Erin D. Michos, MD, MHS

In February 2017, the American Heart Association put forward a scientific statement about the impact of meal timing and frequency and CVD prevention. (St-Onge MP, et al. Circulation. 2017;doi:10.1161/CIR.0000000000000476.) This statement endorsed “mindful eating,” ie, paying attention not only to the quality of food but also the timing and pattern of food consumption. Thoughtful planning of meals in advance can minimize unhealthy snacking out of boredom, emotions or stress. The AHA statement also suggested that eating a greater proportion of the calories earlier in the day had favorable cardiometabolic associations, whereas a late dinner eating pattern was less favorable. 

As the old adage goes, one should “eat breakfast like a king, lunch like a prince, and dinner like a pauper.”

Indeed, other prior studies have found “breakfast skippers” had higher rates of obesity and impaired glucose metabolism, but studies were largely cross-sectional, and it is not clear whether skipping breakfast caused obesity or whether obese individuals skipped breakfast for dieting purposes. However, a 2017 longitudinal study of 50,660 church-community members followed for an average of 7 years found that breakfast eaters experienced a relative decrease in BMI over time compared with breakfast skippers, with the largest decreases among those who had breakfast for their largest meal of the day. (Kahleova H, et al. J Nutr. 2017;doi:10.3945/jn.116.244749.)

In this latest breakfast study of 2017, Uzhova and colleagues reported data from the PESA study of 4,052 adults aged 40 to 54 years free of CVD at baseline who completed dietary questionnaires and extensive vascular imaging in multiple territories. Skipping breakfast was defined as consuming < 5% of daily total calories before 10 a.m., compared with low-energy breakfast (5% to 20% of daily calories) and high-energy breakfast (>20% of total calories) consumers.

Some important observations: No. 1, breakfast skippers (3% of sample) had a lower diet quality overall. Breakfast skippers were more likely to have higher intake of red and processed meats, sugar-sweetened beverages and alcohol; were more likely to have a lower consumption of fruits, vegetables and whole grains; had a lower adherence to a Mediterranean diet pattern; and were more likely to be men and current smokers. Not surprisingly, skipping breakfast was associated with adiposity and adverse cardiometabolic profile. As the authors stated, skipping breakfast could simply be a marker of an unhealthy lifestyle overall.

However, even after adjusting for cardiometabolic risk factors and also for intake of red meat, alcohol and salt, breakfast skippers had a significant approximately 2.6-fold increased risk for generalized atherosclerosis (ie, plaque present in four to six vascular sites), as well as a significant 1.7- to 1.8-fold increased risk for plaque presence in the abdominal aorta, carotid artery and ilofemoral artery, compared with high-energy breakfast consumers. Regarding coronary artery calcium (CAC), skipping breakfast was associated with CAC prevalence (> 0) after adjusting for demographics and cardiometabolic risk factors (OR = 1.62; 95% CI, 1-2.63) but was attenuated after adjusting for red meat, alcohol and salt (OR = 1.43; 95% CI, 0.87-2.36). The PESA study was limited by its cross-sectional design, which limits conclusions about temporality and causality.

Of course, daily breakfast intake should be in conjunction with mindful eating during the remainder of the day and regular physical activity.

A bit of caution: The AHA statement reported that advice related to consuming breakfast in and of itself did not lead to weight loss because of compensatory behaviors the rest of the day. But breakfast consumption in conjunction with a healthier eating pattern could promote a favorable cardiometabolic profile, and the PESA study would suggest healthier arteries as well.