methods: A total of 9926 individuals (including 3004 MAFLD participants) aged 20 years or older were enrolled in the Third National Health and Nutrition Examination Survey and followed for up to 27 years. All participants were classified according to the frequency of breakfast consumption (every day, some days, rarely and never). Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for cardiovascular mortality.

Results: During the 212 239 person-years of follow-up, we documented a total of 2595 deaths including 603 deaths from CVDs. Of these, 1039 deaths including 253 deaths from CVDs were recorded in MAFLD individuals. MAFLD individuals showed higher cardiovascular mortality than MAFLD-free controls (P < 0.001). Furthermore, skipping breakfast was independently associated with high cardiovascular mortality risk (adjusted HR: 2.850, 95% CI: 1.490–5.452; P = 0.002), and a high cerebrovascular disease mortality risk (adjusted HR: 5.570, 95% CI: 1.814–17.099; P = 0.003) in participants with MAFLD. However, skipping breakfast was not associated with cardiovascular mortality in MAFLD-free individuals (adjusted HR: 1.526, 95% CI: 0.701–3.326; P = 0.280).

Conclusions: In this US population-based study, skipping breakfast was associated with a high risk of cardiovascular mortality in MAFLD but not MAFLD-free individuals.


Cardiovascular diseases (CVDs), a leading cause of death that claimed 18.6 million lives globally in 2019,[1] pose growing health and economic burdens to all societies. Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly named non-alcoholic fatty liver disease (NAFLD), affects up to a third of the world's adult population and is an independent risk factor for the increased cardiovascular mortality.[2–4] Considering that CVDs are the most common cause of death in the MAFLD population, it is urgent to take strategies to reduce cardiovascular mortality in the MAFLD population.

Given the absence of FDA-approved pharmacological therapies for MAFLD, dietary interventions remain the cornerstone.[5] Multiple diets, including Dietary Approaches to Stop Hypertension diets, low-carbohydrate diets, and Mediterranean diets, have been evaluated. However, dietary patterns remain largely unexplored.[6] Only caloric restriction was proved effective and consistently recommended in the current guidelines.[7] The American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver/European Association for the Study of Diabetes/European Association for the Study of Obesity (EASL-EASD-EASO), the National Institute for Health and Care Excellence (NICE), and the Asian-Pacific working party all highlight the importance of caloric restriction in the treatment of MAFLD.[8–11] However, more research is needed into how to allocate dietary calories as the specific diet plan and its effect on MAFLD remain unclear. The potential risks of fasting may be a factor to consider.

Breakfast plays an important role in dietary regulation. However, up to 30% of US adults reportedly do not eat breakfast.[12] In recent years, the harm of skipping breakfast to health has gained increasing attention. Asao et al[13] explored the mechanisms underlying skipping breakfast on the NHANES III database and found that a 50% higher fasting leptin level was associated with a 9%-12% higher likelihood of skipping breakfast. Previous studies have reported that skipping breakfast is associated with adverse cardiometabolic perturbations, leading to overweight/obesity,[14] metabolic syndrome,[15] and type 2 diabetes mellitus (T2DM).[16] Skipping breakfast may also increase the risk of CVDs.[17,18] Uzhova et al reported that the omission of breakfast was associated with an increased odds of the early onset and development of atherosclerosis.[18] However, Sievert et al[19] found that participants who skipped breakfast had less total daily energy intake than those assigned to eat breakfast, which might contribute to calorie control. The observations introduce the question of whether skipping breakfast for caloric restriction increases cardiovascular mortality, especially in the MAFLD population. Balancing calorie control to prevent CVDs by skipping breakfast while guarding against its potential risks is a challenge. Large cohort studies with a long-term follow-up and the assessment of clinical endpoints are needed to explore the impact of skipping breakfast on MAFLD individuals.

In this study, by analysing the long-term follow-up results of the NHANES III, 1988–1994, we explored the association of skipping breakfast with cardiovascular mortality in the MAFLD population.