Several clinical conditions are associated with the development of cardiovascular disease (CVD). These conditions include diabetes mellitus, obesity, hypertension and dyslipidaemia and they can be modified by changes in lifestyle.
Among lifestyle factors, diet – including both the nutritional quality and acquired eating patterns – could be a major target of preventative CVD strategies.
Breakfast has previously been associated with factors such as satiety, daily energy intake, metabolic efficiency of the diet and appetite regulation. There have also been studies on the association between omitting breakfast and subsequent increase in cardiometabolic health markers such as obesity, unfavourable lipid profile and diabetes.
This study claims to be the first to investigate the association of breakfast and the development of subclinical atherosclerosis and therefore the association was sought between different breakfast patterns and CVD risk factors and subclinical atherosclerosis.
The PESA study (Progression of Early Subclinical Atherosclerosis) is an ongoing prospective observational study in which males and females between 40 and 54 years of age participate. They were all free of CVD at baseline and the final study sample consisted of 4052 participants.
A computerised dietary questionnaire on 161 food items was obtained. A breakfast pattern was obtained as follows: High-energy breakfast (contributing>20% of total daily energy intake), low-energy breakfast (5% to <20% of total daily energy intake) and skipping breakfast (consuming <5% of total daily energy intake). Height, weight, abdominal circumference, blood pressure and traditional CVD risk factors were also obtained.
The presence of atherosclerosis was sought with a two-dimensional ultrasound assessing carotid arteries, infrarenal abdominal aorta and ilio-femoral arteries. For the presence of atherosclerosis in the coronary arteries calculating coronary calcium score, a 16-slice non-contrast computed scan was used. A multivariate logistic regression was used to assess the association between breakfast patterns and subclinical atherosclerosis.
Skipping breakfast occurred in 2% of participants, 69% had low energy breakfast and 27% were high-energy breakfast takers.
When the breakfast skipper group was compared to the low and high energy breakfast group, those that skipped breakfast were mostly men, more were current smokers and they also consumed the most caloric energy at lunch. The breakfast skippers had the most cardiometabolic risk markers than the other 2 groups and even the low-energy breakfast group had more cardiometabolic risk markers than the high-energy breakfast group. The probabilities of presenting with obesity, abdominal obesity, metabolic syndrome, low HDL-cholesterol and hypertension were also higher in the breakfast skipper group.
In the total PESA group (with all 3 breakfast groups included) the prevalence of atherosclerosis plaques were 62% in breakfast skipper group, 60% in the low-energy group and 13% in the high-energy breakfast group. The distribution of atherosclerotic plaques was seen in ilio-femoral arteries in 44%, carotid arteries in 31%, and the aorta in 24%. An increased coronary artery calcium score was seen in 18.1% of the total population.
The low-energy breakfast group (breakfast skippers) had the highest odds of risk of atherosclerosis with Odds Ratio for abdominal atherosclerotic plaques of 1.79 (95%CI: 1.16-2.77). The odds for ilio-femoral plaques were 1.72 (95% CI: 1.11-2.64).
This is the first time that evidence is presented that different breakfast dietary patterns may have an influence on the risk of subclinical atherosclerosis.
Regularly skipping breakfast is associated with a 1.55 and 2.57-fold higher odds for the presence of generalised subclinical atherosclerosis. This increased risk of atherosclerosis was independent of the presence of traditional cardiovascular risk factors.
In general those participants who regularly skipped breakfast also had other unhealthy lifestyle factors such as example higher prevalence of smoking. This group also had overall unhealthy food choices, frequent eating out and had higher alcohol consumption. They also had the highest prevalence of overweight.
Previously 2 other studies also focused on skipping breakfast and both showed an increased association with cardiovascular disease presence.
The high-energy breakfast group also consumed in general more vegetables and fruits, lean meat, seafood and eggs.
The limitations of this study were the cross-sectional nature and therefore cannot address the temporal association of breakfast skipping and atherosclerosis. There are no follow-up data. Another limitation to keep in mind is that the group who skipped breakfast was small, only 3% of the population that was studied.
In summary: Skipping breakfast could be a marker of a general unhealthy lifestyle and is associated with an increased risk of subclinical atherosclerosis.