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1.  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 
PLoS Medicine  2014;11(9):e1001703.
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
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.
The US National Diabetes Information Clearinghouse provides information about diabetes for patients, health-care professionals, and the general public, including detailed information on diabetes prevention (in English and Spanish)
The UK National Health Service Choices website provides information for patients and carers about type 2 diabetes and about living with diabetes; it also provides people's stories about diabetes; Change4Life, a UK campaign that provides tips for healthy living, has a webpage about the importance of a healthy breakfast
The charity Diabetes UK provides detailed information for patients and carers in several languages, including information on healthy lifestyles for people with diabetes
The UK-based non-profit organization Healthtalkonline has interviews with people about their experiences of diabetes
MedlinePlus provides links to further resources and advice about diabetes and diabetes prevention (in English and Spanish)
Kidshealth, a US-based not-for-profit organization provides information for parents about the importance of breakfast and information for children
More information about the Child Heart and Health Study in England (CHASE) is available
doi:10.1371/journal.pmed.1001703
PMCID: PMC4151989  PMID: 25181492
2.  Irregular breakfast eating and health status among adolescents in Taiwan 
BMC Public Health  2006;6:295.
Background
Regular breakfast eating (RBE) is an important contributor to a healthy lifestyle and health status. The aims of the present study were to evaluate the relationships among irregular breakfast eating (IRBE), health status, and health promoting behavior (HPB) for Taiwanese adolescents.
Methods
A cross-sectional, descriptive design was used to investigate a cluster sample of 1609 (7th -12th grade) adolescents located in the metropolitan Tao-Yuan area during the 2005 academic year. The main variables comprised breakfast eating pattern, body weight, and health promoting behaviors. Data were collected by a self-administered questionnaire.
Results
A total of 1609 participants were studied, 64.1% in junior high school and 35.9% in high school, boys (47.1%) and girls (52.9%) ranging in age from 12–20 years. Of the total participant population, 28.8% were overweight and nearly one quarter (23.6%) reported eating breakfast irregularly during schooldays. The findings indicated that adolescents with RBE had a lower risk of overweight (OR for IRBE vs. RBE = 1.51, 95% CI: 1.12, 2.04), and that the odds of becoming overweight were 51% greater for IRBE than for RBE even after controlling for demographical and HPB variables. IRBE also was a strong indicator for HPB. However, the profile of the high-risk IRBE group was predominantly junior high schoolchildren and/or children living without both parents.
Conclusion
This study provides valuable information about irregular breakfast eating among adolescents, which is associated with being overweight and with a low frequency of health promoting behavior. School and family health promotion strategies should be used to encourage all adolescents to eat breakfast regularly.
doi:10.1186/1471-2458-6-295
PMCID: PMC1764735  PMID: 17150112
3.  Breakfast patterns among low-income, ethnically-diverse 4th-6th grade children in an urban area 
BMC Public Health  2014;14:604.
Background
Increasing school breakfast participation has been advocated as a method to prevent childhood obesity. However, little is known about children’s breakfast patterns outside of school (e.g., home, corner store). Policies that increase school breakfast participation without an understanding of children’s breakfast habits outside of school may result in children consuming multiple breakfasts and may undermine efforts to prevent obesity. The aim of the current study was to describe morning food and drink consumption patterns among low-income, urban children and their associations with relative weight.
Methods
A cross-sectional analysis was conducted of data obtained from 651 4th-6th graders (51.7% female, 61.2% African American, 10.7 years) in 2012. Students completed surveys at school that included all foods eaten and their locations that morning. Height and weight were measured by trained research staff.
Results
On the day surveyed, 12.4% of youth reported not eating breakfast, 49.8% reported eating one breakfast, 25.5% reported eating two breakfasts, and 12.3% reported eating three or more breakfasts. The number of breakfasts consumed and BMI percentile showed a significant curvilinear relationship, with higher mean BMI percentiles observed among children who did not consume any breakfast and those who consumed ≥ 3 breakfasts. Sixth graders were significantly less likely to have consumed breakfast compared to younger children. A greater proportion of obese youth had no breakfast (18.0%) compared to healthy weight (10.1%) and overweight youth (10.7%, p = .01).
Conclusions
When promoting school breakfast, policies will need to be mindful of both over- and under-consumption to effectively address childhood obesity and food insecurity.
Clinical trial registration
NCT01924130 from http://clinicaltrials.gov/.
doi:10.1186/1471-2458-14-604
PMCID: PMC4070352  PMID: 24928474
Childhood obesity; Minority health; Dietary intake
4.  The nutritional impact of breakfast consumption on the diets of inner-city African-American elementary school children. 
To determine the contribution of breakfast-eating behavior to dietary adequacy among low-income African-American children, 1151 children attending grades two through five at four elementary schools in East Orange, New Jersey were studied. Results of a 4-day eating behavior survey and a 24-hour dietary recall reveal that on any given day, 12% to 26% of children attend school without having eaten anything. Thirty-six percent of the children were obese, which did not vary with breakfast-eating behavior. A significantly greater proportion of the children who skipped breakfast compared to those who ate breakfast failed to achieve dietary adequacy for nearly every nutrient studied. More than one third of breakfast skippers consumed < 50% of the recommended dietary allowance for vitamins A, E, B6, and folacin, and nearly one fourth consumed < 50% of the recommended dietary allowance for calories, vitamin C, calcium, and iron. Not eating breakfast results in substantial deficits in dietary intake of a variety of essential nutrients among low-income African-American school children. Efforts to improve the nutritional status of children should include nutrition education to promote breakfast.
PMCID: PMC2607827  PMID: 7731069
5.  The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees 
PLoS Medicine  2012;9(10):e1001320.
Surveying women and children from refugee camps in Algeria, Carlos Grijalva-Eternod and colleagues find high rates of obesity among women as well as many undernourished children, and that almost a quarter of households are affected by both undernutrition and obesity.
Background
Households from vulnerable groups experiencing epidemiological transitions are known to be affected concomitantly by under-nutrition and obesity. Yet, it is unknown to what extent this double burden affects refugee populations dependent on food assistance. We assessed the double burden of malnutrition among Western Sahara refugees living in a protracted emergency.
Methods and Findings
We implemented a stratified nutrition survey in October–November 2010 in the four Western Sahara refugee camps in Algeria. We sampled 2,005 households, collecting anthropometric measurements (weight, height, and waist circumference) in 1,608 children (6–59 mo) and 1,781 women (15–49 y). We estimated the prevalence of global acute malnutrition (GAM), stunting, underweight, and overweight in children; and stunting, underweight, overweight, and central obesity in women. To assess the burden of malnutrition within households, households were first classified according to the presence of each type of malnutrition. Households were then classified as undernourished, overweight, or affected by the double burden if they presented members with under-nutrition, overweight, or both, respectively.
The prevalence of GAM in children was 9.1%, 29.1% were stunted, 18.6% were underweight, and 2.4% were overweight; among the women, 14.8% were stunted, 53.7% were overweight or obese, and 71.4% had central obesity. Central obesity (47.2%) and overweight (38.8%) in women affected a higher proportion of households than did GAM (7.0%), stunting (19.5%), or underweight (13.3%) in children. Overall, households classified as overweight (31.5%) were most common, followed by undernourished (25.8%), and then double burden–affected (24.7%).
Conclusions
The double burden of obesity and under-nutrition is highly prevalent in households among Western Sahara refugees. The results highlight the need to focus more attention on non-communicable diseases in this population and balance obesity prevention and management with interventions to tackle under-nutrition.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Good nutrition is essential for human health and survival. Insufficient food intake causes under-nutrition, which increases susceptibility to infections; intake of too much or inappropriate food, in particular in interaction with sedentary behaviour, can lead to obesity, which increases the risk of non-communicable diseases such as diabetes. During the past 30 years, the prevalence (the proportion of a population affected by a condition) of obesity has greatly increased, initially among adults in industrialized countries, but more recently among children and in less-affluent populations. Now, worldwide, overweight people outnumber under-nourished people. Furthermore, some populations are affected by both under-nutrition and obesity, forms of malnutrition that occur when the diet is suboptimal for health. So, for example, a child can be both stunted (short for his or her age, an indicator of long-term under-nutrition) and overweight (too heavy for his or her age). The emergence of this double burden of malnutrition has been attributed to the nutrition transition—the rapid move because of migration or urbanization to a lifestyle characterized by low levels of physical activity and high consumption of refined, energy-dense foods—without complete elimination of under-nutrition.
Why Was This Study Done?
Refugees are one group of people in whom under-nutrition and obesity sometimes coexist. Worldwide, in 2010, 15.4 million refugees were dependent on host governments and international humanitarian agencies for their food security and well-being. It is essential that these governments and organizations provide appropriate food assistance programs to refugees—policies that are appropriate during acute emergencies may not be appropriate in protracted emergencies and may contribute to the emergence of the double burden of malnutrition among refugees. Unfortunately, the extent to which the double burden of malnutrition affects refugees in protracted emergencies is unknown. In this cross-sectional study (an investigation that looks at the characteristics of a population at a single time), the researchers assessed the double burden of malnutrition among people from Western Sahara who have been living in four refugee camps near Tindouf city, Algeria, since 1975.
What Did the Researchers Do and Find?
The researchers used data from a 2010 survey that measured the height and weight of children and the height, weight, and waist circumference of women living in 2,005 households in the Algerian refugee camps. For the children, they estimated the prevalence of global acute malnutrition (which includes thin, “wasted” children, as indicated by a low weight for height based on the World Health Organization growth standards, and those with nutritional oedema), stunting, and underweight and overweight (low and high weight for age and gender, respectively). For the women, they estimated the prevalence of stunting, underweight (body mass index less than 18.5 kg/m2), overweight (body mass index greater than 25 kg/m2), and central obesity (a waist circumference of more than 80 cm). Among the children, 9.1% had global acute malnutrition, 29.1% were stunted, 8.6% were underweight, and 2.4% were overweight. Among the women, 14.8% were stunted, 53.7% were overweight, and 71.4% had central obesity. Notably, central obesity and overweight in women affected more households than global acute malnutrition, stunting, and underweight in children. Finally, based on whether a household included members with under-nutrition or overweight, alone or in combination, the researchers classified a third of households as overweight, a quarter as undernourished, and a quarter as affected by the double burden of malnutrition.
What Do These Findings Mean?
These findings indicate that there is a high prevalence of the double burden of malnutrition among households in Western Saharan refugee camps in Algeria. Although this study provides no information on men and does not investigate whether the obesity seen in these camps leads to an increased risk of diabetes and other non-communicable diseases, these findings have several important implications for the provision of food assistance and care for protracted humanitarian emergencies. For example, they highlight the need to promote long-term food security and to improve nutrition adequacy and food diversity in protracted emergencies. In addition, they suggest that current food assistance programs that are suitable for acute emergencies may not be suitable for extended emergencies. They also highlight the need to focus more attention on non-communicable diseases in refugee camps and to develop innovative ways to provide obesity prevention and management in these settings. However, as the researchers stress, careful policy and advocacy work is essential to ensure that efforts to deal with the threat of obesity among refugees do not jeopardize support for life-saving food assistance programs for refugees.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001320.
Wikipedia provides background information about the Western Sahara refugee camps near Tindouf, Algeria (note that Wikipedia is a free online encyclopedia that anyone can edit)
The World Health Organization provides information on all aspects of nutrition and obesity (in several languages)
The United Nations World Food Programme is the world's largest humanitarian agency fighting hunger worldwide; its website provides detailed information about hunger and information about its work in the Western Sahara refugee camps in Algeria, including personal stories and photographs of food distribution
The United Nations High Commissioner for Refugees is the United Nations body mandated to lead and coordinate international action to protect refugees and resolve refugee problems worldwide; its website provides detailed information about its work in the Western Sahara refugee camps in Algeria
Oxfam also provides detailed information about its work in the Algerian refugee camps, a description of the camps, and personal stories from people living in the camps
An article published by the Food and Agriculture Organization of the United Nations explains the double burden of malnutrition
doi:10.1371/journal.pmed.1001320
PMCID: PMC3462761  PMID: 23055833
6.  Children's body mass index, participation in school meals, and observed energy intake at school meals 
Background
Data from a dietary-reporting validation study with fourth-grade children were analyzed to investigate a possible relationship of body mass index (BMI) with daily participation in school meals and observed energy intake at school meals, and whether the relationships differed by breakfast location (classroom; cafeteria).
Methods
Data were collected in 17, 17, and 8 schools during three school years. For the three years, six, six, and seven of the schools had breakfast in the classroom; all other schools had breakfast in the cafeteria. Information about 180 days of school breakfast and school lunch participation during fourth grade for each of 1,571 children (90% Black; 53% girls) was available in electronic administrative records from the school district. Children were weighed and measured, and BMI was calculated. Each of a subset of 465 children (95% Black; 49% girls) was observed eating school breakfast and school lunch on the same day. Mixed-effects regression was conducted with BMI as the dependent variable and school as the random effect; independent variables were breakfast participation, lunch participation, combined participation (breakfast and lunch on the same day), average observed energy intake for breakfast, average observed energy intake for lunch, sex, age, breakfast location, and school year. Analyses were repeated for BMI category (underweight/healthy weight; overweight; obese; severely obese) using pooled ordered logistic regression models that excluded sex and age.
Results
Breakfast participation, lunch participation, and combined participation were not significantly associated with BMI or BMI category irrespective of whether the model included observed energy intake at school meals. Observed energy intake at school meals was significantly and positively associated with BMI and BMI category. For the total sample and subset, breakfast location was significantly associated with BMI; average BMI was larger for children with breakfast in the classroom than in the cafeteria. Significantly more kilocalories were observed eaten at breakfast in the classroom than in the cafeteria.
Conclusions
For fourth-grade children, results provide evidence of a positive relationship between BMI and observed energy intake at school meals, and between BMI and school breakfast in the classroom; however, BMI and participation in school meals were not significantly associated.
doi:10.1186/1479-5868-7-24
PMCID: PMC2859739  PMID: 20334667
7.  Eating breakfast and dinner together as a family: Associations with sociodemographic characteristics and implications for diet quality and weight status 
Journal of the Academy of Nutrition and Dietetics  2013;113(12):10.1016/j.jand.2013.08.011.
Background
Research has shown that adolescents who frequently share evening meals with their families experience more positive health outcomes, including diets of higher nutritional quality. However, little is known about families eating together at breakfast.
Objectives
This study examined sociodemographic differences in family meal frequencies in a population-based adolescent sample. Additionally, this study examined associations of family breakfast meal frequency with dietary quality and weight status.
Design
Cross-sectional data from EAT 2010 (Eating and Activity in Teens) included anthropometric assessments and classroom-administered surveys completed in 2009-2010.
Participants/setting
Participants included 2,793 middle and high school students (53.2% girls, mean age=14.4 years) from Minneapolis/St. Paul, MN, public schools.
Main outcome measures
Usual dietary intake was self-reported on a food frequency questionnaire. Height and weight were measured.
Statistical analyses performed
Regression models adjusted for sociodemographic characteristics, family dinner frequency, family functioning, and family cohesion were used to examine associations of family breakfast frequency with dietary quality and weight status.
Results
On average, adolescents reported having family breakfast meals 1.5 times (SD=2.1) and family dinner meals 4.1 times (SD=2.6) in the past week. There were racial/ethnic differences in family breakfast frequency, with the highest frequencies reported by adolescents of Black, Hispanic, Native American, and mixed race/ethnicity. Family breakfast frequency was also positively associated with male sex; younger age; and living in a two-parent household. Family breakfast frequency was associated with several markers of better diet quality (such as higher intake of fruit, whole grains, and fiber) and lower risk for overweight/obesity. For example, adolescents who reported seven family breakfasts in the past week consumed an average of 0.37 additional daily fruit servings compared to adolescents who never had a family breakfast meal.
Conclusions
Results suggest that eating breakfast together as a family may have benefits for adolescents’ dietary intake and weight status.
doi:10.1016/j.jand.2013.08.011
PMCID: PMC3833880  PMID: 24139290
Adolescents; Family meals; Breakfast; Dietary intake; Overweight
8.  Association of breakfast intake with obesity, dietary and physical activity behavior among urban school-aged adolescents in Delhi, India: results of a cross-sectional study 
BMC Public Health  2012;12:881.
Background
In developed countries, regular breakfast consumption is inversely associated with excess weight and directly associated with better dietary and improved physical activity behaviors. Our objective was to describe the frequency of breakfast consumption among school-going adolescents in Delhi and evaluate its association with overweight and obesity as well as other dietary, physical activity, and sedentary behaviors.
Methods
Design: Cross-sectional study. Setting: Eight schools (Private and Government) of Delhi in the year 2006. Participants: 1814 students from 8th and 10th grades; response rate was 87.2%; 55% were 8th graders, 60% were boys and 52% attended Private schools. Main outcome measures: Body mass index, self-reported breakfast consumption, diet and physical activity related behaviors, and psychosocial factors. Data analysis: Mixed effects regression models were employed, adjusting for age, gender, grade level and school type (SES).
Results
Significantly more Government school (lower SES) students consumed breakfast daily as compared to Private school (higher SES) students (73.8% vs. 66.3%; p<0.01). More 8th graders consumed breakfast daily vs.10th graders (72.3% vs. 67.0%; p<0.05). A dose–response relationship was observed such that overall prevalence of overweight and obesity among adolescents who consumed breakfast daily (14.6%) was significantly lower vs. those who only sometimes (15.2%) or never (22.9%) consumed breakfast (p<0.05 for trend). This relationship was statistically significant for boys (15.4 % vs. 16.5% vs. 26.0; p<0.05 for trend) but not for girls. Intake of dairy products, fruits and vegetables was 5.5 (95% CI 2.4-12.5), 1.7 (95% CI 1.1-2.5) and 2.2 (95% CI 1.3-3.5) times higher among those who consumed breakfast daily vs. those who never consumed breakfast. Breakfast consumption was associated with greater physical activity vs. those who never consumed breakfast. Positive values and beliefs about healthy eating; body image satisfaction; and positive peer and parental influence were positively associated with daily breakfast consumption, while depression was negatively associated.
Conclusion
Daily breakfast consumption is associated with less overweight and obesity and with healthier dietary- and physical activity-related behaviors among urban Indian students. Although prospective studies should confirm the present results, intervention programs to prevent or treat childhood obesity in India should consider emphasizing regular breakfast consumption.
doi:10.1186/1471-2458-12-881
PMCID: PMC3549919  PMID: 23075030
Breakfast; Obesity; Adolescent; Diet; Physical activity; Behavior
9.  How accurate are parental responses concerning their fourth-grade children's school-meal participation, and what is the relationship between children's body mass index and school-meal participation based on parental responses? 
Background
This article investigated (1) parental response accuracy of fourth-grade children's school-meal participation and whether accuracy differed by children's body mass index (BMI), sex, and race, and (2) the relationship between BMI and school-meal participation (based on parental responses).
Methods
Data were from four cross-sectional studies conducted from fall 1999 to spring 2003 with fourth-grade children from 13 schools total. Consent forms asked parents to report children's usual school-meal participation. As two studies' consent forms did not ask about lunch participation, complete data were available for breakfast on 1,496 children (51% Black; 49% boys) and for lunch on 785 children (46% Black; 48% boys). Researchers compiled nametag records (during meal observations) of meal participation on randomly selected days during children's fourth-grade school year for breakfast (average nametag days across studies: 7-35) and for lunch (average nametag days across studies: 4-10) and categorized participation as "usually" (≥ 50% of days) or "not usually" (< 50% of days). Weight and height were measured. Concerning parental response accuracy, marginal regression was used with agreement between parental responses and nametag records as the dependent variable; independent variables were BMI, age, sex, race, and study. Concerning a relationship between BMI and school-meal participation, marginal regression was used with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, age, sex, race, and study.
Results
Concerning breakfast participation and lunch participation, 74% and 92% of parents provided accurate responses, respectively. Parental response accuracy was better for older children for breakfast and lunch participation, and for Black than White children for lunch participation. Usual school-meal participation was significantly related to children's BMI but in opposite directions -- positively for breakfast and inversely for lunch.
Conclusions
Parental response accuracy of children's school-meal participation was moderately high; however, disparate effects for children's age and race warrant caution when relying on parental responses. The BMI results, which showed a relationship between school-meal participation (based on parental responses) and childhood obesity, conflict with results from a recent article that used data from the same four studies and found no significant relationship when participation was based on nametag records compiled for meal observations.
doi:10.1186/1479-5868-9-30
PMCID: PMC3342903  PMID: 22429914
Children; School; Obesity; School-meal participation; Parental response accuracy
10.  Diet, Breakfast, and Academic Performance in Children 
Annals of nutrition & metabolism  2002;46(0 1):24-30.
Objective
To determine whether nutrient intake and academic and psychosocial functioning improve after the start of a universal-free school breakfast program (USBP).
Methods
Information was gathered from 97 inner city students prior to the start of a USBP and again after the program had been in place for 6 months. Students who had total energy intakes of <50% of the recommended daily allowance (RDA) and/or 2 or more micronutrients of <50% of RDA were considered to be at nutritional risk.
Results
Prior to the USBP, 33% of all study children were classified as being at nutritional risk. Children who were at nutritional risk had significantly poorer attendance, punctuality, and grades at school, more behavior problems, and were less likely to eat breakfast at school than children who were not at nutritional risk. Six months after the start of the free school breakfast programs, students who decreased their nutritional risk showed significantly greater: improvements in attendance and school breakfast participation, decreases in hunger, and improvements in math grades and behavior than children who did not decrease their nutritional risk.
Conclusion
Participation in a school breakfast program enhanced daily nutrient intake and improvements in nutrient intake were associated with significant improvements in student academic performance and psychosocial functioning and decreases in hunger.
PMCID: PMC3275817  PMID: 12428078
School breakfast; Low-income children; Psychosocial functioning; Nutrition; Dietary intake
11.  Breakfast, midday meals and academic achievement in rural primary schools in Uganda: implications for education and school health policy 
Food & Nutrition Research  2012;56:10.3402/fnr.v56i0.11217.
Background
Underachievement in schools is a global problem and is especially prevalent in developing countries. Indicators of educational performance show that Uganda has done remarkably well on education access-related targets since the introduction of universal primary education in 1997. However, educational outcomes remain disappointing. The absence of school feeding schemes, one of the leading causes of scholastic underachievement, has not been given attention by the Ugandan authorities. Instead, as a national policy, parents are expected to provide meals even though many, especially in the rural areas, cannot afford to provide even the minimal daily bowl of maize porridge.
Objective
To assess and demonstrate the effect of breakfast and midday meal consumption on academic achievement of schoolchildren.
Design, Materials and Methods
We assessed household characteristics, feeding patterns and academic achievement of 645 schoolchildren (aged 9–15 years) in Kumi district, eastern Uganda, in 2006–2007, using a modified cluster sampling design which involved only grade 1 schools (34 in total) and pupils of grade four. Household questionnaires and school records were used to collect information on socio-demographic factors, feeding patterns and school attendance. Academic achievement was assessed using unstandardized techniques, specifically designed for this study.
Results
Underachievement (the proportion below a score of 120.0 points) was high (68.4%); in addition, significantly higher achievement and better feeding patterns were observed among children from the less poor households (p<0.05). Achievement was significantly associated with consumption of breakfast and a midday meal, particularly for boys (p<0.05), and a greater likelihood of scoring well was observed for better nourished children (all OR values>1.0).
Conclusion
We observed that underachievement was relatively high; inadequate patterns of meal consumption, particularly for the most poor, significantly higher scores among children from ‘less poor’ households and a significant association between academic achievement and breakfast and midday meal consumption.
doi:10.3402/fnr.v56i0.11217
PMCID: PMC3280795  PMID: 22347147
academic achievement; primary schools; Uganda; education; school health policy
12.  The effects of breakfast on behavior and academic performance in children and adolescents 
Breakfast consumption is associated with positive outcomes for diet quality, micronutrient intake, weight status and lifestyle factors. Breakfast has been suggested to positively affect learning in children in terms of behavior, cognitive, and school performance. However, these assertions are largely based on evidence which demonstrates acute effects of breakfast on cognitive performance. Less research which examines the effects of breakfast on the ecologically valid outcomes of academic performance or in-class behavior is available. The literature was searched for articles published between 1950–2013 indexed in Ovid MEDLINE, Pubmed, Web of Science, the Cochrane Library, EMBASE databases, and PsychINFO. Thirty-six articles examining the effects of breakfast on in-class behavior and academic performance in children and adolescents were included. The effects of breakfast in different populations were considered, including undernourished or well-nourished children and adolescents from differing socio-economic status (SES) backgrounds. The habitual and acute effects of breakfast and the effects of school breakfast programs (SBPs) were considered. The evidence indicated a mainly positive effect of breakfast on on-task behavior in the classroom. There was suggestive evidence that habitual breakfast (frequency and quality) and SBPs have a positive effect on children's academic performance with clearest effects on mathematic and arithmetic grades in undernourished children. Increased frequency of habitual breakfast was consistently positively associated with academic performance. Some evidence suggested that quality of habitual breakfast, in terms of providing a greater variety of food groups and adequate energy, was positively related to school performance. However, these associations can be attributed, in part, to confounders such as SES and to methodological weaknesses such as the subjective nature of the observations of behavior in class.
doi:10.3389/fnhum.2013.00425
PMCID: PMC3737458  PMID: 23964220
breakfast; behavior; academic performance; children; adolescents; learning
13.  Examining variations in fourth-grade children’s participation in school-breakfast and school-lunch programs by student and program demographics 
Purpose/Objectives
Analyses were conducted to examine variations in fourth-grade children’s participation in school-breakfast and school-lunch programs by weekday, month, socioeconomic status, absenteeism, sex, and school-breakfast location.
Methods
Fourth-grade children were participants in a dietary-reporting validation study during the 2005–2006 or 2006–2007 school years in 17 or 8 schools, respectively, in one South Carolina school district. For the two respective school years, school-breakfast location was the classroom for six and seven schools, and for the remaining schools, the cafeteria. District administrative records provided information about 180 possible days of participation in the school-breakfast and school-lunch programs for each of 1,060 children (91% Black, 52% girls). The state’s Office of Research and Statistics linked data on school-meal participation with information about individual children’s socioeconomic status (eligibility for free or reduced-price school meals) and annual absenteeism from school.
Results
For school-provided breakfast, logistic regression showed participation rate differences by weekday (smallest for Monday [56.1%], largest for Wednesday [57.8%], p<0.0001), month (smallest for April [53.5%], largest for September [60.8%], p<0.0001), socioeconomic status (smallest for full-price status [27.5%], largest for free-meal status [63.4%], p<0.0001), school-breakfast location (smaller for breakfast located in the cafeteria [38%] than classroom [71%], p<0.0001), and absenteeism (p<0.0001). For school-provided lunch, logistic regression showed participation rate differences by weekday (smallest for Friday [81.9%], largest for Thursday [83.3%], p<0.0001), month (smallest for May [78.7%], largest for August [86.0%], p<0.0001), socioeconomic status (smallest for full-price status [72.1%], largest for free-meal status [84.9%], p<0.0001), and absenteeism (p<0.0001). There were no differences in participation rate by sex.
Applications for Child Nutrition Professionals
Administrative participation records are used for forecasting purchasing and production. Using such records in research studies may provide insight into aspects of children’s participation in school-provided meals. Districts and managers are encouraged to share administrative records of children’s participation in school-provided meals with researchers.
PMCID: PMC3972127  PMID: 24701197
14.  Effects of a free school breakfast programme on school attendance, achievement, psychosocial function, and nutrition: a stepped wedge cluster randomised trial 
BMC Public Health  2010;10:738.
Background
Approximately 55,000 children in New Zealand do not eat breakfast on any given day. Regular breakfast skipping has been associated with poor diets, higher body mass index, and adverse effects on children's behaviour and academic performance. Research suggests that regular breakfast consumption can improve academic performance, nutrition and behaviour. This paper describes the protocol for a stepped wedge cluster randomised trial of a free school breakfast programme. The aim of the trial is to determine the effects of the breakfast intervention on school attendance, achievement, psychosocial function, dietary habits and food security.
Methods/Design
Sixteen primary schools in the North Island of New Zealand will be randomised in a sequential stepped wedge design to a free before-school breakfast programme consisting of non-sugar coated breakfast cereal, milk products, and/or toast and spreads. Four hundred children aged 5-13 years (approximately 25 per school) will be recruited. Data collection will be undertaken once each school term over the 2010 school year (February to December). The primary trial outcome is school attendance, defined as the proportion of students achieving an attendance rate of 95% or higher. Secondary outcomes are academic achievement (literacy, numeracy, self-reported grades), sense of belonging at school, psychosocial function, dietary habits, and food security. A concurrent process evaluation seeks information on parents', schools' and providers' perspectives of the breakfast programme.
Discussion
This randomised controlled trial will provide robust evidence of the effects of a school breakfast programme on students' attendance, achievement and nutrition. Furthermore the study provides an excellent example of the feasibility and value of the stepped wedge trial design in evaluating pragmatic public health intervention programmes.
Trial Registration Number
Australian New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12609000854235
doi:10.1186/1471-2458-10-738
PMCID: PMC3009648  PMID: 21114862
15.  Regular Breakfast and Blood Lead Levels among Preschool Children 
Environmental Health  2011;10:28.
Background
Previous studies have shown that fasting increases lead absorption in the gastrointestinal tract of adults. Regular meals/snacks are recommended as a nutritional intervention for lead poisoning in children, but epidemiological evidence of links between fasting and blood lead levels (B-Pb) is rare. The purpose of this study was to examine the association between eating a regular breakfast and B-Pb among children using data from the China Jintan Child Cohort Study.
Methods
Parents completed a questionnaire regarding children's breakfast-eating habit (regular or not), demographics, and food frequency. Whole blood samples were collected from 1,344 children for the measurements of B-Pb and micronutrients (iron, copper, zinc, calcium, and magnesium). B-Pb and other measures were compared between children with and without regular breakfast. Linear regression modeling was used to evaluate the association between regular breakfast and log-transformed B-Pb. The association between regular breakfast and risk of lead poisoning (B-Pb≥10 μg/dL) was examined using logistic regression modeling.
Results
Median B-Pb among children who ate breakfast regularly and those who did not eat breakfast regularly were 6.1 μg/dL and 7.2 μg/dL, respectively. Eating breakfast was also associated with greater zinc blood levels. Adjusting for other relevant factors, the linear regression model revealed that eating breakfast regularly was significantly associated with lower B-Pb (beta = -0.10 units of log-transformed B-Pb compared with children who did not eat breakfast regularly, p = 0.02).
Conclusion
The present study provides some initial human data supporting the notion that eating a regular breakfast might reduce B-Pb in young children. To our knowledge, this is the first human study exploring the association between breakfast frequency and B-Pb in young children.
doi:10.1186/1476-069X-10-28
PMCID: PMC3079601  PMID: 21457535
lead exposure lead poisoning nutrition diet nutrients breakfast
16.  Family structure and breakfast consumption of 11-15 year old boys and girls in Scotland, 1994-2010: a repeated cross-sectional study 
BMC Public Health  2012;12:228.
Background
The benefits of breakfast during childhood and adolescence have been reported previously though few studies have considered family structure inequalities in breakfast consumption. The proportion of young people living in non-traditional family types has increased in recent years, strengthening the need to describe and monitor the impact of the changing family unit on adolescent breakfast consumption. This study aimed to describe changes in daily breakfast consumption among adolescents in Scotland between 1994 and 2010, while also considering family structure inequalities, and the degree to which these have changed over time.
Methods
Data from the 1994, 1998, 2002, 2006 and 2010 Scottish Health Behaviour in School-aged Children (HBSC) surveys were analysed using logistic multilevel regression models for binary outcome variable daily breakfast consumption.
Results
Daily breakfast consumption among adolescents increased between 1994 and 2010, although there were differences by age and sex. In fact those aged over 14.5 years saw decreases in breakfast consumption, and girls saw significantly larger increases than boys. Daily breakfast consumption was more prevalent among adolescents from 'both parent' families, with lowest prevalence among those from single parent families. Trends in daily breakfast consumption between 1994 and 2010 also varied by family structure. While prevalence of daily breakfast consumption increased among those living with 'both parents', the largest proportion of the population, prevalence decreased over time among adolescents of single parent families, and particularly among those living with their father.
Conclusions
Family structure inequalities in daily breakfast consumption increased between 1994 and 2010, while breakfast consumption across the population as a whole increased. As the proportion of young people living in an alternative family structure continues to grow it is important to understand why these inequalities have increased and how these may be overcome. Possible reasons for family structure inequalities and their increase in recent years are discussed.
doi:10.1186/1471-2458-12-228
PMCID: PMC3373369  PMID: 22440153
Breakfast; Nutrition; Adolescent; Socioeconomic factors; Multilevel modelling; Survey methodology
17.  Associations between Family-Related Factors, Breakfast Consumption and BMI among 10- to 12-Year-Old European Children: The Cross-Sectional ENERGY-Study 
PLoS ONE  2013;8(11):e79550.
Objective
To investigate associations of family-related factors with children’s breakfast consumption and BMI-z-score and to examine whether children’s breakfast consumption mediates associations between family-related factors and children’s BMI-z-score.
Subjects
Ten- to twelve-year-old children (n = 6374; mean age = 11.6±0.7 years, 53.2% girls, mean BMI-z-score = 0.4±1.2) and one of their parents (n = 6374; mean age = 41.4±5.3 years, 82.7% female, mean BMI = 24.5±4.2 kg/m2) were recruited from schools in eight European countries (Belgium, Greece, Hungary, the Netherlands, Norway, Slovenia, Spain, and Switzerland). The children self-reported their breakfast frequency per week. The body weight and height of the children were objectively measured. The parents responded to items on family factors related to breakfast (automaticity, availability, encouragement, paying attention, permissiveness, negotiating, communicating health beliefs, parental self-efficacy to address children’s nagging, praising, and family breakfast frequency). Mediation analyses were performed using multi-level regression analyses (child-school-country).
Results
Three of the eleven family-related variables were significantly associated with children’s BMI-z-score. The family breakfast frequency was negatively associated with the BMI-z-score; permissiveness concerning skipping breakfast and negotiating about breakfast were positively associated with the BMI-z-score. Children’s breakfast consumption was found to be a mediator of the two associations. All family-related variables except for negotiating, praising and communicating health beliefs, were significantly associated with children’s breakfast consumption.
Conclusions
Future breakfast promotion and obesity prevention interventions should focus on family-related factors including the physical home environment and parenting practices. Nevertheless, more longitudinal research and intervention studies to support these findings between family-related factors and both children’s breakfast consumption and BMI-z-score are needed.
doi:10.1371/journal.pone.0079550
PMCID: PMC3840060  PMID: 24282508
18.  Report card on school snack food policies among the United States' largest school districts in 2004–2005: Room for improvement 
Background
Federal nutritional guidelines apply to school foods provided through the national school lunch and breakfast programs, but few federal regulations apply to other foods and drinks sold in schools (labeled "competitive foods"), which are often high in calories, fat and sugar. Competitive food policies among school districts are increasingly viewed as an important modifiable factor in the school nutrition environment, particularly to address rising rates of childhood overweight. Congress passed legislation in 2004 requiring all school districts to develop a Wellness Policy that includes nutrition guidelines for competitive foods starting in 2006–2007. In addition, the Institute of Medicine (IOM) recently published recommendations for schools to address childhood obesity.
Methods
Representatives of school districts with the largest student enrollment in each state and D.C. (N = 51) were interviewed in October-November 2004 about each school district's nutrition policies on "competitive foods." District policies were examined and compared to the Institute of Medicine's recommendations for schools to address childhood obesity. Information about state competitive food policies was accessed via the Internet, and through state and district contacts.
Results
The 51 districts accounted for 5.9 million students, representing 11% of US students. Nineteen of the 51 districts (39%) had competitive food policies beyond state or federal requirements. The majority of these district policies (79%) were adopted since 2002. School district policies varied in scope and requirements. Ten districts (53%) set different standards by grade level. Most district policies had criteria for food and beverage content (74%) and prohibited the sale of soda in all schools (63%); fewer policies restricted portion size of foods (53%) or beverages (47%). Restrictions more often applied to vending machines (95%), cafeteria à la carte (79%), and student stores (79%) than fundraising activities (47%). Most of the policies did not address more comprehensive approaches to the school nutrition environment, such as nutrition education (32%) or advertising to students (26%), nor did they include guidelines on physical education (11%). In addition, few policies addressed monitoring (32%) or consequences for non-compliance (11%). No policy restricted foods sold for after-school fundraising or required monitoring physical health indicators (e.g. BMI).
Conclusion
When compared to the Institute of Medicine's recommendations for schools' role in preventing obesity, none of the nutrition policies among each state's largest school district had addressed all the recommendations by 2004–2005. Nutritionists, nurses, pediatricians, parents, and others concerned about child health have an unprecedented opportunity to help shape and implement more comprehensive school district nutrition policies as part of the Congressional requirement for a "Wellness Policy" by 2006–2007.
doi:10.1186/1479-5868-3-1
PMCID: PMC1352376  PMID: 16390544
19.  School meals and the nutrition of schoolchildren. 
The contribution of school meals to the nutrition of 778 primary and secondary schoolchildren attending schools in Kent was assessed using information collected during a survey made in 1968-70 which included a weighed diet record, a socioeconomic questionnaire, and a medical examination. Younger children, those from larger families, those without fathers, and those whose mothers worked were more likely to take school meals. Significantly more children from lower social classes and without fathers received them free. School meals made an important contribution to the nutrition of schoolchildren. Children who took them had higher weekday lunchtime nutrient intake during term-time. Children in lower social classes, larger families, and without fathers who took school meals obtained a higher proportion of their weekday intake of nutrients from lunchtime than other children. This applied in particular to nutrients important for growth. School meals consumed by children in the study broadly met the standard set by the Department of Education and Science. The mean energy and protein content of school meals consumed in the study was slightly lower and the mean fat content higher than the standard set for the meal. The mean sugar content was about one-third higher than the suggested amount of sugar to be included in a school meal. There was no evidence that children who took school meals were taller, heavier, had greater skinfold thickness, or were more likely to be assessed as obese than other children.
PMCID: PMC478912  PMID: 1191886
20.  Differences in Fourth-Graders' Participation Rates Across Four School-Based Nutrition Studies 
Federal policy has encouraged researchers to include children in research studies; thus, it is important to report experiences recruiting children to participate in studies. This article compares fourth-graders' participation rates across four school-based nutrition studies conducted in one school district in a southeastern state. For each study, children were observed eating school meals (breakfast and lunch); interviewed regarding dietary intake; and weighed and measured. For Study 1, children from 11 schools received $10 per interview for up to two interviews conducted in the morning at school. For Study 2, children from 10 schools received $25 if interviewed once in the evening, either by telephone or in a van parked outside the child's home. For Study 3, children from three schools received $10 per interview for up to three interviews held in the evening by telephone. For Study 4, children from six schools received $15 per interview for up to two interviews conducted either in the morning or afternoon at school, or in the evening by telephone. Recruitment procedures were similar for all studies.
Participation rates were 73% (n=635) for Study 1, 57% (n=432) for Study 2, 66% (n=158) for Study 3, and 71% (n=296) for Study 4. Logistic regression was used to determine whether study (1, 2, 3, 4), race (black, white), or gender (male, female) were significant predictors of participation (agreed, denied). The results indicated that study (p<0.0001), race (p=0.0198), and gender (p=0.0188) were significant predictors, however, no two-factor interactions among these effects were significant. Post hoc pairwise comparisons with Bonferroni adjustment indicated that agreement to participate for Study 2 was lower (p<0.0001) than that for Studies 1, 3, and 4, which did not differ. Agreement to participate across all four studies was higher for black (69%) than white (63%; p=0.0054) children and for females (69%) than males (64%; p=0.0209). Schools provide a natural environment for nutrition research because school foodservice programs feed millions of children one or two meals (breakfast and/or lunch) each school day. Observations of children eating school meals provide a convenient and relatively unobtrusive means of validating children's dietary recalls. Thus, at some point, most child nutrition professionals are likely to be involved in research either directly (i.e. by conducting studies themselves) or indirectly (i.e. by allowing others access to their school cafeterias to collect data).
This paper references the following data: Table 1. Similarities and Differences in the Designs for Each of the Four Studies. Table 2. Number and Percent of Fourth-Grade Children Who Agreed or Denied to Participate by Race and Gender Across all Four Studies Combined. Table 3. Number and Percent of Fourth-Grade Children Who Agreed or Denied to Participate by Gender and Race for Each of the Four Studies Separately.
PMCID: PMC1945013  PMID: 17694161
21.  Overweight and Obesity and their Association with Dietary Habits, and Sociodemographic Characteristics Among Male Primary School Children in Al-Hassa, Kingdom of Saudi Arabia 
Objectives:
To assess the magnitude of obesity and overweight among male primary school children, and to find the possible association between obesity/overweight and dietary habits and sociodemographic differentials among them.
Study design and Methods:
A cross-sectional descriptive study, including 1139 Saudi male children enrolled in the 5th and 6th grades in public primary schools in Al Hassa, Kingdom of Saudi Arabia (KSA), was conducted. The test included a multistage random sampling technique, based on interview using Youth and Adolescent Food Frequency Questionnaire, gathering data regarding dietary intake, dietary habits, followed by anthropometric measurements with the calculation of body mass index (BMI), the interpretation of which was based on Cole's tables for the standard definition of overweight and obesity. Sociodemographic data were collected through a parental questionnaire from. Data analysis was performed using the SPSS 12 software (SPSS Inc. Chicago, IL, USA); both univariate and multivariate analyses were performed.
Results:
The age of the school children ranged from 10–14 years. The prevalence of overweight among the subjects was 14.2%, while that of obesity was 9.7%; the prevalence was more in the urban, older age students. The mothers of obese and overweight children were less educated and more working. Missing and or infrequent intake of breakfast at home, frequent consumption of fast foods, low servings per day of fruits, vegetables, milk and dairy products, with frequent consumption of sweets/candy and carbonated drinks were all predictors of obesity and overweight among the schoolchildren studied.
Conclusion:
The prevalence of childhood obesity is escalating and approaching figures that have been reported till now from the developed countries. Less healthy dietary habits and poor selection of food may be responsible for this high prevalence.
doi:10.4103/0970-0218.42058
PMCID: PMC2763675  PMID: 19876479
Body mass index; childhood obesity; dietary habits; Saudi Arabia
22.  The Benefits of Breakfast Cereal Consumption: A Systematic Review of the Evidence Base1234 
Advances in Nutrition  2014;5(5):636S-673S.
There have been no comprehensive reviews of the relation of breakfast cereal consumption to nutrition and health. This systematic review of all articles on breakfast cereals to October 2013 in the Scopus and Medline databases identified 232 articles with outcomes related to nutrient intake, weight, diabetes, cardiovascular disease, hypertension, digestive health, dental and mental health, and cognition. Sufficient evidence was available to develop 21 summary evidence statements, ranked from A (can be trusted to guide practice) to D (weak and must be applied with caution). Breakfast cereal consumption is associated with diets higher in vitamins and minerals and lower in fat (grade B) but is not associated with increased intakes of total energy or sodium (grade C) or risk of dental caries (grade B). Most studies on the nutritional impact are cross-sectional, with very few intervention studies, so breakfast cereal consumption may be a marker of an overall healthy lifestyle. Oat-, barley-, or psyllium-based cereals can help lower cholesterol concentrations (grade A), and high-fiber, wheat-based cereals can improve bowel function (grade A). Regular breakfast cereal consumption is associated with a lower body mass index and less risk of being overweight or obese (grade B). Presweetened breakfast cereals do not increase the risk of overweight and obesity in children (grade C). Whole-grain or high-fiber breakfast cereals are associated with a lower risk of diabetes (grade B) and cardiovascular disease (grade C). There is emerging evidence of associations with feelings of greater well-being and a lower risk of hypertension (grade D), but more research is required.
doi:10.3945/an.114.006247
PMCID: PMC4188247  PMID: 25225349
23.  Agreement between parent and child report on parental practices regarding dietary, physical activity and sedentary behaviours: the ENERGY cross-sectional survey 
BMC Public Health  2014;14(1):918.
Background
Parents and their parenting practices play an important role in shaping their children’s environment and energy-balance related behaviours (EBRBs). Measurement of parenting practices can be parent- or child-informed, however not much is known about agreement between parent and child perspectives. This study aimed to assess agreement between parent and child reports on parental practices regarding EBRBs across different countries in Europe and to identify correlates of agreement.
Methods
Within the ENERGY-project, a cross-sectional survey was conducted among 10–12 year old children and their parents in eight European countries. Both children and parents filled in a questionnaire on 14 parental practices regarding five different EBRBs (i.e. soft drink, fruit juice and breakfast consumption, sports activity and watching TV) and socio-demographic characteristics. Children’s anthropometric measurements were taken at school. We calculated percentages of agreement between children and their parents and weighted kappa statistics (for ordinal variables) per practice and country and assessed factors associated with agreement using multilevel linear regression.
Results
Reports of 6425 children and their parents were available for analysis. Overall mean agreement between parent and child reports was 43% and varied little among countries. The lowest agreement was found for questions assessing joint parent–child activities, such as sports (27%; Kappa (κ) = 0.14) or watching TV (30%;κ = 0.17), and for parental allowance of the child to have soft drinks (32%;κ = 0.24) or fruit juices (32%;κ = 0.19), or to watch TV (27%;κ = 0.17). Having breakfast products available at home or having a TV in the child’s bedroom were the only practices with moderate to good agreement (>60%;κ = 0.06 and 0.77, respectively). In general, agreement was lower for boys, younger children, younger parents, parents with less than 14 years of education, single parents, parents with a higher self-reported body mass index and parents who perceived their child to be underweight.
Conclusions
Parents and children perceive parental practices regarding dietary, physical activity and sedentary behaviours differently in all parts of Europe, with considerable variation across specific practices and countries. Therefore, future studies should assess both, parents and children’s view on parental practices.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-918) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-918
PMCID: PMC4169834  PMID: 25190541
Children; Parent; Parenting; Questionnaire; Inter-observer agreement; Inter-observer variability; Health behaviour; Overweight
24.  Parents and friends both matter: simultaneous and interactive influences of parents and friends on European schoolchildren’s energy balance-related behaviours – the ENERGY cross-sectional study 
Background
The family, and parents in particular, are considered the most important influencers regarding children’s energy-balance related behaviours (EBRBs). When children become older and gain more behavioural autonomy regarding different behaviours, the parental influences may become less important and peer influences may gain importance. Therefore the current study aims to investigate simultaneous and interactive associations of family rules, parent and friend norms and modelling with soft drink intake, TV viewing, daily breakfast consumption and sport participation among schoolchildren across Europe.
Methods
A school-based cross-sectional survey in eight countries across Europe among 10–12 year old schoolchildren. Child questionnaires were used to assess EBRBs (soft drink intake, TV viewing, breakfast consumption, sport participation), and potential determinants of these behaviours as perceived by the child, including family rules, parental and friend norms and modelling. Linear and logistic regression analyses (n = 7811) were applied to study the association of parental (norms, modelling and rules) and friend influences (norm and modelling) with the EBRBs. In addition, potential moderating effects of parental influences on the associations of friend influences with the EBRBs were studied by including interaction terms.
Results
Children reported more unfavourable friend norms and modelling regarding soft drink intake and TV viewing, while they reported more favourable friend and parental norms and modelling for breakfast consumption and physical activity. Perceived friend and parental norms and modelling were significantly positively associated with soft drink intake, breakfast consumption, physical activity (only modelling) and TV time. Across the different behaviours, ten significant interactions between parental and friend influencing variables were found and suggested a weaker association of friend norms and modelling when rules were in place.
Conclusion
Parental and friends norm and modelling are associated with schoolchildren’s energy balance-related behaviours. Having family rules or showing favourable parental modelling and norms seems to reduce the potential unfavourable associations of friends’ norms and modelling with the EBRBs.
doi:10.1186/1479-5868-11-82
PMCID: PMC4098693  PMID: 25001090
Parents; Friends; Social norm; Modelling; Rules; Soft drink; TV viewing; Physical activity
25.  Non-significant relationship between participation in school-provided meals and body mass index during the fourth-grade school year 
Journal of the Academy of Nutrition and Dietetics  2011;112(1):10.1016/j.jada.2011.08.037.
Data from four cross-sectional studies involving fourth-grade children were analyzed to investigate the relationship between participation in school-provided meals and body mass index (BMI), and the effect observed energy intake has on that relationship. Participation and BMI data were available on 1,535 children (51% Black; 51% girls) for four school years (Fall 1999 to Spring 2003; one study per school year) at 13 schools total. Direct meal observations were available for a subset of 342 children (54% Black; 50% girls) for one to three breakfasts and one to three lunches per child for a total of 1,268 school meals (50% breakfast). Participation in breakfast, lunch, and combined (both meals on the same day) was determined from nametag records compiled for meal observations for each study. Weight and height were measured. A marginal regression model was fit with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, combined participation, sex, age, race, and study. For the subset of children, observed energy intake at breakfast, lunch, and combined was included in additional analyses. Participation in breakfast, lunch, and combined was not significantly associated with BMI regardless of whether analyses included observed energy intake (P values > 0.181). The relationship between observed energy intake at breakfast and lunch, separately and combined, with BMI was positive (P values < 0.01). In conclusion, these results do not support a relationship between school-meal participation and BMI but do support a relationship between observed energy intake at school meals and BMI during fourth grade.
doi:10.1016/j.jada.2011.08.037
PMCID: PMC3880248  PMID: 22709640
Children; school; obesity; school meal programs; school-meal observations

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