Associations between deprivation, attitudes towards eating breakfast and breakfast eating behaviours in 9–11-year-olds

Breakfast skipping and cognitive and emotional engagement at school: a cross-sectional population-level study

OBJECTIVE

Research on the consequences of breakfast skipping among students tends to focus on academic outcomes, rather than student well-being or engagement at school. This study investigated the association between breakfast skipping and cognitive and emotional aspects of school engagement.

DESIGN

Cross-sectional study using data from a population-level survey of children and adolescents' well-being and engagement at school. Linear regression with adjustment for confounders was used to estimate the effect of breakfast skipping on school engagement.

SETTING

Government schools (i.e. public schools) in South Australia.

PARTICIPANTS

The participants were students, Grades 4-12, who completed the Wellbeing and Engagement Collection in 2019. The analysis sample included 61 825 students.

RESULTS

Approximately 9·6 % of students reported always skipping breakfast, with 35·4 % sometimes skipping and 55·0 % never skipping. In the adjusted linear regression models, children and adolescents who always skipped breakfast reported lower levels of cognitive engagement (β = -0·26 (95 % CI -0·29, -0·25)), engagement with teachers (β = -0·17 (95 % CI -0·18, -0·15)) and school climate (β = -0·17 (95 % CI -0·19, -0·15)) compared with those who never skipped breakfast, after controlling for age, gender, health, sleep, sadness and worries, parental education, socio-economic status and geographical remoteness.

CONCLUSION

Consistent with our hypothesis, skipping breakfast was associated with lower cognitive and emotional engagement, which could be due to mechanisms such as short-term energy supply and long-term health impacts. Therefore, decreasing the prevalence of breakfast skipping could have a positive impact on school engagement.

Breakfast: A Crucial Meal for Adolescents' Cognitive Performance According to Their Nutritional Status. The Cogni-Action Project

This study aimed to determine whether pupils who have breakfast just before a cognitive demand, do not regularly skip breakfast, and consume a high-quality breakfast present higher cognitive performance than those who do not; furthermore, to establish differences according to their nutritional status. In this study, 1181 Chilean adolescents aged 10–14 years participated. A global cognitive score was computed through eight tasks, and the body mass index z-score (BMIz) was calculated using a growth reference for school-aged adolescents. The characteristics of breakfast were self-reported. Analyses of covariance were performed to determine differences in cognitive performance according to BMIz groups adjusted to sex, peak height velocity, physical fitness global score, and their schools. A positive association was found in adolescents’ cognitive performance when they had breakfast just before cognitive tasks, did not regularly skip breakfast, presented at least two breakfast quality components, and included dairy products. No significant differences were found between breakfast components, including cereal/bread and fruits/fruit juice. Finally, pupils who were overweight/obese who declared that they skipped breakfast regularly presented a lower cognitive performance than their normal-BMIz peers. These findings suggest that adolescents who have breakfast just prior to a cognitive demand and regularly have a high quality breakfast have better cognitive performance than those who do not. Educative nutritional strategies should be prioritized, especially in “breakfast skippers” adolescents living with overweight/obesity.

Mediators of socioeconomic inequalities in dietary behaviours among youth: A systematic review

Children and adolescents with a lower socioeconomic position have poorer dietary behaviours compared to their counterparts with a higher socioeconomic position. A better understanding of the mechanisms behind such socioeconomic inequalities is vital to identify targets for interventions aimed at tackling these inequalities. This systematic review aimed to summarize existing evidence regarding the mediators of socioeconomic differences in dietary behaviours among youth. A systematic literature search of MEDLINE, Embase, PsycINFO, and Web of Science databases yielded 20 eligible studies. The dietary behaviours included in the reviewed studies were the intake of fruit and vegetables, sugar-sweetened beverages, unhealthy snacks/fast food and breakfast. The consistent mediators of the effects of socioeconomic position on dietary behaviours among youth were: self-efficacy, food preferences and knowledge at the intrapersonal level; and availability and accessibility of food items at home, food rules and parental modelling at the interpersonal level. Few studies including mediators at the organisational, community or policy levels were found. Our review found several modifiable factors at the intrapersonal and interpersonal levels that could be targeted in interventions aimed at combating inequalities in dietary behaviours among youth. Rigorous studies exploring organisational, community and policy level mediators are warranted.

Use of the School Setting During the Summer Holidays: Mixed-Methods Evaluation of Food and Fun Clubs in Wales

OBJECTIVE

School summer holiday clubs in deprived areas of Wales were evaluated to examine opportunities for healthy eating and physical activity and explore delivery processes.

METHODS

Ten Food and Fun clubs participated in 2016. Quantitative data (child and parent surveys; N = 196, N = 84) assessed the opportunity to provide children with breakfast and lunch. A sub-sample of children wore an accelerometer (N = 41) to evaluate the opportunity for achieving 1-hour of moderate to vigorous activity (MVPA) at club. Features of successful club delivery were identified through; focus groups (child and parent; N = 74, N = 69) and interviews (staff/volunteer; N = 32).

RESULTS

Opportunities for healthy eating were delivered with high fidelity: 86% of children reported breakfast consumption and 75% eating a healthy lunch. On club days, children reported consuming fewer sugary snacks (66%), fewer sugary drinks (81%), and more fruits and vegetables (67%). About 71% of children achieved the recommended MVPA at club, with children engaging in more MVPA (+17 minutes/day, p < .01) on average compared to non-club days. Successful delivery processes were: use of school facilities and staff; flexible partnership-working; and whole family involvement.

CONCLUSIONS

Schools appear to provide a suitable setting for the delivery of healthy eating and physical activity opportunities during school summer holidays.

Effects of eating breakfast on children and adolescents: A systematic review of potentially relevant outcomes in economic evaluations

BACKGROUND

Breakfast is often described as the most important meal of the day. Several studies have focused on examining if breakfast habits have any short-term effects on school attendance, academic achievement, and general health in children and adolescents. Informed decisions of whether to promote eating breakfast or not require a more long-term perspective.

OBJECTIVE

The aim of this study was to conduct a systematic review of scientific publications studying the effects identified as potentially relevant for the economic evaluation of eating breakfast in children and adolescents.

DESIGN

A systematic literature review was conducted. Studies were identified by searching the electronic databases PubMed, CINAHL, Web of Science, and PsycINFO between January 2000 and October 2017. The inclusion criteria applied were published articles from peer-reviewed journals with full text in English, quantitative studies collecting primary data with school-aged children, and adolescents aged from 6 to 18 years as participants, performed entirely or partly in countries with advanced economies, except Japan and Taiwan.

RESULTS

Twenty-six studies fulfilled the inclusion criteria, and studies that were judged to be of at least moderate quality were included in the analysis. The results of the review of eating breakfast studies showed positive and conclusive effects on cognitive performance, academic achievement, quality of life, well-being and on morbidity risk factors.

CONCLUSIONS

The overall assessment of the studies indicated positive effects of eating breakfast. How the identified effects influence societal costs and an individual's quality-adjusted life years require further research.

Changing the behaviour of children living in Dutch disadvantaged neighbourhoods to improve breakfast quality: Comparing the efficacy of three school-based strategies

Children's breakfast habits are suboptimal. A novel school-based education programme was developed and tested with the aim of improving children's attitude, knowledge and breakfast quality. A pre- and post-test design was used with four conditions: group-based education, role modelling, tailored feedback with goal setting, and a combination of these three delivery modes. Two hundred eighty children from disadvantaged communities (9.3 ± 0.8 years) participated in three lessons at school over a two-month period. Children's attitude, knowledge and breakfast behaviour were evaluated by a pre- and post-questionnaire completed by the children. A follow-up measure was executed at 24 weeks. The data were analysed by repeated measures ANOVA. At baseline, 90% of the children ate breakfast on the measurement day; 60-76% of the children ate breakfast daily. Between pre- and post-test, a significant time effect was found for children's attitude, self-efficacy, knowledge and behaviour (all p < 0.05). Children in the feedback condition improved most favourably: correct classification of breakfast products increased by 10 products (out of 44) and breakfast quality score improved by 25 points (on a 100-point scale). The feedback condition also resulted in positive changes in the home setting. The follow-up test showed a decline in children's knowledge and their breakfast quality across conditions. To conclude, this study showed that a three-lesson school programme based on individual feedback and goal setting is most effective for changing knowledge on breakfasting and self-reported breakfast quality among children aged 8-10 years living in disadvantaged neighbourhoods. To maintain effectiveness, longer-term programmes embedded in the school curriculum are needed to enhance breakfast quality. Future research should explore the optimal duration and intensity of such programmes and should incorporate the topic of suitable portion sizes.

The Association Between Maternal Factors and Preadolescent Breakfast Skipping: The Mediating Role of Preadolescent Attitudes Toward Breakfast

BACKGROUND

Although skipping breakfast is common among children and adolescents, daily breakfast consumption is a healthy habit that is particularly important in childhood. There is a link between children's attitudes toward breakfast, breakfast-skipping behaviors, and maternal factors. Evidence demonstrating a clear relationship between maternal factors and preadolescent attitudes and behaviors toward breakfast skipping is scarce.

AIMS

This study aims to examine the mediation effect of preadolescent attitudes toward breakfast on the associations between maternal involvement (encouragement and control of breakfast eating) and preadolescent breakfast skipping.

METHODS

A cross-sectional descriptive study was conducted across Jordan in public and private primary schools in 2015. A sample of 1,915 preadolescent students (10-11 years) and their mothers (N = 1,299) was generated through proportional cluster stratification sampling. The interrelationships were examined among the participants' demographics, the number of preadolescent skipped breakfasts during a given week, self-reported attitudes toward breakfast, and perceived maternal encouragement and control of breakfast-eating variables.

RESULTS

Analysis revealed that preadolescent attitudes toward breakfast and mothers' involvement in preadolescent breakfast were negatively correlated with preadolescent breakfast skipping. Linear regressions revealed that maternal involvement (i.e., encouragement and control of breakfast eating, and educational attainment levels) was predictive of preadolescent attitudes toward breakfast consumption. Multiple regressions using bootstrapping analysis showed that preadolescent attitudes partially mediated the effect of mothers' control and encouragement of breakfast consumption over preadolescent breakfast-skipping behavior.

LINKING EVIDENCE TO ACTION

Results suggest that preadolescent attitudes, maternal encouragement, and control of breakfast eating influenced preadolescent breakfast skipping. These findings emphasize the importance of carefully assessing preadolescent attitudes toward breakfast, maternal encouragement, and control of breakfast consumption when developing interventions aimed at reducing breakfast-skipping behavior.

Breakfast eating among Brazilian adolescents: Analysis of the National Dietary Survey 2008-2009

ABSTRACT Objective: To characterize breakfast eating among Brazilian adolescents. Methods: Food intake was estimated based on a 1-day food record of adolescents aged 10-19 years, according to the first National Diet Survey (2008-2009). Breakfast was considered as the first meal of the day eaten between 4 and 11 am. Results: Ninety-three percent of adolescents reported eating breakfast. This meal contributed to 17.7% of the daily energy intake. The most commonly consumed food groups were: coffee and tea, breads, butter/margarine, milk, cakes and cookies, packaged snacks, corn-based dishes, cheese, processed meats, and fruit juice. In the Northern region there was a higher frequency of coffee and tea and roots and tubers intake and lower frequency of milk intake than that in the other regions in the country. In the Northeastern region, the intake of corn and eggs was high; in the Southern region, there was high intake of processed meats and fruits. Adolescents from families in the first income quartile reported higher intake of coffee and tea, packaged snacks, corn, and roots and tubers intake, and lower intake of milk and dairy products. Adolescents from families in the highest income quartile reported higher intake of milk, fruit juice, cheese, and sugar-added beverages. Conclusion: In Brazil, the contribution of breakfast to daily energy intake among adolescents is low. The nutritional quality of breakfast improved with increased income. The three most frequently consumed items were coffee and tea, breads, and butter/margarine.

Mediators of the association between parental education and breakfast consumption among adolescents : the ESSENS study

BACKGROUND

Regular breakfast consumption has several health benefits. However, breakfast skipping is common among adolescents, in particular among those with a low socioeconomic background. The aims of the study were to explore individual and home environmental correlates of breakfast consumption, and to assess their potential mediating role in the association between parental education and breakfast consumption.

METHODS

A cross-sectional study including 706 adolescents with a mean age of 13.6 (SD = 0.3) was conducted between October and December 2016. Data were collected at school through an online questionnaire. Regression analyses were used to explore whether parental modelling, parental co-participation in breakfast consumption, parental rules, the availability of breakfast foods at home and screen time were associated with breakfast consumption. Mediation analyses were conducted to assess whether these factors mediated the association between parental education and breakfast consumption.

RESULTS

Breakfast consumption was significantly positively associated with parental education (OR = 1.97 (95% CI 1.43-2.72)). A higher parental modelling (OR = 2.17 (95% CI 1.70-2.79)), a higher parental co-participation in breakfast consumption (OR = 1.37 (95% CI 1.26, 1.49)), higher parental rules (OR = 1.36 (95% CI 1.21, 1.53)) and a higher availability of breakfast foods at home (OR = 2.21 (95% CI 1.65, 2.97)) were associated with higher odds of being a daily breakfast consumer. Higher levels of screen time (hrs/day) were associated with lower odds of being a daily breakfast consumer (OR = 0.85 (95% CI 0.79, 0.91). Parental modelling (B = 0.254 (95% CI 0.149, 0.358)) and the availability of breakfast foods at home (B = 0.124 (95% CI 0.033, 0.214)) were significantly positively related to parental education, whereas screen time (hrs/day) (B = -1.134 (95% CI -1.511, -0.758)) was significantly inversely related to parental education. Parental modelling, the availability of breakfast foods at home and screen time were found to mediate parental educational differences in breakfast consumption.

CONCLUSIONS

Increasing the availability of breakfast food, improving parental modelling of breakfast consumption and targeting screen time might be promising strategies to reduce parental educational differences in breakfast consumption.

Association between economic status and body mass index among adolescents: a community-based cross-sectional study in Japan

BACKGROUND

Childhood overweight and obesity is a growing health challenge in Japan and might be associated with childhood poverty. We aimed to investigate the association between low economic status and body mass index (BMI) and to reveal the mediators of this association among junior high school students in Japan.

METHODS

Junior high school students (N = 2968) from two cities in Shizuoka, Japan, were surveyed. Questionnaires assessed subjective economic status, weight, and height. Economic status was categorized into low and non-low, and BMI z-scores were calculated using the WHO Growth Reference. Multivariate regression analyses were conducted to determine the association between economic status and BMI z-scores, adjusted for covariates and stratified by gender.

RESULTS

Among girls, low economic status was significantly positively associated with BMI z-scores in the crude model (coefficient: 0.35; p = 0.001). In a model adjusted for breakfast skipping, the coefficient of economic status decreased by 28.57 % but remained significant (coefficient: 0.25; p = 0.017). In the final model adjusted for other possible covariates, low economic status remained significantly positively associated with BMI z-score (coefficient: 0.22; p = 0.044). The same association was not found for boys.

CONCLUSIONS

Low economic status was positively associated with higher BMI among girls in junior high school in Japan, but this was not true for boys. Childhood poverty might be associated with overweight and obesity among adolescent girls in Japan. Health policies at junior high schools to discourage breakfast skipping might be effective for countering the association between childhood poverty and overweight in adolescent girls.

Applying an extended theory of planned behaviour to predict breakfast consumption in adolescents

BACKGROUND/OBJECTIVES

Breakfast skipping increases during adolescence and is associated with lower levels of physical activity and weight gain. Theory-based interventions promoting breakfast consumption in adolescents report mixed findings, potentially because of limited research identifying which determinants to target. This study aimed to: (i) utilise the Theory of Planned Behaviour (TPB) to identify the relative contribution of attitudes (affective, cognitive and behavioural) to predict intention to eat breakfast and breakfast consumption in adolescents and (ii) determine whether demographic factors moderate the relationship between TPB variables, intention and behaviour.

SUBJECTS/METHODS

Questionnaires were completed by 434 students (mean 14±0.9 years) measuring breakfast consumption (0-2, 3-6 or 7 days), physical activity levels and TPB measures. Data were analysed by breakfast frequency and demographics using hierarchical and multinomial regression analyses.

RESULTS

Breakfast was consumed everyday by 57% of students, with boys more likely to eat a regular breakfast, report higher activity levels and report more positive attitudes towards breakfast than girls (P<0.001). The TPB predicted 58% of the variation in intentions. Overall, the model was predictive of breakfast behaviours (P<0.001), but the relative contribution of TPB constructs varied depending on breakfast frequency. Interactions between gender and intentions were significant when comparing 0-2- and 3-6-day breakfast eaters only highlighting a stronger intention-behaviour relationship for girls.

CONCLUSIONS

Findings confirm that the TPB is a successful model for predicting breakfast intentions and behaviours in adolescents. The potential for a direct effect of attitudes on behaviours should be considered in the implementation and design of breakfast interventions.

Universal Free School Breakfast: A Qualitative Process Evaluation According to the Perspectives of Senior Stakeholders

In the last decade, the provision of school breakfast has increased significantly in the UK. However, there is an absence of knowledge regarding senior stakeholder views on the processes and potential outcomes on different groups, within the communities served by school breakfast programs. The purpose of this study was to examine the views and experiences of senior level stakeholders and thereby provide an original qualitative contribution to the research. A sample of senior level stakeholders was recruited, including senior officers, directors, and elected members, from within a Local Authority (LA) involved in the leadership, implementation and delivery of a council-wide universal free school breakfast (UFSB) program, and from the senior staff body of mainstream primary and special schools, participating in the program. A grounded theory analysis of the data collected identified issues encountered in the implementation and delivery, and views on the funding and future of a USFB program, in addition to perceived outcomes for children, parents, families, schools, and the wider community. The results refer to both positive and negative issues and implications associated with the program, according to the perspectives of senior level stakeholders. Perceived positive outcomes included benefits to children, families, schools, and the community. For instance, alleviating hunger, improving health outcomes, and conferring financial benefits, with the potential to cumulate in overall improvements in educational, social, and behavioral outcomes. Reported negative implications included the absence of an effective communication strategy in implementing the USFB program; in addition to concerns about the impacts of "double-breakfasting" on obesity levels among children, particularly in less deprived communities. Findings were validated using theoretical sampling and saturation, triangulation methods, member checks, and inter-rater reliability measures. In presenting these findings, this paper provides a unique qualitative insight into the processes, issues and outcomes of a council-wide UFSB program within a socioeconomically deprived community, according to the perceptions of senior level stakeholders.

Breakfast frequency among adolescents: associations with measures of family functioning

OBJECTIVE

To investigate (i) associations between adolescents' frequency of breakfast and family functioning (close relations to parents, quality of family communication and family support) and (ii) if any observed associations between breakfast frequency and family functioning vary by sociodemographic factors.

DESIGN

School-based cross-sectional study. Students completed a web-based questionnaire. Associations were estimated by multilevel multivariate logistic regression.

SETTING

Danish arm of the Health Behaviour in School-aged Children study, 2014.

SUBJECTS

Adolescents aged 13 and 15 years (n 3054) from a random sample of forty-one schools.

RESULTS

Nearly one-quarter of the adolescents had low breakfast frequency. Low breakfast frequency was associated with low family functioning measured by three dimensions. The OR (95 % CI) of low breakfast frequency was 1·81 (1·40, 2·33) for adolescents who reported no close relations to parents, 2·28 (1·61, 3·22) for adolescents who reported low level of quality of family communication and 2·09 (1·39, 3·15) for adolescents who reported low level of family support. Joint effect analyses suggested that the odds of low breakfast frequency among adolescents with low family functioning compared with high family functioning were highest among adolescents being girls, immigrants and living in other than a traditional family structure.

CONCLUSIONS

Low breakfast frequency was associated with low family functioning measured by close relations to parents, quality of family communication and family support. Further, analyses suggested that the associations were more pronounced among girls, immigrants and adolescents from other family structure than traditional. The study highlights the importance of the family setting in promoting regular breakfast frequency among adolescents.

Associations of Child Temperament with Child Overweight and Breakfast Habits: A Population Study in Five-Year-Olds

This study examines the associations of child temperament with overweight/obesity and breakfast habits. Participants were 17,409 five-year-olds whose mothers partake in the Norwegian Mother and Child Cohort Study (MoBa), and completed a questionnaire at the child’s 5th birthday. Temperament was assessed as externalizing, internalizing and sociable temperament. Breakfast habits differentiated between “every day”, “4 to 6 times a week”, and “0 to 3 times a week”. The child’s weight status was determined by Body Mass Index-percentiles and categorized as normal weight versus overweight/obese. Children with externalizing temperament had higher odds of being overweight and higher odds of not eating breakfast daily. Children high in internalizing temperament had higher odds of not eating breakfast daily, but not of being overweight. Children with average scores of sociability were more prone to being overweight but had normal breakfast habits. All results were adjusted for key confounders. That five-year-olds high in externalizing temperament had a higher risk to be overweight adds important information to the literature. The association of externalizing temperament with child breakfast habits so early in life is intriguing, as parents mostly control eating patterns in children that young. Mechanisms mediating this association should be explored.

Association between breakfast consumption and educational outcomes in 9-11-year-old children

Objective

Breakfast consumption has been consistently associated with health outcomes and cognitive functioning in schoolchildren. Evidence of direct links with educational outcomes remains equivocal. We aimed to examine the link between breakfast consumption in 9–11-year-old children and educational outcomes obtained 6–18 months later.

Design

Data on individual-level free school meal entitlement and educational outcomes (Statutory Assessment Tests (SATs) at Key Stage 2) were obtained via the SAIL databank and linked to earlier data collected on breakfast consumption. Multilevel modelling assessed associations between breakfast consumption and SATs.

Setting

Trial of the Primary School Free Breakfast Initiative in Wales.

Subjects

Year 5 and 6 students, n 3093 (baseline) and n 3055 (follow-up).

Results

Significant associations were found between all dietary behaviours and better performance in SATs, adjusted for gender and individual- and school-level free school meal entitlement (OR=1·95; CI 1·58, 2·40 for breakfast, OR=1·08; CI 1·04, 1·13 for healthy breakfast items). No association was observed between number of unhealthy breakfast items consumed and educational performance. Association of breakfast consumption with educational performance was stronger where the measure of breakfast consumption was more proximal to SATs tests (OR=2·02 measured 6 months prior to SATs, OR=1·61 measured 18 months prior).

Conclusions

Significant positive associations between self-reported breakfast consumption and educational outcomes were observed. Future research should aim to explore the mechanisms by which breakfast consumption and educational outcomes are linked, and understand how to promote breakfast consumption among schoolchildren. Communicating findings of educational benefits to schools may help to enhance buy-in to efforts to improve health behaviours of pupils.

A cross-sectional observational study of the nutritional intake of UK primary school children from deprived and non-deprived backgrounds: implications for school breakfast schemes

BACKGROUND

This study examined the nutritional intake of 9-11 year old children in Wales, UK, to assess the rationale for, and potential of, school breakfast initiatives. It also examined the possible unintended consequence of over consumption.

METHODS

The study employed a cross-sectional observational design within a randomized controlled trial of a free school breakfast programme. A total of 111 primary schools were randomly assigned to an intervention condition (in which a free school breakfast programme was implemented) or a control condition (in which implementation of the scheme was delayed). Sub-samples of children completed multiple-pass 24-hr dietary recall interviews at baseline (n = 581), and 12 months later (n = 582). Deprivation was assessed for each child in terms of whether or not they were entitled to free school meals.

RESULTS

Prior to the introduction of the programme, rates of breakfast skipping were low and there was little evidence of widespread nutritional deficiency. However, there was a subset of children who consumed inadequate levels of a range of vitamins and minerals and 29 % of children ate very little for breakfast (less than 100 kcal). Children that ate larger breakfasts, had higher daily intakes of all nutrients that were examined. Children from deprived backgrounds consumed significantly lower levels of several vitamins and minerals at breakfast. Following the introduction of the breakfast scheme in intervention schools, there was little difference in the nutritional quality of school versus home breakfasts (n = 35 and 211 respectively). Where children ate breakfast at both school and home (n = 33), their overall energy intake was higher, but not significantly so.

CONCLUSIONS

Although the overall diet of this group of children was generally good prior to the breakfast scheme, the results suggest that such schemes could be beneficial for a subset of children who are poorly nourished and for those children who consume very little for breakfast.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18336527.

Conceptual framework of a simplified multi-dimensional model presenting the environmental and personal determinants of cardiometabolic risk behaviors in childhood

Clinical manifestations of cardiometabolic risk (CMR) may be set early in childhood due to unfavorable behaviors or lifestyle patterns related to diet and physical activity. Several factors may determine the adoption of such lifestyle-related behaviors, which researchers have tried to cluster under certain frameworks or models. In this context, the framework developed and proposed by this review gathers all the present knowledge regarding these determining factors to date and groups them into three main categories related to personal characteristics and the social and physical environment. Based on the proposed framework, a large variety of personal, social and physical environmental factors can positively or negatively influence CMR-related behaviors (either directly or indirectly via their interrelations), thus leading to decreased or increased risk, respectively. This framework could be of great value to public health policy makers and legislators for designing and implementing interventional programs tailored to the needs of susceptible population groups who are most in need for such initiatives. Targeting the correlates as potential determinants of CMR-related behaviors, and not just on the behaviors themselves, has been shown previously to be the most effective approach for tackling health issues related to CMR starting from early life stages.

Socio-economic position as a moderator of 9–13-year-old children’s non-core food intake

Objective

There is limited understanding as to why children of low socio-economic position (SEP) consume poorer diets than children of high SEP. Evidence suggests that determinants of dietary intake may differ between SEP groups. The present study aimed to determine if SEP moderated associations of personal and environmental predictors with children’s non-core food and sweetened drink intakes and unhealthy dietary behaviours.

Design

Children completed online questionnaires and parents completed computer-assisted telephone interviews to assess intrapersonal and environmental dietary predictors. Dietary intake was measured using an FFQ. Parents reported demographic information for maternal education, occupation and employment, and household income.

Setting

Twenty-six primary schools in South Australia, Australia.

Subjects

Children aged 9–13 years and their parents (n 395).

Results

Multiple personal and home environment factors predicted non-core food and sweetened drink intakes, and these associations were moderated by SEP. Maternal education moderated associations of girls’ sweetened drink intake with self-efficacy, cooking skills and pressure to eat, and boys’ non-core food intake with monitoring, parent’s self-efficacy and home environment. Maternal occupation and employment moderated associations of sweetened drink intake with attitudes, self-efficacy, pressure to eat and food availability, and non-core food intake with parents’ self-efficacy and monitoring. Income moderated associations with pressure to eat and home environment.

Conclusions

Identifying differences in dietary predictors between socio-economic groups informs understanding of why socio-economic gradients in dietary intake may occur. Tailoring interventions and health promotion to the particular needs of socio-economically disadvantaged children may produce more successful outcomes and reduce socio-economic disparities in dietary intake.

School- and family-level socioeconomic status and health behaviors: multilevel analysis of a national survey in wales, United Kingdom

BACKGROUND

Interventions to address inequalities in adolescent health behaviors often target children from less affluent families, or schools in poorer areas. Few studies have examined whether school- or family-level affluence predicts health behaviors independently, or in combination.

METHODS

This article reports secondary analysis of the Welsh Health Behavior in School-aged Children (HBSC) survey. Mixed-effects logistic regression models test associations of school and family socioeconomic status (SES) with smoking, fruit and vegetable consumption, alcohol consumption, and physical activity.

RESULTS

Higher family SES was associated with healthier behaviors, except in relation to alcohol consumption. For all behaviors except physical activity, school-level SES was independently associated with healthier behaviors. In higher SES schools, a stronger association of family SES with health behavior was observed, particularly in relation to smoking and physical activity.

CONCLUSIONS

School and family SES may exert independent and combined influences upon adolescent health behaviors. Targeting interventions toward deprived schools may fail to address substantial inequalities within more affluent schools. Targeting deprived families may fail to address behaviors of children from affluent families, attending more deprived schools. Identifying universal health improvement interventions which have greater effects among children from poorer backgrounds may be a more effective means of reducing inequalities.

Psychosocial mediators between socioeconomic status and dietary habits among Japanese older adults

INTRODUCTION

OBJECTIVES

The purpose of this study was to examine psychosocial mediators between socioeconomic status (SES) and eating habits in older Japanese adults.

SUBJECTS AND METHODS

A questionnaire was mailed to a representative sample of people who were 60 years and older (N=1,000) living in a suburban area within the Tokyo city metropolitan limits, in Japan. There were 552 effective participants in the study.

DESIGN

Dietary habits were evaluated by assessing the diversity of food that was consumed. SES was evaluated by educational attainment and household income. Four dimensions of psychosocial mediators were assessed: control expectancy, self-efficacy, social influence, and social support. Indirect effects of SES through the mediators were evaluated by using a multiple mediator model.

RESULTS

The relationship between education and dietary habits was mediated by three variables excluding social support. Especially, social influence had the strongest mediating effect. These three significant variables explained the majority of differences in dietary habits resulting from education. The effects of household income were also similarly mediated by the identical variables.

CONCLUSIONS

Control expectancy, self-efficacy, and social influence mediate the relationship between SES and dietary habits.

The effect of breakfast composition and energy contribution on cognitive and academic performance: a systematic review

BACKGROUND

Most studies that assess the effects of breakfast on subsequent mental abilities compared performance in subjects who had or had not consumed this meal. However, characteristics of breakfast itself may induce metabolic and hormonal alterations of the gastrointestinal tract and potentially modify cognitive performance. Moreover, as far as the evidence on the positive effects of having breakfast is becoming more robust, interest may shift to the specific characteristics of an adequate breakfast.

OBJECTIVE

The objective was to summarize existing evidence on the role of nutrient composition or energy intake at breakfast on the accomplishment of school-related tasks and cognition.

DESIGN

We conducted a systematic review of the literature through the PubMed database.

RESULTS

From the literature search, we identified 102 articles, 15 of which met the inclusion criteria. Of these, 3 studies provided information on the relation between cognitive and academic performance and energy intake at breakfast, 11 provided the same information for the macronutrient composition of breakfast, and 1 investigated both the aspects. Eleven studies considered breakfast meals differing in glycemic index/load. Selected studies were generally carried out in well-nourished children and adults of both sexes from general education. They were mostly experimental studies of short duration and had a limited number of subjects. Cognitive and academic performance was investigated by looking at multiple domains, including memory, attention, reasoning, learning, and verbal and math abilities, with a variety of test batteries scheduled at different time points in the morning. Breakfast options differed in terms of included foods and place and time of administration.

CONCLUSIONS

There is insufficient quantity and consistency among studies to draw firm conclusions. However, whereas the hypothesis of a better and more sustained performance with a breakfast providing >20% daily energy intake still needs substantiation, there does appear to be emerging, but still equivocal, evidence that a lower postprandial glycemic response is beneficial to cognitive performance.

The role of socio-economic position as a moderator of children's healthy food intake

Children of low socio-economic position (SEP) consume poorer diets than those of high SEP; however, there is limited understanding of why socio-economic gradients in diet occur. Some evidence suggests that determinants of dietary intake may differ between SEP groups. The aim of the present study was to determine whether the associations between personal and environmental variables and children's fruit and vegetable intake, and healthy dietary behaviours are moderated by SEP. A total of 395 children aged 9 to 13 years and their parents were recruited in Adelaide, South Australia. Personal and environmental dietary predictors were measured using child-completed online questionnaires and telephone interviews with parents. Dietary intake was measured using an online FFQ. First, dietary predictors were identified using correlated component regression, and subsequently tested for moderation by four SEP indicators using partial least-squares structural equation modelling. Fruit and vegetable intake and healthy behaviours were predicted by self-efficacy, attitudes and a supportive home environment. For girls, only the associations of self-efficacy with healthy behaviours were moderated by occupation. For boys, income moderated the associations of fruit and vegetable intake with attitudes, and healthy behaviours with supportive home environments. Occupation and employment moderated the associations of boys' family environments and fruit intake, and attitudes with healthy behaviours. Reducing socio-economic disparities in children's healthy dietary intake may be more successfully achieved by tailoring health promotion policies and interventions according to variables that moderate the relationships between dietary intake and SEP.

Associations between predictors of children's dietary intake and socioeconomic position: a systematic review of the literature

Socioeconomically disadvantaged children are at higher risk of consuming poor diets, in particular less fruits and vegetables and more non-core foods and sweetened beverages. Currently the drivers of socioeconomically related differences in children's dietary intake are not well understood. This systematic review explored whether dietary predictors vary for children of different socioeconomic circumstances. Seven databases and reference lists of included material were searched for studies investigating predictors of 9-13-year-old children's diet in relation to socioeconomic position. Individual- and population-based cross-sectional, cohort and epidemiological studies published in English and conducted in developed countries were included. Twenty-eight studies were included in this review; most were conducted in Europe (n = 12) or North America (n = 10). The most frequently used indicators of socioeconomic position were parent education and occupation. Predictors of children's dietary intake varied among children of different socioeconomic circumstances. Socioeconomic position was consistently associated with children's nutrition knowledge, parent modelling, home food availability and accessibility. Indeterminate associations with socioeconomic position were observed for parent feeding practices and food environment near school. Differences in the determinants of eating between socioeconomic groups provide a better understanding of the drivers of socioeconomic disparities in dietary intake, and how to develop targeted intervention strategies.

Impacts of the Primary School Free Breakfast Initiative on socio-economic inequalities in breakfast consumption among 9-11-year-old schoolchildren in Wales

Objectives

Universal interventions may widen or narrow inequalities if disproportionately effective among higher or lower socio-economic groups. The present paper examines impacts of the Primary School Free Breakfast Initiative in Wales on inequalities in children's dietary behaviours and cognitive functioning.

Design

Cluster-randomised controlled trial. Responses were linked to free school meal (FSM) entitlement via the Secure Anonymised Information Linkage databank. Impacts on inequalities were evaluated using weighted school-level regression models with interaction terms for intervention × whole-school percentage FSM entitlement and intervention × aggregated individual FSM entitlement. Individual-level regression models included interaction terms for intervention × individual FSM entitlement.

Setting

Fifty-five intervention and fifty-six wait-list control primary schools.

Subjects

Approximately 4500 children completed measures of dietary behaviours and cognitive tests at baseline and 12-month follow-up.

Results

School-level models indicated that children in intervention schools ate a greater number of healthy items for breakfast than children in control schools (b = 0·25; 95 % CI 0·07, 0·44), with larger increases observed in more deprived schools (interaction term b = 1·76; 95 % CI 0·36, 3·16). An interaction between intervention and household-level deprivation was not significant. Despite no main effects on breakfast skipping, a significant interaction was observed, indicating declines in breakfast skipping in more deprived schools (interaction term b = −0·07; 95 % CI −0·15, −0·00) and households (OR = 0·67; 95 % CI 0·46, 0·98). No significant influence on inequality was observed for the remaining outcomes.

Conclusions

Universal breakfast provision may reduce socio-economic inequalities in consumption of healthy breakfast items and breakfast skipping. There was no evidence of intervention-generated inequalities in any outcomes.

Exploring subgroup effects by socioeconomic position of three effective school-based dietary interventions: the European TEENAGE project

OBJECTIVES

The aim of this study was to explore subgroup effects by high and low socioeconomic position (SEP) of three previously conducted, effective European interventions.

METHODS

Reanalyses stratified by SEP were conducted by the research groups of each study. All studies were school-based: two multi-component interventions targeting intake of fat or fruit and vegetables (FV), and a free breakfast initiative.

RESULTS

Computer-tailored advice affected fat intake among low, but not high SEP girls after 1 year. A multi-component intervention affected the total FV intake in both SEP groups, vegetable intake in low SEP and fruit intake in high SEP across three countries after 1 year, whereas free fruit affected total FV and fruit intake equally in both SEP groups in one country after 2 years. Providing a free healthy breakfast increased consumption of healthy food items only in the low SEP group.

CONCLUSIONS

Reanalysing intervention studies by SEP is a quick and easy way to explore patterns in effects by SEP across interventions. Providing healthy food might be a promising strategy for decreasing social inequalities.

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.

Eating habits and total and abdominal fat in Spanish adolescents: influence of physical activity. The AVENA study

OBJECTIVE

To evaluate the association between specific dietary habits and body fatness in Spanish adolescents, and to analyze the role of leisure-time physical activity (LTPA) in this association.

METHODS

In this cross-sectional study, 1,978 adolescents (1,017 girls) aged 13.0-18.5 years from the AVENA (Alimentación y Valoración del Estado Nutricional en Adolescentes) study were included. Particular dietary habits (breakfast, mid-morning snack, lunch, afternoon snack, dinner, and nighttime snack, as well as time spent eating, number of meals, consumption of soft drinks, and ready-to-eat foods) and LTPA were self-reported and analyzed as dichotomic variables (yes/no). The sum of six skinfold thicknesses and waist circumference (WC) values were the main body fatness variables.

RESULT

Skinfolds and WC values were lower in adolescents who reported consumption of mid-morning snack, afternoon snack, more than four meals per day, and an adequate speed of eating, independently of participation in LTPA. Moreover, a beneficial influence of breakfast consumption on skinfolds and WC values was observed in those adolescent boys who did not participate in LTPA (p for interactions = .044 and .040, respectively).

CONCLUSIONS

In Spanish adolescents, certain healthy dietary habits (i.e., mid-morning snack, afternoon snack, > 4 meals per day, adequate eating speed) are associated with lower body fatness, independently of engaging in LTPA. In addition, among boys with non-LTPA, those who skipped breakfast showed the highest body fatness values, indicating a beneficial influence of daily breakfast on body fat in this particular group.

Family- and school-based correlates of energy balance-related behaviours in 10-12-year-old children: a systematic review within the ENERGY (EuropeaN Energy balance Research to prevent excessive weight Gain among Youth) project

OBJECTIVE

To identify family- and school-based correlates of specific energy balance-related behaviours (physical activity, sedentary behaviour, breakfast consumption, soft drink consumption) among 10-12-year-olds, using the EnRG framework (Environmental Research framework for weight Gain prevention).

DESIGN

A literature review to identify observational studies exploring at least one family- or school-based correlate of the specific behaviours, resulting in seventy-six articles.

SETTING

Eighteen studies were conducted in Europe, forty-one studies in North America and seventeen studies in Australasia.

SUBJECTS

Healthy children aged 10-12 years.

RESULTS

Parental and maternal physical activity, doing physical activities with parents and parental logistic support were identified as the most important, positive correlates of physical activity. Parental rules was the most important correlate of sedentary behaviour and was inversely related to it. School socio-economic status was positively related to physical activity and inversely related to sedentary behaviour. The available studies suggested a positive relationship between soft drink availability at home and consumption. Soft drink availability and consumption at school were the most important school-based correlates of soft drink consumption. A permissive parenting style was related to more soft drink consumption and less breakfast consumption.

CONCLUSIONS

An important role has been awarded to parents, suggesting parents should be involved in obesity prevention programmes. Despite the opportunities a school can offer, little research has been done to identify school-environmental correlates of energy balance-related behaviours in this age group. Obesity prevention programmes can focus on the most important correlates to maximize the effectiveness of the programme. Future research should aim at longitudinal studies.

The contribution of breakfast cereals to the nutritional intake of the materially deprived UK population

BACKGROUND/OBJECTIVES

Breakfast is an important source of micronutrients in the diet and its consumption has been linked to positive health outcomes. The present analysis investigated the contribution that breakfast cereals make to the nutrient intakes of the materially deprived (low income) UK population.

SUBJECTS/METHODS

Data for 3728 respondents aged 2 years and over from the UK Low Income Diet and Nutrition Survey (2003-2005) were analysed. Nutrient intakes of consumers and non-consumers of breakfast cereal were compared.

RESULTS

Breakfast cereals were consumed by 49% of men, 58% of women, 80% of boys and 80% of girls, and median intakes were: 35, 25, 29 and 21 g/d, respectively. Consumers of breakfast cereals had higher intakes of thiamin, riboflavin, niacin, biotin, folate, vitamin B(6), vitamin B(12), iron and zinc than non-consumers. Breakfast cereal consumption was also related to higher intakes of calcium, attributable to higher milk consumption. The intake of wholegrain and high-fibre breakfast cereals was associated with a higher intake of non-starch polysaccharides. Intakes of niacin, biotin, calcium and zinc were higher but that of vitamin B(6) was lower among consumers of exclusively wholegrain and high-fibre breakfast cereals compared with consumers of other breakfast cereals. There were no significant differences observed in intakes of non-milk extrinsic sugars according to type of breakfast cereal consumed.

CONCLUSIONS

Breakfast cereals make a significant contribution to the micronutrient intake of the low-income UK population.

Does consuming breakfast influence activity levels? An experiment into the effect of breakfast consumption on eating habits and energy expenditure

OBJECTIVE

To experimentally compare the effects of eating or skipping breakfast on energy expenditure, activity levels and dietary habits.

DESIGN

A randomised cross-over trial, lasting 2 weeks. Participants were provided breakfast during one week and were required to fast until mid-day during the other week.

SETTING

University campus.

SUBJECTS

Forty-nine participants (twenty-six female and twenty-three male participants) were recruited. Food intake was monitored using food diaries, and energy expenditure was assessed using pedometers and heart rate monitors. Morningness-eveningness, physical activity and health were assessed using validated questionnaires.

RESULTS

Across all participants, daily energy expenditure did not differ between the two experimental conditions. Total energy intake over 24 h did not vary with condition (male participants: 8134 (sd 447) kJ/d and 7514 (sd 368) kJ/d; female participants: 7778 (sd 410) kJ/d and 7531 (sd 535) kJ/d, for the breakfast and no-breakfast conditions, respectively). However, when comparing habitual breakfast eaters with those with irregular or breakfast-skipping habits, it was found that male non-habitual breakfast eaters consumed significantly (P = 0·029) more energy during the breakfast condition. Furthermore, female participants who were habitual breakfast eaters were found to eat significantly (P = 0·005) more and later in the day under the no-breakfast condition.

CONCLUSIONS

Although the suggestion that breakfast is a behavioural marker for appropriate dietary and physical activity patterns is not refuted by the present findings, our data suggest that the effect of breakfast may vary as a function of gender and morning eating habits, and thus there may be other mechanisms that link BMI and breakfast consumption behaviour.

Café da manhã: caracterização, consumo e importância para a saúde

O café da manhã é uma das três principais refeições do dia, mas, apesar da sua importância para a saúde, a diminuição do seu consumo é uma modificação importante no comportamento alimentar atual. Neste estudo, reflete-se sobre a caracterização dessa refeição e a implicação de seu consumo para a saúde; discutem-se, também, sua importância e as recomendações de consumo. Após revisão de artigos e respectivas contribuições científicas em bases de dados da área, pode-se afirmar que o café da manhã, objeto desta comunicação, é ainda bastante carente de pesquisas na literatura científica. Contudo, evidências científicas associam o consumo habitual de café da manhã a baixo risco de sobrepeso e obesidade, bem como melhoria na capacidade de aprendizagem. Estudos identificam que o perfil dos consumidores frequentes dessa refeição é de não fumantes que praticam atividade física, que controlam o peso e que não fazem uso frequente de álcool. Os autores pesquisados sugerem, assim, uma relação positiva entre o consumo de café da manhã e um estilo de vida saudável, justificando a recomendação de programas de incentivo ao seu consumo.

Free healthy breakfasts in primary schools: a cluster randomised controlled trial of a policy intervention in Wales, UK

Objective

The present study evaluated the impact of a national school programme of universal free healthy breakfast provision in Wales, UK.

Design

A cluster randomised controlled trial with repeated cross-sectional design and a 12-month follow-up. Primary outcomes were breakfast skipping, breakfast diet and episodic memory. Secondary outcomes were frequency of eating breakfast at home and at school, breakfast attitudes, rest-of-day diet and class behaviour.

Setting

Primary schools in nine local education authority areas.

Subjects

A total of 4350 students (aged 9–11 years) at baseline and 4472 at follow-up in 111 schools.

Results

Students in intervention schools reported significantly higher numbers of healthy food items consumed at breakfast and more positive attitudes towards breakfast eating at 12 months. Parents in intervention schools reported significantly higher rates of consumption of breakfast at school and correspondingly lower rates of breakfast consumption at home. No other significant differences were found.

Conclusions

The intervention did not reduce breakfast skipping; rather, pupils substituted breakfast at home for breakfast at school. However, there were improvements in children’s nutritional intake at breakfast time, if not the rest of the day, and more positive attitudes to breakfast, which may have implications for life-course dietary behaviours. There was no impact on episodic memory or classroom behaviour, which may require targeting breakfast skippers.

Breakfast trends in children and adolescents: frequency and quality

Objective

Although breakfast is important for obesity prevention and dietary quality, breakfast skipping is a common behaviour. Knowledge of changes in breakfast habits may provide potential behaviour targets for intervention programmes. The present study describes the actual data on trends in breakfast habits and composition.

Design

A total of 7800 3 d dietary records of 1081 participants aged 2–18 years collected between 1986 and 2007 in the DONALD (Dortmund Nutritional and Anthropometric Longitudinally Designed) Study were analysed using mixed linear models.

Results

Breakfast was eaten at 78 % of all record days; regular breakfast (breakfast was eaten on all three recorded weekdays) was eaten in 75 % of records. During the study period, the number of records with regular breakfast decreased significantly in 6–12- and 13–18-year-olds (P= 0·0084 and 0·0350, respectively). Of all breakfast meals, 62 % were bread meals and 21 % were ready-to-eat cereal (RTEC) meals. RTEC meals nearly doubled from the youngest to the oldest age group (P< 0·0001). During the study period, the percentage of bread meals decreased, whereas the percentage of RTEC meals increased (P< 0·0001). A higher percentage of RTEC meals than the bread meals was in accordance with the food-based guidelines (36 %v. 20 %,P< 0·0001), i.e. a breakfast including grain, dairy and fruit/vegetables.

Conclusions

In the DONALD Study sample, a negative age and time trend in breakfast consumption was verified. Interventions regarding breakfast habits should be aimed at adolescents and should focus on fruit/vegetables.

Meal and snacking patterns of school-aged children in Scotland

BACKGROUND

Current lifestyles and the choice and availability of foods may influence the eating patterns of children. The aim of this study was to investigate the meal and snacking patterns of school-aged children in Scotland.

METHODS

A sub-sample of 156 children (5-17 years) from the national Survey of Sugar Intake among Children in Scotland completed a 4-day non-weighed diet diary. Meals and snacks were defined using a food-based classification system based on 'core' and 'non-core' foods. The first eating event containing a solid food item up to and including 0900 hours (1100 hours on weekend days) was defined as breakfast. Frequency of meal and snack consumption was compared between age, sex, body mass index (BMI) and socio-economic sub-groups, between term-time and school holidays and between weekdays and weekend days. Intakes of total fat, saturated fatty acids (SFA) and non-milk extrinsic sugars (NMES) on these days were also compared.

RESULTS

Children ate a median of 3.3 meals plus 2.0 snacks per day, which did not vary between age and BMI groups. In all, 83% of children ate breakfast on all 4 days. Boys ate more meals than girls but the number of snacks was similar. Children from lower socio-economic groups tended to eat more meals and fewer snacks. Snacks accounted for 21% of the total daily energy intake, 22% of total fat, 24% of SFA and 39% of NMES intake. Daily intake of energy, total fat, SFA and NMES did not differ between term-time and holidays or weekdays and weekend days.

CONCLUSIONS

Children tended to follow a traditional pattern of three meals a day, which was consistent between age and BMI subgroups and between school term-time and holidays.

A commentary on current practice in mediating variable analyses in behavioural nutrition and physical activity

OBJECTIVE

To critique current practice in, and provide recommendations for, mediating variable analyses (MVA) of nutrition and physical activity behaviour change.

STRATEGY

Theory-based behavioural nutrition and physical activity interventions aim at changing mediating variables that are hypothesized to be responsible for changes in the outcome of interest. MVA are useful because they help to identify the most promising theoretical approaches, mediators and intervention components for behaviour change. However, the current literature suggests that MVA are often inappropriately conducted, poorly understood and inadequately presented. Main problems encountered in the published literature are explained and suggestions for overcoming weaknesses of current practice are proposed.

CONCLUSION

The use of the most appropriate, currently available methods of MVA, and a correct, comprehensive presentation and interpretation of their findings, is of paramount importance for understanding how obesity can be treated and prevented.

Meal patterns among children and adolescents and their associations with weight status and parental characteristics

OBJECTIVES

To describe the meal patterns of Jena schoolchildren and their associations with children's weight status and parental characteristics.

DESIGN

Cross-sectional study.

SETTING

Twenty schools in Jena (100,000 inhabitants), south-east Germany.

SUBJECTS

A total of 2054 schoolchildren aged 7-14 years with information on BMI standard deviation score (BMI-SDS) and weight status (based on German reference values), of whom 1571 had additional information about their parents (parental education and employment status, weight status according to WHO guidelines) and meal patterns (school lunch participation rate, meal frequencies, breakfast consumption and frequency of family meals).

RESULTS

Weight status of the children was associated with weight status, education and employment status of the parents. Meal patterns were strongly dependent on children's age and parental employment. As age increased, the frequency of meal consumption, participation rate in school lunches and the number of family meals decreased. Using linear regression analysis, a high inverse association between BMI-SDS and meal frequency was observed, in addition to relationships with parental weight status and paternal education.

CONCLUSIONS

Age-specific prevention programmes should encourage greater meal frequency. The close involvement of parents is essential in any strategy for improving children's (families') diets.

Obese and female adolescents skip breakfast more than their non-obese and male peers

We examined the association between overweight/gender and skipping breakfast among adolescent students in Tehran city using a cross-sectional study and a multistage random sampling method. All educational zones in Tehran city were covered during the educational year of 2000–01. In total, 2321 students aged 11–16 years (1068 male; 1263 female) participated in the study. Weight and height were measured and body mass index (BMI; kg/m2) was calculated. Overweight, pre-obesity and obesity were defined as BMI ≥ 85th, 85th to 95th, and ≥ 95th percentile of age-sex-specific BMI reference values, respectively. Self-reported frequency of breakfast consumption was categorized as usual/always, often, and rarely/never (5–7, 2–4 and 0–1 times/wk, respectively). Student’s t and Chi-square tests were employed to analyze the data. Statistical inferences were made at α = 0.05. In boys and girls, the mean ± standard deviation of BMI was 19.8 ± 4.0 and 20.6 ± 4.1 kg/m2, the 18.8% and 23.1% were overweight, and 7.3% and 8.3% were obese, respectively. There was a significant difference in the frequency of breakfast consumption between obese and normal male students (P < 0.001). Differences between pre-obese and normal, and obese and normal female students were also significant (P < 0.002 and P < 0.001, respectively). A significant difference was found in the frequency of breakfast consumption between male and female adolescents in all three categories (P < 0.001). These results suggest that obese and female adolescents are more likely to skip breakfast than their normal and male peers and are therefore at higher risk for growth deficits and low educational performance. Preventive/educational programs are urgently needed in this age group.

Free breakfasts in schools: design and conduct of a cluster randomised controlled trial of the Primary School Free Breakfast Initiative in Wales [ISRCTN18336527]

Background

School-based breakfast provision is increasingly being seen as a means of improving educational performance and dietary behaviour amongst children. Furthermore, recognition is growing that breakfast provision offers potential as a means of addressing social inequalities in these outcomes. At present however, the evidence base on the effectiveness of breakfast provision in bringing about these improvements is limited.

Methods/Design

This paper describes the research design of a large scale evaluation of the effectiveness of the Welsh Assembly Government's Primary School Free Breakfast Initiative. A cluster randomised trial, with school as the unit of randomisation was used for the outcome evaluation, with a nested qualitative process evaluation. Quantitative outcome measures included dietary habits, attitudes, cognitive function, classroom behaviour, and school attendance. The study recruited 111 primary schools in Wales, of which 56 were randomly assigned to control condition and 55 to intervention. Participants were Year 5 and 6 students (aged 9–11 years) in these schools. Data were collected for all 111 schools at each of three time points: baseline, 4 month and 12 month follow-up. This was achieved through a repeated cross-sectional survey of approximately 4350 students on each of these occasions. Of those students in Year 5 at baseline, 1975 provided data at one or both of the follow-ups, forming a nested cohort. The evaluation also included a nested process evaluation, using questionnaires, semi-structured interviews and case studies with students, school staff, and local authority scheme coordinators as key informants.

Discussion

An overview of the methods used for the evaluation is presented, providing an example of the feasibility of conducting robust evaluations of policy initiatives using a randomised trial design with nested process evaluation. Details are provided of response rates and the flow of participants. Reflection is offered on methodological issues encountered at various stages through the course of the study, focusing upon issues associated with conducting a randomised trial of a government policy initiative, and with conducting research in school settings.

Trial registration

Current Controlled Trials ISRCTN18336527