Skipping Breakfast Is Not a New Cardiovascular Risk Factor

A new study suggests skipping breakfast may lead to heart attack and stroke, but the data is a bit… starved.

This week, was your mom right all along when she told you that breakfast was the most important meal of the day?

The answer to that question appears in the Journal of the American College of Cardiology in this article, linking skipping breakfast to cardiovascular death.

Association of Skipping Breakfast With Cardiovascular and All-Cause Mortality

Association of Skipping Breakfast With Cardiovascular and All-Cause Mortality

It’s OK to be skeptical on this one, folks. We get studies saying eating X leads to heart disease, or cancer, or dementia, or prevents one of those things every other week it seems.  But let’s not discard these studies out of hand – there is some learning to do here.

Researchers used the well-worn National Health and Nutrition Examination Survey (NHANES) to identify 6,550 individuals between age 40 and 75 without a prior history of cancer or cardiovascular disease and who had adequate follow-up information to conduct the analysis.

The first red flag is that sample size. The article states there were around 40,000 participants in the dataset they were analyzing, but only 6,550 met their inclusion criteria.

Mmm…. pie for breakfast.

We are not told which individuals were kicked out of the study for which reason, but the fact that only 16% of participants were analyzed raises questions of whether the results can be broadly applicable.

Not pictured: those who eat breakfast have time to eat breakfast.

At baseline, the participants were asked how often they ate breakfast. The majority reported eating breakfast every day, but a sizeable number didn’t eat breakfast at all, breaking their poor mothers’ hearts. 

Like all lifestyle measurements, at baseline individuals who didn’t eat breakfast differed in substantial ways from those who ate it every day. 

They were more likely to be black, less likely to be married, more likely to be a former smoker, more likely to be a heavy drinker, and much more likely to be physically inactive.

Your adjustment for income is bad and you should feel bad.

Now, of course the authors adjusted for these factors, but I am concerned that their adjustment for family income was inadequate – using three discrete categories of income instead of a more thorough adjustment for income as a continuous variable.

This is particularly problematic in a study like this because income might be a significant predictor of the ability to eat breakfast every day and, as we’ve discussed many times, higher income is a strong predictor of better outcomes for reasons that are fun to debate at dinner parties and political rallies.

We don’t need no stinkin’ dose response!

On average, 6 out of every 1000 people who eat breakfast every day died from a cardiovascular cause yearly during follow-up. 7 out of 1000 people who never ate breakfast died each year.

This small difference was statistically significant given the large number of people in this study, but the lack of a dose-response, as you can see in this graph, diminishes my appetite for the findings a bit.

When we examine a study like this, we have two questions to ask.  First, is there causality here? If there is, we can recommend that our patients start eating breakfast to reduce the risk of heart attack. But given these findings I’m not too excited about prescribing breakfast to our patients.

If there is no causality, the second question is can we use breakfast eating as a new risk predictor? After all, we ask our patients if they smoke, if they drink, how much exercise they get. Should we add “do you always eat breakfast” to the list of screening questions.

In short, no.  Since the magnitude of risk was so minimally different between the always and never breakfast eaters, there’s minimal yield to waste time discussing it with patients. Better to use that time to, you know, convince them to get some exercise, or complain about the electronic health record.

So what do we tell our moms? Well, of course we tell them that they were right all along. But between you, me, and a bowl of corn flakes, don’t worry too much about breakfast eating. There are bigger fish to fry.

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