Blackwell Publishing AsiaMelbourne, AustraliaNDINutrition & Dietetics1446-6368Journal of the Dieticians Association of Australia, including the Journal of the New Zealand Dietetic Associationxxx 20056311520Original ArticleEating breakfast and children’s daily dietN.C. Wilson et al.

Nutrition & Dietetics 2006; 63: 15–20

DOI: 10.1111/j.1747-0080.2006.00019.x

ORIGINAL RESEARCH

Eating breakfast and its impact on children’s daily diet Noela C. WILSON,1 Winsome R. PARNELL,2 Mark WOHLERS1 and Philippa M. SHIRLEY1 LINZ ® Activity and Health Research Unit and 2Department of Human Nutrition, University of Otago, Dunedin, New Zealand 1

Abstract Objective: To describe the impact of breakfast eating on the nutrient intakes of New Zealand children aged 5–14 years. Design: Secondary data analysis of a cross-sectional national survey. Subjects: A total of 3275 children aged 5–14 years. Setting: Dietary data were collected primarily in the homes of the children. Main outcome measures: ‘Breakfast consumption’ was based on whether any food items were consumed between 6 and 9 a.m. from 24-hour diet recall data. Nutrient intake was also based on 24hour diet recall. Data analyses: Demographic profile of breakfast eaters was determined. Difference in daily nutrient intakes between breakfast and non-breakfast eaters was determined. Results: In total, 84% of New Zealand children reported eating breakfast. Younger children were more likely to eat breakfast than older children. Breakfast habits differed between Ma ori, Pacific and ‘New Zealand European & Others’ children. When intakes were adjusted for the demographic variables that significantly affected breakfast consumption patterns, daily nutrient intake of children who ate breakfast compared with those who did not, was significantly better. This was true for all ethnic groups. Cereal (including cold, ready-to-eat and cooked) was the most common breakfast food. Conclusion: Although the majority of New Zealand children consume breakfast, a significant improvement in daily nutrient intake could be achieved for children of all ethnic groups who currently do not consume breakfast.

Key words: breakfast, children, diet, New Zealand, nutrients, nutritional epidemiology.

INTRODUCTION ‘Nutritionists have traditionally recognized breakfast as the most important meal of the day’,1 and having breakfast is recognised as a healthy practice by many authors.2–4 It has also been stated that ‘breakfast makes an important contribution to the nutrient intake of children’.4 N.C. Wilson, PhD, Director W.R. Parnell, PhD, Senior Lecturer M. Wohlers, MSc, Biostatistician P.M. Shirley, Research Assistant Correspondence: N.C. Wilson, LINZ® Activity and Health Research Unit, University of Otago, PO Box 56, Dunedin, New Zealand. Email: [email protected] N.C. Wilson and W.R. Parnell were involved in the study design, data collection and primary data analysis. M. Wohlers undertook the statistical analyses. P.M. Shirley undertook the literature review and completed preliminary data analyses.

© 2006 Dietitians Association of Australia

Literature on children’s breakfast consumption has been dominated by Northern Hemisphere studies and most study samples have been relatively small (n < 200). The Australian 1995 National Nutrition Survey included 2193 children aged 4–15 years,5 and the frequency of breakfast eating has been reported.6 However, to date there have been no reports on the impact of breakfast eating on nutrient intake of Australian children. The 2002 national survey of the nutritional status of New Zealand (NZ) children aged 5–14 years was conducted with 3275 children of diverse ethnic backgrounds.7 These data provide an opportunity to explore, in detail, breakfast food patterns among NZ children, the influence of ethnic background and how their choices might impact on their overall nutrition status. The aim of the present study was to compare the nutrient intake of NZ children who have something to

15

N.C. Wilson et al.

eat before 9 a.m. with those who do not. The selection of breakfast food and beverage items by NZ children was also documented.

METHODS Children in the 2002 National Children’s Nutrition Survey (CNS02) completed a three-pass 24-hour diet recall (using direct data entry) in which the time of all food and beverage items consumed was recorded.7 Interviews were conducted in the home, and interviews with children aged five to nine years were only undertaken with a parent or caregiver present. Children who consumed at least one item between 6 and 9 a.m. were classified as breakfast eaters. All other children were classified as non-breakfast eaters. The New Zealand Index of Deprivation, which is based on area of residence, was used as the index of socioeconomic status.8 Each child’s residential address was placed into one of 10 categories based on eight dimensions of deprivation, including income, access to a car and living space. Finally, each child was categorised into one of five quintiles of NZDep01 from I (least deprived) to V (most deprived). Ethnicity was self-reported by each child or their parent based on their response to the question ‘Which ethnic group do you belong to’. Although up to three ethnic groups could be chosen, a single ethnic category was assigned using the NZ census system of priority recoding of ethnicity: Ma ori, Pacific and all remaining NZ European & Others (NZEO). Weight status (normal weight, overweight, obese) was determined using internationally based cut-off points for body mass index for defining overweight and obesity among children.9 Body mass index was determined using the calculation: weight (kilograms) divided by height (metres) squared. Weight was measured by trained staff using scales calibrated daily, to the nearest 0.2 kg; up to three measurements were recorded for each child. Weight was defined as the average weight of the two closest measurements. Height was measured by trained staff using a portable stadiometer, with up to three measurements made to the nearest 0.1 cm. Height for each child was defined as the mean of the two closest measurements. All analyses were performed with the statistical software package STATA (version 8.0, Stata Corporation, College Station, TX, USA). The survey commands allowed the survey weightings and primary sampling units (schools) developed from the two-stage clustered sampling procedure of the CNS027 to be taken into account, giving appropriate population estimates, standard errors and test statistics.7 A t-test, taking into

16

account survey design and probability weights, was used to determine whether breakfast eaters and nonbreakfast eaters differed with respect to gender, ethnicity, age and socioeconomic status. Nutrient intakes were calculated from the 24-hour diet recall using the NZ Food Composition database.10 Differences were considered statistically significant at P < 0.05.

RESULTS A total of 3725 children aged 5–14 years completed the 24-hour diet recall. In total, 84% were classified as breakfast consumers (Table 1). Fewer female children (80.8%) compared with male children (87.0%), ate breakfast. Breakfast consumption was highest in the two younger age groups and lower in the 11–14 years age group. Breakfast consumption was highest among NZEO (87.9%) followed by Ma ori (77.6%) and Pacific (71.0%) children. The number of children who ate breakfast in each NZDep01 quintile decreased with increasing level of deprivation from 95.7% in NZDep01-I to 77.2% in NZDep01-V. A lower per cent of

Table 1 Demographic profile of children who consumed breakfast (total sample, n = 3275) %(a) Proportion of total sample consuming breakfast Gender Male Female Age group (years) 5–6 7–10 11–14 Ethnicity Ma ori Pacific NZEO NZDep01 ratings I (least deprived) II III IV V (most deprived) School status Urban Rural

84.0 87.0 80.8 86.8 87.3 79.3 77.6 71.0 87.9 95.7 84.9 82.5 79.0 77.2 82.6 90.1

(a)

Significant differences at 0.05 level using a t-test taking into account survey design and probability weights, are as follows: male versus female; 11–14 years versus 5–6 years, 7–10 years; Maori versus Pacific, NZEO; NZEO versus Pacific; NZDep01-I versus II, III, IV, V; NZDep01-II versus V; urban versus rural. NZEO = New Zealand European & Others.

© 2006 Dietitians Association of Australia

Eating breakfast and children’s daily diet

Table 2 Mean daily intake of selected nutrients by breakfast consumption status Nutrient intake Energy (kJ) Total fat (g) Saturated fat (g) % Energy from fat Protein (g) % Energy from protein Carbohydrate (g) % Energy from CHO Dietary fibre (g) Vitamin A (µg) Vitamin C (mg) Thiamin (mg) Riboflavin (mg) Calcium (mg) Iron (mg) Zinc (mg) Folate (µg)

Breakfast consumed Mean (95% CI)(a) 8748 (8575, 8922) 78 (76, 79) 34.2 (33.3, 35.1) 32.8 (32.3, 33.2) 72 (70, 75) 13.8 (13.6, 14.1) 279 (273, 285) 54.0 (53.4, 54.5) 18.7 (18.3, 19.2) 679 (651, 708) 117 (110, 123) 1.8 (1.5, 2.0) 2.0 (1.8, 2.3) 788 (758, 818) 11.6 (11.3, 12.0) 10.2 (9.8, 10.6) 257 (249, 266)

Breakfast not consumed Mean (95% CI) 7982 (7612, 8353) 74 (69, 78) 32.1 (30.2, 33 9) 34.1 (33.2, 35.0) 65 (62, 68) 13.6 (13.2, 14.0) 249 (236, 262) 52.8 (51.8, 53 9) 16.0 (15.0, 17.0) 555 (506, 603) 99 (88, 110) 1.1 (1.0, 1.3) 1.4 (1.2, 1.6) 650 (597, 703) 9.6 (9.0, 10.1) 8.9 (8.3, 9.4) 190 (175, 205)

P-value(b) 0.000 0.075 0.032 0.012 0.000 0.311 0.000 0.049 0.000 0.000 0.006 0.000 0.001 0.000 0.000 0.000 0.000

(a)

Adjusted for age, gender, ethnicity, NZDep01 rating and rural/urban differences. Difference between children who ate breakfast compared with those who did not, using a t-test. CHO = carbohydrate.

(b)

children attending urban schools (83.1%) ate breakfast than children attending rural schools (90.0%). The mean daily nutrient intake of breakfast eaters compared with non-breakfast eaters, after adjusting for age, gender, ethnicity, NZDep01 and urban/rural differences, was significantly higher for a wide range of nutrients (Table 2), and for energy intake. Although there is no statistically significant difference in total fat intake between groups, the overall diet of the breakfast group had a lower per cent energy from fat, as a result of their higher energy intake. Significant differences between the mean intake of energy and nutrients comparing breakfast consumers and non-breakfast consumers by ethnicity are presented in Table 3. There were significantly higher intakes for breakfast eaters of all three ethnic groups in the following nutrients: protein, dietary fibre and folate. Pacific children who ate breakfast also had significantly higher energy and carbohydrate intakes. M a ori and Pacific children, but not NZEO children, who consumed breakfast had higher iron and zinc intakes, than children who had not consumed breakfast. The energy intakes of obese, overweight and normal weight children, were not significantly different in either the breakfast or non-breakfast groups (Table 4). Similarly, the per cent of children in each weight category

© 2006 Dietitians Association of Australia

was not influenced by breakfast status. Although breakfast provided only 16.2% of the daily energy intake (Table 5), it provided a significant proportion of the daily intake of calcium (29.9%), iron (26.9%), zinc (20.2%), thiamin (37.0%), riboflavin (35.1%) and folate (36.8%). Although Pacific children had the lowest prevalence of breakfast consumption, the per cent contribution made by breakfast to total intake, was higher for energy, fat, carbohydrate and vitamin A, than in the other two ethnic groups. Breakfast cereal (all types) was the most commonly consumed food chosen by more than half of the children (Table 6). Bread (including toast) was the second most popular item (35.1%), and chocolate flavoured drinks (e.g. Milo) the most frequently chosen beverage (13.9%).

DISCUSSION A strength of these data is that they are from a representative group of NZ children where multistage sampling ensures that results can be extrapolated to all NZ children and statements can be made about different ethnic groups. Most NZ children (84%) aged 5–14 years ate or drank something before school but more NZEO than M a ori or Pacific children reported eating in this time period. This may illustrate a cultural difference in

17

N.C. Wilson et al.

Table 3 Difference in mean daily nutrient intake of breakfast versus non-breakfast consumers, by ethnicity M aori(a) Diff Energy (kJ) % Energy from fat Protein (g) Carbohydrate (g) Dietary fibre (g) Vitamin A (µg) Thiamin (mg) Riboflavin (mg) Calcium (mg) Iron (mg) Zinc (mg) Folate (µg) (a) (b) (c)

(b)

Pacific(a) (c)

P-value

Diff

(b)

1021 7.1

0.046

3.7 131

0.000 0.045

3.1 1.7 91

0.000 0.005 0.000

NZEO(a) (c)

P-value

0.015

12.8 28 3.5

0.000 0.049 0.003

166 2.3 2.0 69

0.010 0.000 0.001 0.000

Diff

(b)

P-value(c)

−2.5 6.9

0.016 0.024

2.1 181 0.6 0.5 159

0.028 0.002 0.002 0.019 0.014

69

0.000

Data adjusted for age, gender, NZDep01 rating, rural/urban differences. Difference between mean intake of breakfast consumers and non-breakfast consumers. t-test.

Table 4 Weight status and energy intakes, by breakfast status Weight status and daily energy Obese % Daily energy (kJ) Overweight % Daily energy (kJ) Normal % Daily energy (kJ)

Breakfast(a) Mean (95% CI)

Non-breakfast Mean (95% CI)

7.5 (6.1, 9.2) 8910 (8330, 9488)

8.9 (6.8, 11.6) 8031 (7337, 8726)

21.7 (19.6, 24.0) 8842 (8498, 9186)

21.0 (17.6, 24.8) 8072 (7434, 8710)

69.4 (66.9, 71.9), 8725 (8495, 8954)

67.4 (62.9, 71.7) 8077 (7571, 8583)

(a) Adjusted for gender, age, ethnicity, NZDep01 rating and rural/urban differences.

the view that eating before the day’s activities start, is important. The 13.7% of children aged 7–10 years who did not report eating breakfast is very similar to the 13% of 10-year olds who reported not eating any breakfast in the period 1987–88 in the Los Angeles Bogalusa heart study.1 Among NZ children, those who are least likely to eat breakfast are in the 11–14 years age group and this is similar to a Scottish study where breakfast omission was most frequent among young adults,4 and to the results from a Swedish study11 and the Australian National Nutrition Survey.6 Clearly, there is a challenge

18

in NZ as in Australia and other developed countries to encourage the habit of breakfast eating, throughout childhood and into adulthood. A Canadian study by Chao and Vanderkooy12 noted that breakfast omission was more common among economically disadvantaged children. This is congruent with the present study where breakfast eating decreased in frequency with increasing level of deprivation. However, in a study of 699 13-year-old Australians, 12% skipped breakfast, but this appeared to be related to individual choice rather than socioeconomic status.3 Given that some children do not eat breakfast, the question of their overall dietary adequacy is important. Numerous studies have concluded that children who skip breakfast have significantly lower daily nutrient intakes than those who do not,1,2,13–15 and the data from the present study support these conclusions. Reviews of the benefits of breakfast consumption are equivocal in their conclusions about the influence of this meal on cognitive function and learning, but unequivocal in their conclusions that this meal enhances dietary intake.12,16 Sjoberg and coworkers in Sweden concluded that omitting breakfast may increase the risk of a poorer nutrient intake, in their experimental study of 1245 older children, teenagers aged 15–16 years.11 The enhanced daily nutrient intake of children in the present study who ate breakfast compared with that of children who missed this meal reinforces the need to encourage healthy eating at this period of the day. Breakfast eating has the potential to reduce some of the low intakes of nutrients noted in specific ethnic

© 2006 Dietitians Association of Australia

Eating breakfast and children’s daily diet

Table 5 Contribution of breakfast to daily energy and nutrient intake % Daily intake contributed by breakfast Whole population Energy Fat Protein Carbohydrate Calcium Iron Zinc Dietary fibre Vitamin A Vitamin C Thiamin Riboflavin Folate

M aori

16.2 (15.8, 16.7)(a) 13.1 (12.5, 13.7) 18.0 (17.5, 18.5) 18.1 (17.5, 18.6) 29.9 (28,9, 30,9) 26.9 (26.0, 27.8) 20.2 (19.5, 20.9) 17.9 (17.2, 18.6) 19.4 (18.5, 20.4) 14.0 (13.0, 15.0) 37.0 (35.6, 38.3) 35.1 (34.0, 36.3) 36.9 (352, 38.6)

Pacific

16.2 (15.5, 17.0) 13.3 (12.5, 14.0) 117.7 (16.9, 18.4) 18.1 (17.3, 18.8) 29.7 (28.5, 30.9) 27.0 (26.0, 28.0) 19.9 (19.1, 20.7) 18.7 (17.6, 19.8) 20.8 (19.4, 22.2) 12.6 (11.1, 14.1) 37.1 (35.3, 38.8) 34.2 (33.0, 35.5) 37.4 (34.7, 40.1)

18.7 16.7 18.6 20.6 31.4 26.4 20.1 19.4 24.3 13.5 34.0 31.7 34.6

(17.3, (15.1, (16.9, (19.2, (29.6, (23.6, (18,4, (17.4, (22.7, (12.5, (30.3, (29.0, (31.2,

20.2)(b) 18.3)(b) 20.2) 21.9)(b) 33.1) 29.2) 21.8) 21.4) 25.9)(b) 14.5) 37.8) 34.4) 38.1)

NZEO 16.0 12.7 18.1 17.9 29.8 26.9 20.3 17.5 18.5 14.5 37.2 35.7 37.0

(15.5, (12.0, (17.4, (17.2, (28.5, (25.7, (19,4, (16.6, (17.3, (13.5, (35.5, (34.2, (34.9,

16.6) 13.4) 18.8) 18.5) 31.2) 28.1) 21.2) 18.4) 19.7) 15.7) 39.0) 37.2) 39.1)

(a)

Mean (95% CI). Confidence intervals do not overlap with Maori and NZEO children. NZEO = New Zealand European & Others.

(b)

Table 6 Items consumed at breakfast(a) Food/beverage item Breakfast cereal(b) Bread/toast Chocolate flavoured drinks (e.g. Milo) Juice/fruit drink Milk (beverage, not flavoured) Tea/coffee Fruit(c) Muffins/cake Dietary supplement Egg Other savoury dishes Confectionary(d) Sandwiches/pizza/burgers (a) (b) (c) (d)

Frequency of consumption among breakfast eaters 56.9 (53.8, 60.0)(b) 35.1 (32.4, 37.8) 13.9 (12.2, 15.5) 11.2 8.2 5.4 5.4 4.7 4.3 3.3 3.0 2.2 2.2

(9.4, (6.5, (4.2, (4.1, (3.5, (3.0, (2.3, (2.0, (1.6, (1.4,

13.1) 9.8) 6.5) 6.7) 5.9) 5.5) 4.2) 3.9) 2.9) 2.9)

Mean per cent (95% CI). Cereal includes cold, ready-to-eat and cooked breakfast cereals. Fruit includes fresh, canned and dried. Confectionary includes chocolate and sweets.

groups. Pacific children typically have low intakes of dietary fibre, vitamin A, riboflavin, folate and calcium.7 Pacific children who ate breakfast had higher daily intakes of dietary fibre (3.5 g), folate (69 µg) and calcium (166 mg). However, in light of higher obesity levels in Pacific children,7 reducing the observed elevated energy and fat intakes in breakfast consumers, while increasing the daily nutrient intake, is important. Ma ori children who had breakfast had a better nutrient intake

© 2006 Dietitians Association of Australia

with respect to dietary fibre, vitamin A, iron, zinc and folate without any corresponding increase in energy intake. NZEO children who ate breakfast did not have a higher total energy, but did have a lower per cent energy from fat in their overall diet. It is of interest to note that NZEO children, compared with the other two ethnic groups, were the least likely to experience poor nutrient intakes in their overall diets.7 In summary, breakfast consumption is associated with a better nutrient intake in NZ children aged 5– 14 years, when compared with those who do not report eating breakfast. Breakfast consumption has significant nutrient intake advantages for all three ethnic groups.

ACKNOWLEDGEMENTS The 2002 Children’s Nutrition Survey was funded by the Ministry of Health. Other principal investigators for the survey came from the University of Auckland (David Schaaf, Robert Scragg) and Massey University (Eljon Fitzgerald).

REFERENCES 1 Nicklas TA, O’Neil CE, Berenson GS. Nutrient contribution of breakfast, secular trends, and the role of ready-toeat cereals: a review of data from the Bogalusa Heart Study. Am J Clin Nutr 1998; 67: 757S–63S. 2 Ortega R, Requejo A, Lopez-Sobaler A et al. Differences in the breakfast habits of overweight/obese and normal weight school children. Int J Vitam Nutr Res 1998; 68: 125–32.

19

N.C. Wilson et al.

3 Shaw ME. Adosescent breakfast skipping: an Australian study. Adolescence 1998; 33 (132): 851–7. 4 Ruxton CH, O’Sullivan KR, Kirk TR, Belton NR, Holmes MA. The contribution of breakfast to the diets of a sample of 136 primary-schoolchildren in Edinburgh. [Erratum appears in Br J Nutr 1996 Dec; 76 (6): following 914.] Br J Nutr 1996; 75: 419–31. 5 Australian Bureau of Statistics. National Nutrition Survey: Users’ Guide 1995. Belconnen, ACT: Australian Bureau of Statistics, Department of Health and Family Services, 1997; 160. 6 Australian Bureau of Statistics. National Nutrition Survey: Selected Highlights Australia 1995. Belconnen, ACT: Australian Bureau of Statistics, Department of Health and Family Services, 1997; 60. 7 Parnell WR, Scragg RKR, Wilson NC, Schaaf D, Fitzgerald EDH. NZ Food: NZ Children: Key Results of the 2002 National Children’s Nutrition Survey. Wellington: Ministry of Health, 2003; 267. 8 Salmond C, Crampton R. NZDep2001 Index of Deprivation. Wellington: Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago, 2002. 9 Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity

20

10

11

12 13

14

15

16

worldwide: international survey (Comment). BMJ 2000; 320 (7244): 1240–43. Crop and Food Research. FOOD FILES. The New Zealand food composition database. Palmerston North, New Zealand: New Zealand Institute of Crop and Food Research, 1993. Sjoberg A, Hallberg L, Hoglund D, Hulthen L. Meal pattern, food choice, nutrient intake and lifestyle factors in the Goteborg adolescence study. Eur J Clin Nutr 2003; 57: 1569–78. Chao E, Vanderkooy P. An overview of breakfast nutrition. J Can Diet Assoc 1989; 50: 225–8. Kleinman RE, Hall S, Green H et al. Diet, breakfast, and academic performance in children. Ann Nutr Metab 2002; 46 (Suppl 1): 24–30. Hooper M, Evers S. What do Ontario children eat for breakfast? Food group, energy and macronutrient intake. Can J Diet Pract Res 2003; 64: 28–30. Nicklas TA, Bao W, Webber LS, Berenson GS. Breakfast consumption affects adequacy of total daily intake in children. J Am Diet Assoc 1993; 93: 886–91. Pollitt E, Mathews R. Breakfast and cognition: an integrative summary. Am J Clin Nutr 1998; 67: 8045– 135.

© 2006 Dietitians Association of Australia