Importance of Breakfast in Relation to Obesity

A critical evaluation

Through many influential sources, such as research and advertising, breakfast has been widely portrayed as the most important meal of the day. In fact, much epidemiological evidence tends to support this notion by demonstrating that breakfast skipping leads to an increased risk of obesity (McCrory et al, 2014; Browns et al, 2013). Since the 1980’s, the prevalence of overweight and obesity has sharply risen worldwide, with 1.9 billion adults being characterized as overweight and 600 million as obese in 2014 (WHO, 2015). In the UK alone, the proportion of men and women characterized as obese has increased by 14% and 10% from the early 1990’s to 2015 (Public Health England, 2017). For an individual, obesity is usually the result of an imbalance between energy consumed and energy expended (WHO, 2016). Although energy imbalance ultimately leads to weight gain, the primary factors are not yet completely understood. Currently, there is no evidence linking specific foods to obesity, however recently, much attention has been given to eating behaviours, such as breakfast eating, as they may represent a combined effect of a number of nutrients, and breakfast habits could potentially demonstrate an interplay between other lifestyle factors, such as an overall poor diet and physical inactivity. If eating behaviours are observed to be causally linked to weight gain, then they could potentially represent practical strategies for obesity prevention. On these grounds, this essay will explore a wide variety of evidence regarding the association between breakfast skipping and weight gain. Furthermore, we shall discuss whether breakfast eating habits have been linked with overall dietary health and physical activity, as these factors are now known to be strongly linked with obesity.

It is reasonable to assume that one’s beliefs about breakfast will influence the likelihood of an individual engaging in this behaviour. For example, early research reported that the majority of habitual breakfast eaters believed that ‘breakfast was important for providing energy and increasing productivity throughout the morning’ (Chapman et al, 1998). More recently, among a UK national representative sample, it was reported that 64% of the population habitually consumed breakfast, whilst 6% skipped it. Moreover, the breakfast eaters believed that breakfast maintained weight control, whereas breakfast skippers believed that missing breakfast supported weight loss (Reeves et al, 2013). This evidence signifies that eating behaviours, such as breakfast skipping, are largely determined by what individuals believe. Some beliefs about scientific matters are thought true despite substantial evidence disproving them, whereas other science-based beliefs are allegedly true even though inadequate evidence exists to support or disprove them (McCrory et al, 2014). This is important because a widely accepted belief is that frequently consuming breakfast compared with skipping breakfast is preventative of weight gain or causes weight loss.

A recent meta-analysis reported that the risk for overweight and obesity increases by 55% when breakfast is skipped (Browns et al, 2013).  As this association has often been reported, a theory has been developed which, if correct, may potentially explain how breakfast skipping can lead to weight gain.  The theory states that ‘when breakfast is skipped, there is an overcompensation for the energy missed at breakfast by ingesting more energy than one otherwise would have consumed at breakfast alone’ (Pereira et al, 2011). On the other hand, let’s also consider that breakfast skipping could result in no weight change over time (in a scenario where breakfast skipping does not lead to overcompensation) or to weight loss (in a scenario where there is absence of compensation). While cross-sectional studies have generally reported that breakfast skipping leads to weight gain, currently, there are limited high quality experimental evidence supporting this notion. It is also important to point out that all of the studies reviewed in the Browns et al (2013) meta-analysis, were cross-sectional thereby causality cannot be concluded from their findings.

Whilst randomized controlled trials do not directly allow conclusions to be drawn concerning fluctuations in energy balance, they do allow for conclusions to be made about temporary changes which, if constant over time, could potentially result in changes in energy balance. Yet, short-duration (≤ 1 week) randomized controlled trials investigating the effects of breakfast skipping on successive energy intake have been equivocal (Astbury et al, 2011; Leidy et al, 2013; Levitsky et al, 2013). For example two of these studies reported that impromptu lunch intake was greater after breakfast skipping, compared to when breakfast was consumed (Astbury et al, 2011; Leidy et al, 2013). In contrast, Levitsky et al (2013) showed under compensation at lunch, signifying that ‘the collective intake across breakfast and lunch remained lower in the breakfast skipping condition’. On the other hand, longer-duration (2-3 weeks) randomized controlled trials do not appear to show a relationship between breakfast skipping and weight gain (Farshchi et al, 2005; Schlundt et al, 1992; Tuttle et al, 1950). Although the results of these experimental trials are varied, they do not support for the theory that ‘breakfast skipping leads to overeating’.

Furthermore, in prospective studies with up to 10 years follow-up, it has been observed that individuals who regularly ingest breakfast appear to gain less weight (Odegaard et al, 2013; Purslow et al, 2008; van der Heijden et al, 2007). One explanation for this could be that skipping breakfast may merely be an indication of overall lifestyle, for example, substantial evidence suggests that ‘skipping breakfast is associated with a less nutritious diet and less physical activity’ (Szajewska et al, 2010; Rampersaud et al, 2005). This is significant because both of these modifiable factors are strongly correlated with the increased risk of obesity and other chronic diseases. For example, much epidemiological evidence shows a relationship between eating breakfast and healthier food choices and dietary habits (Skinner et al, 1985; Lattimore et al, 2010), whereas, breakfast skippers are associated with whole diets that are inadequate (Christakis et al, 1968; Serra-Majem et al, 2002). Of the studies mentioned above, two are outdated, nevertheless, they have been included to demonstrate that the association between breakfast consumption and healthy lifestyle habits has been repeatedly observed over the last 50 years or so, demonstrating that this relationship has remained constant over time. To further explain the results mentioned above, a recent review by Rampersaud et al (2005), revealed that habitual breakfast skippers were more likely to be overweight compared to breakfast eaters, regardless of a higher overall energy intake in the breakfast eating group. It is possible that the combination of breakfast skipping with additional poor eating behaviours, such as an insufficient fruit and vegetable consumption, is contributing to the results observed in this study, as it has been previously established that a low intake of fruit and vegetables increases the risk for obesity and type 2 diabetes mellitus (Hamer et al, 2007).

Regarding physical activity, much epidemiological evidence reports that ‘breakfast skippers are less likely to participate in physical activity’ (Cohen et al, 2003; Keski-Rahkonen et al, 2003; Aarnio et al, 2002). A proposed mechanism is that skipping breakfast may lead to lethargy and physical inactivity throughout the day (Pollitt et al, 1998; Meyers et al, 1989 ; Shaw et al, 1998) thereby contributing to positive energy balance and thus weight gain. Although there is a vast amount of evidence supporting the idea that breakfast skipping is associated with poor dietary habits and physical inactivity, no conclusions can be drawn yet as the evidence which has mostly found these positive associations have been drawn from cross-sectional and prospective studies which as mentioned before, do not prove causality.

Clearly, obesity is a significant public health problem due to its high prevalence and important health consequences. Therefore, in order to provide practical recommendations for the control and/or prevention of obesity, its causal factors must be identfied. Although there is substantial evidence linking breakfast skipping to weight gain, a reasoned conclusion cannot be drawn as the majority of studies reporting this association merely identify a relationship, not a causal pathway as they are cross-sectional or observational studies. On the other hand, experimental trials can usually determine causation.  Regarding the trials reviewed in this essay, short-term trials have demonstrated effects of breakfast skipping on energy intake and appetite later in the day, although together these results are ambiguous, also longer-term randomized controlled trials have not show effects of breakfast skipping on energy imbalance and subsequent weight change.

Overall, the evidence we have discussed here does not strongly support the widely accepted theory that breakfast skipping leads to an overcompensation of energy in subsequent meals, nor does the evidence support a common belief that breakfast contributes to weight gain or loss. It can however be argued that whether an individual eats breakfast or not, this will not directly influence their risk of weight gain or obesity. In fact it could be argued that other lifestyle behaviours, such as physical inactivity and inadequate diets, are actually the factors driving this observed association. An integral issue when evaluating the impact that lifestyle behaviours have on obesity is that these behaviours are very difficult to precisely measure within a large, generalizable population. Equally, trying to establish that one factor alone is impacting weight gain is a difficult task, as seen in this essay, many factors interact with and affect each other. Therefore, as to whether breakfast is the most important meal of the day with regards to the obesity, the jury is still out, so to speak. In the meantime, the simple recommendation to eat less and exercise more appears to still be the most effective tool in the prevention and treatment of obesity.

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