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The importance of breakfast cereal for family health

Jacqui Lowdon
Registered Dietitian

This article aims to provide a deeper understanding of the scientific evidence supporting the importance of breakfast as a meal, and why fortified breakfast cereal, even pre-sweetened breakfast cereal, is a valuable choice for the UK population

Most people can quote the adage "Breakfast is the most important meal of the day"; and yet surveys of breakfast habits in Europe and the USA have found that as many as 10-30% of children and adolescents regularly skip it. Worryingly, this practice continues into adulthood, often setting poor eating habits for future generations.1 

In the UK, one in six children (equating to over 2 million) and one in five adults fail to eat breakfast every day.2 To help stem this trend, the Food Standards Agency has included "Don't skip breakfast" as one of its eight top Eatwell tips. Additionally, as healthcare professionals, we have a vital role to advocate the virtues of breakfast and of making the right choices.

Breakfast provides essential nutrients
Rampersaud et al conducted a review of the studies looking at the heath benefits of breakfast, and highlighted the important role that breakfast cereal plays in the diet of young people. Those who did eat breakfast cereal were more likely to meet nutrient requirements than those who did not (fibre, calcium, vitamins and minerals).1 This is true for a number of studies - breakfast provides essential nutrients which, when skipped, are unlikely to be made up for during the rest of the day.3-5

There is always a belief that healthy eating is expensive, but for around only 10p, a typical bowl of cereal contributes at least 20% of an adult's recommended daily amounts (RDA) for B vitamins and 17% for iron. This is salient when considering that nearly 50% of girls in the UK aged 11-18 years have an iron intake below the lower reference nutrient intake (LRNI).6 Breakfast cereals also tend to be low in fat and saturated fat, despite unfounded media attention that they often contain only very modest amounts of sugar and salt. Essentially, they are a micronutrient-dense (rather than energy-dense), affordable food, and an important part of a healthy balanced diet.

Calcium
Calcium intake in the UK is significantly below recommended levels. This is partly attributed to a decline in milk consumption, with up to 15% of 15-18 year olds not drinking any milk at all.6 This is likely to be a challenge recognised by dietitians working with this age group who are conscious of the importance of bone development during this time. As a result, the average intake for calcium (as well as zinc, potassium and magnesium) is below the RNI for boys and girls.6 In contrast, young people and adults who do consume breakfast cereals indirectly increase their calcium intake, as breakfast cereals serve as a vehicle to help drive 42% of total milk consumed in the UK.7,8

Fibre
Fibre has long been associated with digestive health, but the benefits extend much further, including satiety, heart health, decreased risk of some cancers and type 2 diabetes. In fact, in Changing health, choosing a better diet (2004), the Department of Health suggest increasing fibre intakes in order to:

  • Regulate bowel habits.
  • Reduce risk of bowel cancers.
  • Protect against CHD (by lowering blood cholesterol).
  • Promote satiety, help with energy balance.
  • Reduce rapid rises in blood sugar levels.

Despite the benefits, as many as eight in 10 adults and schoolchildren do not meet the guideline daily amount for fibre.9 Breakfast cereals contribute 10% of the fibre in the diet of young people and the consumption of breakfast cereal is generally associated with higher fibre intake.6,10

Because fibre helps with the feeling of satiety (or keeping you full), it poses a great solution for parents sending children off to school, as well as people trying to manage their weight. Neither of the two groups wants to feel hungry during the morning; therefore, choosing products that are classified as "high in fibre" (products with over 6 g per 100 g) can help.

Sugar
Pre-sweetened breakfast cereals have incorrectly been implicated in the media within the aetiology of (among others) obesity, diabetes and dental caries. As a health professional, it is vital that we provide evidence-based advice to our patients and help provide context and clarity in a backdrop of confusing media headlines. We need to bear in mind the important contribution of the micronutrients as stated above, along with the fact that breakfast cereals make only a small contribution to both sugar intakes (5% according to the National Diet and Nutrition Survey (NDNS)) and that purchased in the nation's shopping baskets (3.6% in 2009).11

[[Box 1 Kelloggs]]

Many dietitians and practice nurses will be reluctant to encourage people (especially children) to eat what appear to be breakfast cereals with "very high" sugar contents. But in perspective, a bowl of pre-sweetened cereal contains only one to two teaspoons of sugar per serving, which is often less than that commonly added to plainer cereals such as porridge and wheat biscuits, and less than that found in a yoghurt or toast with jam (as shown in Figure 1).

[[Fig 1 Kelloggs]]

Even with varying sugar contents, breakfast cereals usually provide around just 150 kcal per bowl. And, as highlighted above, they also contribute important nutrients, such as iron, B vitamins and calcium. The addition of sugar to cereals helps to make them an enjoyable start to the day, and an enjoyable way to get essential nutrients, therefore supporting the breakfast habit. Enjoyment is also particularly important when many parents are struggling to get their children to eat before getting them out of the door to school.

As practice nurses and dietitians, we are all too aware of the role of sugar and dental caries. However, when data from the NDNS were compared with dental data collected from 1,450 children in the UK, it was found that breakfast cereals - regardless of whether they were pre-sweetened - were not related to dental caries.12

This highlights the importance of factors such as frequency and other meal constituents on cariogenic potential rather than just the sugar content.13,14 Although a significant correlation was found between cereal sugar content and acid production and longer oral retention times for pre-sweetened cereals compared to unsweetened cereals, this was only evident when the cereals were eaten without milk. Most children eat cereals with milk.15
 
Salt
Recent years have seen significant public health awareness regarding salt due to intakes in the UK exceeding the maximum amount recommended of 6 g/day. Changes in dietary behaviour have to be carried out gradually and often by stealth to remain enjoyable and therefore sustainable.
Despite making only marginal contributions to dietary intakes (5% according to the NDNS), the breakfast cereal industry has worked hard over the last 12 years to reduce amounts by a staggering 49%, while retaining consumer enjoyment.9 A typical 30 g bowl of cereal, such as cornflakes, contains just 6% of the guideline daily amount (GDA) for salt.

Breakfast and performance
The primary fuel for our brains is glucose, which is dependent on a constant supply in the blood stream.16 After sleeping, when effectively the body has been "fasting", it is important that we boost the levels of glucose in the circulation, further emphasising the importance of eating breakfast.
When looking at the evidence, there is increasing evidence for the beneficial effects of breakfast in improving mental performance, including attention, problem-solving, reading, and listening comprehension in children. Not only is performance comparatively more efficient immediately after consuming breakfast, but also throughout the following hours.1,17-19

Weight control
As well as not having enough time, trying to lose weight is a common reason for many people skipping breakfast. In fact, there is a positive correlation between skipping breakfast and obesity in adults.20 In contrast, there is growing evidence that regular breakfast eaters tend to be slimmer than those who
skip breakfast.21,22

However, these findings are not true for all types of breakfast. Indeed, studies show that it is the consumption of breakfast cereal specifically (even pre-sweetened) that drives the association. A recent systematic review looked at the relationship between the consumption of breakfast cereals and body mass index (BMI). It was consistently shown that adults and children who regularly ate breakfast cereals tended to have a lower BMI and were less likely to be overweight than those who did not. The reasons for this remain unclear as there is no evidence showing breakfast cereals drive a lower daily energy intake or increased energy expenditure.23

Making the right choice
Front of pack labelling on products can help consumers make more informed choices about their dietary health. The majority of breakfast cereals now carry GDAs on the front of packs, indicating exactly what a serving of the product will provide. Consumers can use these to make comparisons between products, and make informed choices about what products are right for themselves and for their family.

Conclusion
As healthcare professionals, encouraging the breakfast habit is an important element of advocating healthy living! Breakfast cereals make an ideal option, providing an enjoyable, economical, rich source of nutrition for the whole family. l

References
1. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc 2005;105:743-60.
2. Taylor Nelson and Sofres (TNS) Family Food Panel 2003.
3. Cho S, Dietrich M, Brown CJ, Clark CA, Block G. The effect of breakfast type on total daily energy intake and body mass index: results from the Third National Health and Nutrition Examination Survey (NHANES III). J Am Coll Nutr 2003;22(4):296-302.
4. Gibson, O'Sullivan. Breakfast cereal consumption patterns and nutrient intakes in British schoolchildren. J R Soc Health 1995;115(6):366-70.
5. Preziosi P, Galan P, Deheeger M, Yacoub N, Drewnowski A, Hercberg S. Breakfast type, daily nutrient intakes and vitamin and mineral status of French children, adolescents and adults. J Am Coll Nutr 1999;18(2):171-8.
6. Wenlock G, Farron M. National Diet and Nutrition Survey: young people aged 4 to 18 years. Volume 1: Report of the diet and nutrition survey. London: The Stationery Office; 2000.
7. Song WO, Chun OK, Kerver J, Cho S, Chung CE, Chung SJ. Ready-to-eat breakfast cereal consumption enhances milk and calcium intake in the US population. J Am Diet Assoc 2006;106:1783-9.
8. TNS World panel - Feb 2007
9. Henderson L, Gregory J. The National Diet and Nutrition Survey: adults aged 19-64 years. London: The Stationery Office; 2003.
10. McNulty H, Eaton-Evans J, Cran G et al. Nutrient intakes and impact of fortified breakfast cereals in schoolchildren. Arch Dis Child 1996;75(6):474-81.
11. TNS World Panel Nutrition Service 2009
12. Gibson SA. Breakfast cereal consumption in young children: associations with non-milk extrinsic sugars and caries experience: further analysis of data from the UK National Diet and Nutrition Survey of children aged 1.5-4.5 years. Public Health Nutr 2000;3(2):227-32.
13. Ismail AI. Food cariogenicity in Americans aged from 9 to 29 years assessed in a national cross-sectional survey, 1971-74. J Dent Res 1986;65(2):1435-40.
14. Rugg-Gunn AJ, Hackett AF, Appleton DR, Jenkins GN, Eastoe JE. Relationship between dietary habits and caries increment assessed over two years in 405 English adolescent school children. Arch Oral Biol 1984;29(12):983-92.
15. Minton KL, Berry CW. Cariogenic potential of presweetened breakfast cereals. Pediatr Dent 1985;7:282-6.
16. Garrow JS, James WPT, Ralph A. Human Nutrition and Dietetics. 10th edn. Oxford: Churchill Livingstone; 2000.
17. Bellisle F. Effects of diet on behaviour and cognition in children. Br J Nutr 2004;92(Suppl 2): S227-32.
18. Mahoney CR, Taylor HA, Kanarek RB, Samuel P. Effect of breakfast composition on cognitive processes in elementary school children. Physiol Behav 2005;85:635-45.
19. Pollitt E, Mathews R. Breakfast and cognition: an integrative summary. Am J Clin Nutr 1998;67:S804-13.
20. Song WO, Chun OK, Obayashi S et al. Is consumption of breakfast associated with body mass index in US adults? J Am Diet Assoc 2005;105:1373-82.
21. Ma Y, Bertone ER, Stanek EJ 3rd, et al. Association between eating patterns and obesity in a free-living US adult population. Am J Epidemiol 2003;158:85-92.
22. Summerbell CD, Moody RC, Shanks J, Stock MJ, Geissler C. Relationship between feeding pattern and body mass index in 220 free-living people in four age groups. Eur J Clin Nutr 1996;50:513-19.
23. De La Hunty A, Ashwell M. Are people who regularly eat breakfast cereals slimmer than those who don't? A systematic review of the evidence. British Nutrition Foundation Nutrition Bulletin 2007;32:119-29.

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