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      Regular Breakfast Consumption and Type 2 Diabetes Risk Markers in 9- to 10-Year-Old Children in the Child Heart and Health Study in England (CHASE): A Cross-Sectional Analysis

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          Abstract

          Angela Donin and colleagues evaluated the association between breakfast consumption and composition and risk markers for diabetes and cardiovascular disease in 9- and 10-year-olds.

          Please see later in the article for the Editors' Summary

          Abstract

          Background

          Regular breakfast consumption may protect against type 2 diabetes risk in adults but little is known about its influence on type 2 diabetes risk markers in children. We investigated the associations between breakfast consumption (frequency and content) and risk markers for type 2 diabetes (particularly insulin resistance and glycaemia) and cardiovascular disease in children.

          Methods and Findings

          We conducted a cross-sectional study of 4,116 UK primary school children aged 9–10 years. Participants provided information on breakfast frequency, had measurements of body composition, and gave fasting blood samples for measurements of blood lipids, insulin, glucose, and glycated haemoglobin (HbA1c). A subgroup of 2,004 children also completed a 24-hour dietary recall. Among 4,116 children studied, 3,056 (74%) ate breakfast daily, 450 (11%) most days, 372 (9%) some days, and 238 (6%) not usually. Graded associations between breakfast frequency and risk markers were observed; children who reported not usually having breakfast had higher fasting insulin (percent difference 26.4%, 95% CI 16.6%–37.0%), insulin resistance (percent difference 26.7%, 95% CI 17.0%–37.2%), HbA1c (percent difference 1.2%, 95% CI 0.4%–2.0%), glucose (percent difference 1.0%, 95% CI 0.0%–2.0%), and urate (percent difference 6%, 95% CI 3%–10%) than those who reported having breakfast daily; these differences were little affected by adjustment for adiposity, socioeconomic status, and physical activity levels. When the higher levels of triglyceride, systolic blood pressure, and C-reactive protein for those who usually did not eat breakfast relative to those who ate breakfast daily were adjusted for adiposity, the differences were no longer significant. Children eating a high fibre cereal breakfast had lower insulin resistance than those eating other breakfast types ( p for heterogeneity <0.01). Differences in nutrient intakes between breakfast frequency groups did not account for the differences in type 2 diabetes markers.

          Conclusions

          Children who ate breakfast daily, particularly a high fibre cereal breakfast, had a more favourable type 2 diabetes risk profile. Trials are needed to quantify the protective effect of breakfast on emerging type 2 diabetes risk.

          Please see later in the article for the Editors' Summary

          Editors' Summary

          Background

          Worldwide, more than 380 million people have diabetes, a disorder that is characterized by high levels of glucose (sugar) in the blood. Blood sugar levels are usually controlled by insulin, a hormone released by the pancreas after meals (digestion of food produces glucose). In people with type 2 diabetes (the commonest type of diabetes) blood sugar control fails because the fat and muscle cells that normally respond to insulin become insulin resistant. Type 2 diabetes can often be controlled initially with diet and exercise and with drugs such as metformin and sulfonylureas. However, many patients eventually need insulin injections to control their blood sugar levels. Long-term complications of diabetes, which include an increased risk of heart disease and stroke (cardiovascular disease), reduce the life expectancy of people with diabetes by about 10 years compared to people without diabetes. Risk factors for the condition include being over 40 years old and being overweight or obese.

          Why Was This Study Done?

          Experts predict that by 2035 nearly 600 million people will have diabetes so better strategies to prevent diabetes are urgently needed. Eating breakfast regularly—particularly a high fiber, cereal-based breakfast—has been associated with a reduced risk of type 2 diabetes (and a reduced risk of being overweight or obese) in adults. However, little is known about whether breakfast eating habits affect markers of type 2 diabetes risk in children. In this cross-sectional study (an observational investigation that studies a group of individuals at a single time point), the researchers examine the associations between breakfast consumption (both frequency and content) and risk markers for type 2 diabetes, particularly insulin resistance and glycemia (the presence of sugar in the blood), in an ethnically mixed population of children; insulin resistance and glycemia measurements in children provide important information about diabetes development later in life.

          What Did the Researchers Do and Find?

          The researchers invited 9–10 year old children attending 200 schools in London, Birmingham, and Leicester to participate in the Child Heart and Health Study in England (CHASE), a study examining risk factors for cardiovascular disease and type 2 diabetes in children of South Asian, black African-Caribbean, and white European origin. The researchers measured the body composition of the study participants and the levels of insulin, glucose, and other markers of diabetes risk in fasting blood samples (blood taken from the children 8–10 hours after their last meal or drink). All the participants (4,116 children) reported how often they ate breakfast; 2,004 children also completed a 24-hour dietary recall questionnaire. Seventy-four percent of the children reported that they ate breakfast every day, 11% and 9% reported that they ate breakfast most days and some days, respectively, whereas 6% reported that they rarely ate breakfast. Children who ate breakfast infrequently had higher fasting insulin levels and higher insulin resistance than children who ate breakfast every day. Moreover, the children who ate a high fiber, cereal-based breakfast had lower insulin resistance than children who ate other types of breakfast such as low fiber or toast-based breakfasts.

          What Do These Findings Mean?

          These findings indicate that children who ate breakfast every day, particularly those who ate a high fiber breakfast, had lower levels of risk markers for type 2 diabetes than children who rarely ate breakfast. Importantly, the association between eating breakfast and having a favorable type 2 diabetes risk profile remained after allowing for differences in socioeconomic status, physical activity levels, and amount of body fat (adiposity); in observational studies, it is important to allow for the possibility that individuals who share a measured characteristic and a health outcome also share another characteristic (a confounder) that is actually responsible for the outcome. Although trials are needed to establish whether altering the breakfast habits of children can alter their risk of developing type 2 diabetes, these findings are encouraging. Specifically, they suggest that if all the children in England who do not eat breakfast daily could be encouraged to do so, it might reduce population-wide fasting insulin levels by about 4%. Moreover, encouraging children to eat a high fiber breakfast instead of a low fiber breakfast might reduce population-wide fasting insulin levels by 11%–12%. Thus, persuading children to eat a high fiber breakfast regularly could be an important component in diabetes preventative strategies in England and potentially worldwide.

          Additional Information

          Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001703.

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          Most cited references21

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          Use of 3,5-dichloro-2-hydroxybenzenesulfonic acid/4-aminophenazone chromogenic system in direct enzymic assay of uric acid in serum and urine.

          A new direct colorimetric procedure for uric acid assay in serum or urine is described, utilizing a 3,5-dichloro-2-hydroxybenzene sulfonic acid/4-aminophenazone chromogenic system in the presence of horseradish peroxidase and uricase from Aspergillus flavus. This chromogen system has a high absorptivity, affording useful results with sample/reagent volume ratios as low as 0.025. The procedure is applicable to serum, plasma, or diluted urine. A single working reagent is used; the reaction is complete in less than 15 min at room temperature. The red dye formed is measured at 520 nm; a blank sample measurement is not needed. The standard curve for the method is linear for uric acid concentrations up to 1500 mumol/L. Average analytical recovery of uric acid in human sera and urine exceeded 99%; within-run and between-run precision studies showed CV's of less than or equal to 1.2 and less than or equal to 2.2%, respectively. The new procedure correlated well with the uricase/catalase and uricase/ultraviolet methods. The method is suitable for automation.
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            Skipping breakfast and prevalence of overweight and obesity in Asian and Pacific regions: a meta-analysis.

            In Western countries, skipping breakfast is associated with a high prevalence of overweight and obesity. This meta-analysis aimed to determine if the same relationship exists in Asian and Pacific regions. A systematic literature search was performed for observational studies using a cross-sectional design that examined the relationship between frequency of eating breakfast and overweight or obesity. Odds ratios (ORs) for overweight or obesity were pooled with a variance-based method. Nineteen studies (93,108 total participants and 19,270 overweight or obese cases) were included. The pooled OR [95% confidence intervals (CI)] of overweight or obesity for the lowest vs. highest category of breakfast frequency was 1.75 [1.57 to 1.95] (P<0.001). Between-study heterogeneity in the association's strength was highly significant (I-squared=36.4%, P<0.001), although a positive OR was shown in all but one included study. However, no study characteristics could be identified to explain the heterogeneity. This meta-analysis suggests that a positive association between skipping breakfast and overweight and obesity is globally observed regardless of cultural diversity among countries. Promoting the eating of breakfast in all populations may be beneficial. Copyright © 2011 Elsevier Inc. All rights reserved.
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              At-home breakfast consumption among New Zealand children: associations with body mass index and related nutrition behaviors.

              The evidence supporting the relationship between breakfast consumption and body weight is growing, but the mechanisms to explain this relationship are less understood. This study aims to describe the relationship between breakfast consumption and body mass index (BMI) and relevant nutrition behaviors. Cross-section design using the New Zealand's 2002 National Children's Nutrition Survey. Participants were interviewed about their food habits and physical activity, completed a food frequency questionnaire, and were weighed and measured for height. A nationally representative sample of 3,275 children aged 5 to 14 years. Breakfast consumption, BMI, and nutrition behaviors. The demographic characteristics of children by breakfast consumption were generated by cross-tabulations. Regression models were used to examine the relationships between breakfast consumption and BMI and nutrition behaviors. Breakfast consumption was most frequent among boys, children aged 5 to 6 years, children aged 7 to 10 years, New Zealand European children, and children from more affluent neighborhoods. Age differences in breakfast consumption increased with socioeconomic deprivation; older children experiencing the most socioeconomic deprivation were the least likely to eat breakfast. Skipping breakfast was associated with a higher BMI (P=0.002). Children who missed breakfast were significantly less likely to meet recommendations for fruit and vegetable consumption (P=0.005) and more likely to be frequent consumers of unhealthy snack foods. No relationship was found between breakfast consumption and physical activity. Results from our study suggest that efforts to increase breakfast consumption should be prioritized for older children from more deprived backgrounds. Increasing at home breakfast consumption may limit the amount of unhealthful snack foods children consume later in the day. Schools also have the potential to make a reasonable nutritional impact by providing healthful and affordable breakfast options for children who do not eat breakfast at home.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                PLoS
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, USA )
                1549-1277
                1549-1676
                September 2014
                2 September 2014
                : 11
                : 9
                : e1001703
                Affiliations
                [1 ]Population Health Research Institute, Division of Population Health Sciences and Education, St George's University of London, London, United Kingdom
                [2 ]Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
                [3 ]Medical Research Council Human Nutrition Research, Cambridge, United Kingdom
                [4 ]Institute of Cardiovascular and Medical Sciences, University of Glasgow School of Medicine, Glasgow, United Kingdom
                Simon Fraser University, Canada
                Author notes

                The authors have declared that no competing interests exist.

                Conceived and designed the experiments: CGO AMS DGC PHW. Performed the experiments: ASD PHW DGC CGO AMS. Analyzed the data: ASD CMN ARR SAJ MRP NS DGC PHW. Wrote the first draft of the manuscript: ASD. Contributed to the writing of the manuscript: ASD CMN CGO ARR MRP SAJ AMS NS DGC PHW. ICMJE criteria for authorship read and met: ASD CMN CGO ARR MRP SAJ AMS NS DGC PHW. Agree with manuscript results and conclusions: ASD CMN CGO ARR MRP SAJ AMS NS DGC PHW. Enrolled patients: PHW.

                Article
                PMEDICINE-D-14-00428
                10.1371/journal.pmed.1001703
                4151989
                25181492
                7d87e0e5-4be1-4a0b-a270-971e0d932090
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 5 February 2014
                : 27 June 2014
                Page count
                Pages: 12
                Funding
                This research is supported by a Diabetes UK research grant (grant reference BDA 11/0004317). Data collection in the CHASE Study was supported by grants from the Wellcome Trust (grant reference 068362/Z/02/Z) and the National Prevention Research Initiative (NPRI) (grant reference G0501295). The Funding Partners for this NPRI award were: British Heart Foundation; Cancer Research UK; Department of Health; Diabetes UK; Economic and Social Research Council; Medical Research Council; Research and Development Office for the Northern Ireland Health and Social Services; Chief Scientist Office, Scottish Executive Health Department; and Welsh Assembly Government. Diabetes prevention research at St George's, University of London is supported by the NIHR CLAHRC South London. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology and Life Sciences
                Nutrition
                Medicine and Health Sciences
                Epidemiology
                Pediatric Epidemiology
                Public and Occupational Health

                Medicine
                Medicine

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