Is Breakfast Important to Cardiovascular Health? Further Support for an Important Daily Meal

Many things in our daily lives are associated with the development of atherosclerosis and subsequently suffering a cardiovascular event.  These include diabetes, hypertension, and dyslipidemia.^1-3 Diet has always been and continues to be a highly researched field for preventing cardiovascular disease and lowering events.  Research continues in understanding nutritional quality, eating patterns, and daily energy intake.^4-6 As we continue to lead busier and busier lives, the effect on our eating patterns becomes greater.  One particular effect may be the likelihood to consume breakfast, perhaps omitting it completely from our daily life routine.  If this is the case, what is the association between different breakfast patterns and the development of atherosclerosis? Two years ago I wrote about the following study showing the important relationship between breakfast and the potential for atherosclerosis.  I show these results again for your review.

To understand the association researchers from Spain studied the association between breakfast patterns and cardiovascular risk factors and the presence, distribution, and extension of subclinical atherosclerosis.⁷ Lifestyle, multi-vascular imaging data, and clinical information were collected from 4,052 participants of the Progression of Early Subclinical Atherosclerosis Study (PESA) who were free of cardiovascular events at baseline.  Participants were adults between 40-54 years old who filled out a questionnaire of self-reported food intake over the past 15 days.  Three patterns of breakfast consumption were studied; high-energy breakfast (> 20% of total daily energy intake-27% of the study population); low-energy breakfast (5-20% of total daily energy intake-70%); and skipping breakfast (<5% of total daily energy intake-3%).  Compared with high-energy breakfast intake, those persons who skipped breakfast had a higher prevalence of non-coronary atherosclerosis (HR: 1.55 [95% CI: 0.97-2.46]) and generalized atherosclerosis (HR: 2.57 [95% CI: 1.54-4.31]). Atherosclerotic plaques were found in the aorta and carotid arteries.  Low-energy breakfast was associated with more carotid artery and illiofemoral artery plaques.  Skipping breakfast is characterized by overall unhealthy food choices, frequent eating out, and busy schedules.  Men, smokers, those or eat more red meat and drink more alcohol are more likely to skip breakfast. Persons who skipped breakfast were more frequently overweight or obese. 

Recently, a second study supports the study from Spain.  In a prospective cohort study from the National Health and Nutrition Examination Study of 1994 the frequency of eating breakfast to all-cause and cardiovascular mortality was investigated through using weighted Cox proportional hazards regression models in US adults aged 40-75 years old.⁸ 

The 6,550 participants (mean age 53.2 years; 48.0% male) in this study reported that 5.1% never consumed breakfast, 10.9% rarely consumed breakfast, 25.0% consumed breakfast some days, and 59.0% consumed breakfast every day. During 112,148 person-years of follow-up, 2,318 deaths occurred including 619 deaths from cardiovascular disease. After adjustment for age, sex, race/ethnicity, socioeconomic status, dietary and lifestyle factors, body mass index, and cardiovascular risk factors, participants who never consumed breakfast compared with those consuming breakfast everyday had hazard ratios of 1.87 (95% confidence interval: 1.14 to 3.04) for cardiovascular mortality and 1.19 (95% confidence interval: 0.99 to 1.42) for all-cause mortality.

This second study reinforces what has been stated from the founder of the American Dietetic Association Lenna Frances Cooper who stated “in many ways the breakfast is the most important meal of the day”.⁹ Clinicians should pay closer attention to dietary intake, especially meal consumption during the day as part of their overall cardiovascular assessment.  Those who do not eat breakfast or have breakfast on the run appear to be more prone to the development of subclinical atherosclerosis and therefore at higher risk of a cardiovascular event.  Educating patients about the importance of a healthy nutritious breakfast appears to be important to overall health.

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy. 

References:

1. Zhang X, Imperatore G, Thomas W, et al. Effect of lifestyle interventions on glucose regulation among adults without impaired glucose tolerance or diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2017;123:149-64.
2. Lin PH, Yet WT, Svetkey LP, et al. Dietary intakes consistent with the DASH dietary pattern reduce blood pressure increase with age and risk for stroke in a Chinese population. Asia Pac J Clin Nutr 2013;22:482-91.
3. Sonestedt E, Hellstrand S, Drake I, et al. Diet quality and change in blood lipids during 16 years of follow-up and their interaction with genetic risk for dyslipidemia. Nutrients 2016;8:274.
4. Goldberg GR, Black AE, Jebb SA, et al. Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Deviation of cut-off limits to identify under-recording. Eur J Clin Nutr 1991;45:569-81.
5. Smith TJ, Dotson LE, Young AJ, et al. Eating patterns and leisure-time exercise among active duty military personnel: comparison to the Healthy People objectives. J Acad Nutr Diet 2013;113:907-19.
6. de Castro JM. The time of day of food intake influences overall intake in humans. J Nutr 2004;134:104-11.
7. Uzhova I, Fuster V, Fernȁndez-Ortiz, et al. The importance of breakfast in atherosclerotic disease. J Am Coll Cardiol 2017;70:1833-42.
8. Rong S, Snetselaar LG, Xu G, et al. Association of skipping breakfast with cardiovascular and all-cause mortality. J Am Coll Cardiol 2019;73(16):.doi:10.1016/j.jacc.2019.01.065 (https://www.onlinejacc.org/content/73/16/2015)
9. Rubin F. Does skipping breakfast lead to weight loss or weight gain? JAMA 2019; Published online May 1, 2019. doi:10.1001/jama.2019.2927