Breakfast, the most important meal of the day, is still undervalued and given lesser prominence than deserved. Man lives by his own set of preferences and priorities in which eating a healthy morning breakfast exists down in the list for most people. We become our own nutritionists and dietitians dictating food intake practises and diet routines to achieve several goals including weight loss, fat loss and more. In this process, breakfast becomes the most affected meal of the day as we skip it based on multiple factors such as absence of time to prepare food and eat, weight loss strategies or calorie restrictions. We skip breakfast 1, 2, or even 3 times a week and for some others eating breakfast is a luxury indulgence when they have time. Such repeated instances of breakfast skipping have been associated with a number of health problems including cardiometabolic risks, obesity, insulin insensitivity and type 2 diabetes. Besides affecting the health of the individual skipping breakfast makes a person sluggish, lose concentration, lack focus and optimal memory skills and perform not up to the expected standard.
Type 2 diabetes mellitus (T2DM) prevails as one of the leading causes of morbidity and mortality rates worldwide owing to our unhealthy lifestyle and dietary practises. Unbalanced blood sugar levels bring about microvascular (retinopathy, nephropathy and neuropathy) and macrovascular (coronary artery disease and cerebrovascular disease) complications that contributes to increased medical expenses and health degradation too.
Aichi Workers’ Cohort Study
Japan has a 10.2% diabetes rate in male workers aged between 40 and 69 years and a 4.7% rate in female workers in large-scale companies in 2008-2010 and 15.0% in men and 8.0% in women in the National Health and Nutrition Study in 2011. Almost 14.4% men and 11.1% women skip breakfast which is a modifiable risk factor for T2DM and finding out the reason behind this can help us correct the risk and lead a healthier life. This motivated a group of researchers to extract data from the Aichi workers’ cohort study that included 6648 Japanese civil servants in Aichi prefecture aged 35-66 years in 2002. All of them answered a questionnaire regarding their lifestyle and medical history and were followed up until 2011.
T2DM prevalence in the participants were examined through two methods: One, by noting down the year when fasting blood glucose (FBG) levels reached ≥126 mg/dL and the date of onset was set as July 1st. Second, the answers from the questionnaires helped the researchers know the existence of diabetes in patients and the year of onset. All the participants were probed for their breakfast habits using yet another self-administered questionnaire and eating frequency was assessed using five categories-every day, almost every day with occasional skips, 3-5 days/week, 1-2 days/week and none. Using the frequency response all the participants were split into two groups-breakfast eaters (included those who reported eating breakfast every day and almost every day with occasional skips) and breakfast skippers (all the other categories). The brief-type dietary history questionnaire (BDHQ) included data on intake of fish, fruits, vegetables, whole-grains, cereals, coffee, sugar-sweetened beverages and snacks and also speed of eating classified as very fast, relatively fast, medium, relatively slow and slow. Height, weight, BMI, blood glucose levels and insulin concentration were noted down.
The participants were analysed for their smoking habits classified as current, former and never; the number of days they were engaged in physical activity classified into two categories ≥3 days/week or <3 days/week. Work timings were noted and scheduled into 4 categories-shift work including night shifts, shiftwork but without night shifts, without shiftwork but with night work and without shiftwork or night work. Sleep duration was classified as <7h or ≥7h and stress was classified into 4 categories including very much, much, ordinary and little.
Of the 4631 who participated 90.4% ate breakfast. On a comparative basis, those who skipped breakfast were following a worse lifestyle that included current smoking, alcohol consumption, increased intake of sugar-sweetened beverages and decreased intake of fruits and vegetables. Results showed that:
Chronotype as a Middle Man between Skipping Breakfast & Type 2 Diabetes Incidence
Cross-sectional and longitudinal studies show increased cardiometabolic risk in kids and adults who skip breakfast. A long-term study spanning more than 20 years showed that those who skipped breakfast at childhood and adulthood showed greater waist circumference and higher fasting insulin, total cholesterol and LDL cholesterol than those who eat breakfast. A big-scale long-term study spanning more than 16 years on 29,206 participants showed that skipping breakfast was associated with a 21% increased risk of type 2 diabetes. But, a study on low-income Latino diabetic patients showed that breakfast skipping was linked to increased plasma glucose levels but not haemoglobin (HbA1C) levels that’s generally taken as the standard for diabetes measurement.
The circadian cycle ensures regulation of a number of daily physiological rhythms including sleep/wake and feeding behaviour, peripheral tissue metabolism, energy expenditure and hormonal profiles. Each of us are at our peak energy levels at different times during the day-some during the early morning hours called as ‘morning lark’ and some during late nights called as ‘night owls’. The chronotype of the individual can be deduced from self-reported sleep times. We all love to stay late nights and get up even later but a study shows that those who do so are at a 2.5 times higher risk of type 2 diabetes which in turn indicates that a later chronotype keeps the individual at a higher risk of T2DM. Likewise, those with a later chronotype often eat less or skip eating altogether after waking up late in the morning. These individuals prefer to eat more of alcohol, fat and cholesterol, especially during dinner compared to those with an early chronotype. Maybe that’s why late risers probably suffer from poor glycemic control. A study focused on knowing more about the role of chronotype in patients with T2DM and skipping breakfast.
The study team invited patients from the Rush University Medical Centre and once chosen all of them self-reported age and race, recorded height, weight, BMI and entered the recent Hb1Ac values. Bedtime, wakeup time, sleep onset latency and sleep duration both during weekdays and weekends during the previous month was recorded. Mid-sleep time as the midpoint between sleep onset and wake time was calculated and mid-sleep time on free days (MSF) was arrived at from mid-sleep time on weekend nights with adjustments for sleep duration on weekend nights was calculated. SDF is calculated sleep duration on weekend nights and SDw is calculated sleep duration on weekday nights. All the participants mentioned their perceived actual sleep duration and preferred sleep duration on weekdays. They answered a 24-h dietary recall to know about the content and timing of the meal over the previous day. Total calorie intake over the day was also calculated using this data.
Comparison between breakfast eaters (n=172) and breakfast skippers (n=22) showed that those who skipped breakfast were significantly younger and had higher HbA1c levels and BMI but had no difference between groups in median diabetes duration, insulin use or number of diabetes complications. Those who skipped breakfast generally had a later chronotype as their bedtime routine was later than those who ate breakfast. More number of breakfast skippers complained of lack of appetite during morning hours and reported consuming fewer total calories during the previous day. These guys consumed a major portion of their calories during lunch and dinner compared to those who ate breakfast. It was seen that breakfast skipping was associated with significantly high HbA1c levels. To see the effect of chronotype on diabetes and breakfast skipping a series of regression models were performed. In the first model, skipping breakfast was linked to higher HbA1c levels and in the second model it was linked to later MSF. In the third model MSF was linked to HbA1c and the fourth model suggested that MSF and breakfast skipping was linked to higher HbA1c. Chronotype did not entirely have an impact on breakfast skipping and HbA1c levels but it was seen that both chronotype and breakfast skipping remained independently linked to poor glycemic control. Behavioral interventions in the form of eating breakfast or modifying sleep time could be considered strategies for improving glycemic control in the participants.
The meta-analysis results from 2015 showed a direct link between breakfast skipping and type 2 diabetes risk but we don’t have any dose-dependent studies until now that can confirm whether skipping once a week would be less destructive than skipping twice per week. It is also not right to categorize all those who skip breakfast into one single category without paying heed to the frequency of times as this does have an important impact on the results.
A meta-analysis of studies on skipping breakfast and type 2 diabetes using two random-effects models was done-standard random-effects model meta-analyses and dose-dependent meta-analysis. Though six studies met the inclusion criteria only 4 had BMI data. The standard random effects meta-analysis showed a 32% increased type 2 diabetes risk before adjusting BMI and a 22% increased risk after adjusting for BMI. Pooled RR value was 1.06 suggesting an increased risk of 5% after adjusting for BMI. There was an increased risk of 55% seen for 4-5 days of skipping breakfast/week before adjusting BMI and an increased risk of 40% after adjusting for BMI. It was observed that prolonged periods of fasting including skipping breakfast led to an increased postprandial insulin resistance during the next meal and increased ghrelin (hunger hormone linked with weight gain) levels as well. But we also have data showing that intermittent fasting, alternate day fasting and daily calorie restriction helped reduce diabetes risk factors such as body weight, viscera fat, fasting insulin and insulin resistance and we need long-term trials to confirm anything.
Glucose concentration and markers of insulin resistance (such as high cholesterol and inflammation) are higher after lunch on days when individuals skipped breakfast. This inflammation affects insulin sensitivity thereby increasing one’s risk for obesity and type 2 diabetes. It is always recommended to start the day on a healthy note with fruits, whole grains, milk, eggs and nuts while avoiding high-sugar and processed foods.
Breakfast Skipping is Positively Associated with Incidence of Type 2 Diabetes Mellitus: Evidence from Aichi Workers’ Cohort Study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411234/
The Relationship between Breakfast Skipping, Chronotype & Glycemic Control in Type 2 Diabetes: https://www.tandfonline.com/doi/abs/10.3109/07420528.2013.821614?journalCode=icbi20
Breakfast Skipping & Type 2 Diabetes: Where Do We Stand? https://academic.oup.com/jn/article/149/1/1/5280617
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