Pediatric Annals

CME 

The Most Important Meal of the Day: Why Children Skip Breakfast and What Can Be Done About It

Lisa Wilhelm Jackson, MS, RD, LDN, CNSC

Abstract

CME Educational Objectives

1.Discuss the important effects skipping meals can have on the overall long-term well-being of a child.

Identify strategies parents can use to promote a consistent adequate breakfast meal.

Provide specific ideas for a breakfast meal that match differing family lifestyles.

We all experience that morning rush to get somewhere — to work, to school, or to complete a number of important errands before we reach those final destinations. Many adults skip meals for a variety of reasons. Children and teenagers are no different.

Eating behaviors can promote or diminish healthy nutrition. A child consuming breakfast with family members on a regular basis is ideal but not always realistic. More and more children have two working parents who are rushing out to work in the morning, have limited income or a lack of healthy options at home, or possess a lack of education on the benefits of breakfast. Evidence shows that breakfast consumption reduces weight gain by improving satiety and decreasing binge eating later in the day. High-fiber cereals (ie, >2 g per serving) and whole-grain products improve satiety and decrease binge eating at lunch or after school. The total dietary fiber intake should equal age plus 5 g for young children and up to 14 g/1,000 calories for adolescents.

In the National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study, 2,379 white and black females aged 9 to 19 years were followed on an annual basis. The more frequently breakfast was consumed was associated with a higher calcium and fiber intake and, consequently, a lower body mass index. This article focuses on the NHLBI guidelines for cardiovascular risk reduction in children and adolescents, including practical suggestions about breakfast meal planning and food choices. These recommendations offer real-time dietary suggestions and practical advice for patients’ families.

Abstract

CME Educational Objectives

1.Discuss the important effects skipping meals can have on the overall long-term well-being of a child.

Identify strategies parents can use to promote a consistent adequate breakfast meal.

Provide specific ideas for a breakfast meal that match differing family lifestyles.

We all experience that morning rush to get somewhere — to work, to school, or to complete a number of important errands before we reach those final destinations. Many adults skip meals for a variety of reasons. Children and teenagers are no different.

Eating behaviors can promote or diminish healthy nutrition. A child consuming breakfast with family members on a regular basis is ideal but not always realistic. More and more children have two working parents who are rushing out to work in the morning, have limited income or a lack of healthy options at home, or possess a lack of education on the benefits of breakfast. Evidence shows that breakfast consumption reduces weight gain by improving satiety and decreasing binge eating later in the day. High-fiber cereals (ie, >2 g per serving) and whole-grain products improve satiety and decrease binge eating at lunch or after school. The total dietary fiber intake should equal age plus 5 g for young children and up to 14 g/1,000 calories for adolescents.

In the National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study, 2,379 white and black females aged 9 to 19 years were followed on an annual basis. The more frequently breakfast was consumed was associated with a higher calcium and fiber intake and, consequently, a lower body mass index. This article focuses on the NHLBI guidelines for cardiovascular risk reduction in children and adolescents, including practical suggestions about breakfast meal planning and food choices. These recommendations offer real-time dietary suggestions and practical advice for patients’ families.

Q: Oftentimes, children and adolescents skip meals, especially breakfast. What do the National Heart, Lung, and Blood Institute guidelines for children recommend and what practical suggestions can pediatricians adopt to encourage healthy eating?

We all experience that morning rush to get somewhere — to work, to school, or to complete a number of important errands before we reach those final destinations. Many adults skip meals for a variety of reasons. Children and teenagers are no different.

Reasons for skipping meals may include a lack of appetite, a lack of time, or for weight-loss purposes. In 2012, Nutrition Research and Practice published a study on the prevalence of obesity caused by meal skipping in Korean elementary school children.1 The researchers compiled national survey responses from 2,335 fifth-grade students from 118 elementary schools by stratified cluster sampling. The regular meal (RM) eating group (n = 1,476) consisted of students consuming breakfast, lunch, and dinner at least 6 to 7 days per week. The meal skipping (MS) group (n = 859) consumed breakfast, lunch, and dinner ≤ 3 to 5 days a week. The intake frequency of fruits, vegetables, and milk was lower in the MS group compared with the RM group (P < .001). The daily intake of soft drinks and nonperishable foods was significantly higher in the MS group than the RM group (P < .05).

Eating behaviors can promote or diminish healthy nutrition. A child consuming breakfast with family members on a regular basis is ideal but not always realistic. More and more children have two working parents who are in a rush to get out in the morning, have limited income or a lack of healthy options at home, or possess a lack of education on the benefits of breakfast.

In the National Heart, Lung, and Blood Institute Growth and Health Study,2 2,379 white and black females aged 9 to 19 years were followed on an annual basis. The more frequently breakfast was consumed was associated with a higher calcium and fiber intake and, consequently, a lower body mass index.

This article focuses on the National Heart, Lung, and Blood Institute guidelines for cardiovascular risk reduction in children and adolescents, including practical suggestions about breakfast meal planning and food choices. These recommendations offer real-time dietary suggestions and practical advice for patients’ families.

Time Management and Meal Planning

With busy parents often citing “time” as a major obstacle in providing their children with proper nutrition, the Sidebar provides tips for children who only have time for an “on-the-go” breakfast, children who have time for a 5-minute breakfast, and children who have time to sit down for a balanced breakfast.

Sidebar.

Time Management Tips and Breakfast Consumption

Tips for a child who has time for an “on-the-go” breakfast:

  • Consume breakfast in the car or during walk to school. Suggest easy-to-carry food (eg, apple, banana, or milk in a water bottle). Offer whole fruit (eg, pears and apples), which contains higher levels of fiber than peeled fruit.
  • Pour cereal into a sealable sandwich bag. This way the child or adolescent can consume the dry cereal in the car or bus. Choose fortified cereal containing 3 g fiber and <10 g sugar per serving. The fiber will improve their level of satiety.
  • Offer low-fat string cheese, which can be peeled on the move.
  • Try a slice of whole wheat bread with peanut butter or hummus. This can be placed in a sandwich bag and consumed on the way to school.
  • Offer a hard-boiled egg. May add a dash of pepper.
  • For older children, consider adding a small handful of almonds, which contain omega-3 fatty acids and protein.

Tips for a child who has time for a 5-minute breakfast:

  • Offer fortified cereal with skim milk. Choose cereals with <10 g sugar and at least 3 g fiber per serving. May add chopped fresh fruit as a substitute for sugary cereal.
  • Provide fresh fruit, such as apples, bananas, oranges, mangos, blueberries, raspberries, blackberries, pears, or melons. Fresh fruit is naturally high in fiber and vitamins.
  • Make a fruit smoothie containing frozen/fresh fruit, skim milk, and ice in the blender. Blend until smooth.
  • Toast a piece of whole-wheat bread. Add a thin layer of peanut butter, tub margarine, or jelly.
  • Make scrambled eggs. If the child wants more than 1 egg, just add the egg whites from the additional eggs.
  • For beverages, offer skim or low-fat milk, even for children younger than 2 years.
  • If the child likes yogurt, suggest low-fat Greek yogurt. More brands are offering a wide variety of flavors, some including granola as a topping.

Tips for a child who has time for a balanced breakfast:

  • Make an omelet with 1 oz shredded chicken; ½ cup chopped vegetables including tomatoes, bell peppers, broccoli, and spinach; and ⅓ cup low-fat cheese. If the child would benefit from weight loss, opt for an egg white omelet with no cheese. Add 1 slice of whole wheat toast and ½ cup fruit for a balanced breakfast.
  • Make a fruit smoothie containing ½ to 1 cup frozen or fresh fruit, ¼ cup oatmeal, ½ cup fat-free milk, ½ cup plain Greek yogurt, and ice in the blender. Blend until smooth.
  • Make 1 cup slow-cooked oatmeal. May add ½ to 1 cup chopped fruit to oatmeal for a sweeter flavor. Add 1 scrambled egg on the side. Avoid instant oatmeal, which contains higher levels of sugar and overprocessed grains.

Children rely on their families to help make changes. When the family is involved, children do not feel singled out or punished, and their success rates improve. Ask the parents to make their own goals. Some may include the following:

  • Serve meals at the table. Children will eat two to three times more when sitting in front of the television or computer. Plus, they will have fewer distractions at the table.
  • Eat meals together as a family. This can be difficult with many parents working full time. Remember that a 5-minute breakfast spent together is better than no breakfast.
  • Let your child be involved in menu planning. Make a list of foods you want for the week. This is especially helpful for parents of picky eaters.
  • Have patience for finicky appetites. Remember that small children may need 15 presentations of the same food before they accept it.

Breakfast Foods to Improve Weight Loss

With the prevalence of childhood obesity and the cardiovascular risks that accompany it, parents occasionally cut out breakfast in hopes of curbing calorie intake. In fact, breakfast consumption reduces weight gain by improving satiety and decreasing binge eating later in the day.2 High-fiber cereals (ie, > 2 g per serving) and whole-grain products also improve satiety and decrease binge eating at lunch or after school.

Total dietary fiber intake should equal age plus 5 g for young children and up to 14 g/1,000 calories for adolescents.2 Choose fortified cereal containing at least 3 g fiber and < 10 g sugar per serving. Other healthy options include fresh fruit and substituting skim milk for 2% or whole milk. Avoid juice and other high-sugar beverages. Encourage consumption of high-fiber foods (A complete guide to high-fiber nutritious foods can be found in Table 1).3

High-Fiber Breakfast Options

Table 1. High-Fiber Breakfast Options

In addition, sample breakfast portion sizes for the average 6-year-old child are shown in Table 2.4

Sample Breakfast Portion Sizes for a 6-Year-Old Child (Pick One from Each Food Group)

Table 2. Sample Breakfast Portion Sizes for a 6-Year-Old Child (Pick One from Each Food Group)

Public Health for Families with Limited Incomes

For those families with limited resources, pediatricians should consider recommendations of the Special Supplemental Nutrition Program for Women, Infants, and Children (ie, WIC) and other school-based programs. Many US children can now receive school breakfast and lunch, greatly diminishing socioeconomic factors and improving dietary intake. As of May 2013, WIC food packages for children aged 1 to 4 years provided a monthly allowance of 16 quarts milk, 36 ounces breakfast cereal, 1 dozen eggs, $6 in cash vouchers for fruits and vegetables, 2 pounds whole wheat bread, and 1 pound legumes.5

The School Breakfast Program, a federally assisted meal program, operates at approximately 89,000 schools and institutions. It operates similarly to the National School Lunch Program. The Healthy, Hunger-Free Kids Act of 2010 instructed the United States Department of Agriculture to update the School Breakfast Program nutrition standards. Starting in the 2013–2014 school year, more whole grains will be offered, followed in subsequent years by decreased sodium levels and increased fruits and vegetables. Family incomes between $29,965 and $42,643 for a family of four qualify for reduced-price meals. Breakfast must cost them less than $0.30. Family incomes below $29,965 for a family of four are eligible for free breakfast. In 2011, more than 12.1 million children participated in the School Breakfast Program.6

Conclusion

Evidence shows that children who skip meals have a higher risk of childhood obesity and consume larger volumes of soft drinks, high-fat foods, and snacks. The 1999 to 2006 National Health and Nutrition Examination Survey7 indicated that 9- to 13-year-old children who skipped breakfast had a higher body mass index, a larger waist circumference, and a higher prevalence of obesity compared with those who consumed breakfast. Children who continue skipping breakfast into adulthood have an increased obesity risk, increased fasting insulin levels, and increased cholesterol levels, which can lead to abnormal blood metabolism. Nutritional education for children, adolescents, and their parents is needed to encourage daily breakfast consumption and the avoidance of meal skipping. This education, easily addressed by clinicians during well visits, should encourage nutritional label reading as well as the adequate intake of fruits, vegetables, and low-fat dairy products each morning.

References

  1. Kim H-Y, Lee N-R, Lee J-S, et al. Meal skipping relates to food choice, understanding of nutrition labeling, and prevalence of obesity in Korean fifth grade children. Nutr Res Pract. 2012;6(4):328–333. doi:10.4162/nrp.2012.6.4.328 [CrossRef]
  2. Barton BA, Eldridge AL, Thompson D, et al. The relationship of breakfast and cereal consumption to nutrient intake and body mass index: the National Heart, Lung and Blood Institute Growth and Health Study. J Am Diet Assoc. 2005;105:1383–1389. doi:10.1016/j.jada.2005.06.003 [CrossRef]
  3. US Department of Agriculture, Agricultural Research Service. 2012. USDA National Nutrient Database for Standard Reference, Release 25. Nutrient Data Laboratory Home Page, www.ars.usda.gov/ba/bhnrc/ndl. Accessed Aug. 16, 2013.
  4. Bunting D, D’Souza S, Nguyen J, et al. Texas Children’s Hospital Pediatric Nutrition Reference Guide. 8th ed. Houston, TX: Texas Children’s Hospital; 2008:27–28.
  5. Women, Infants and Children (WIC). United States Department of Agriculture (2013). Available at: www.fns.usda.gov/wic/. Accessed May 10, 2013.
  6. School Breakfast Program. United States Department of Agriculture (2013). Available at: www.fns.usda.gov/sbp. Accessed May 10, 2013.
  7. Deshmukh-Taskar PR, Nicklas TA, O’Neil CE, et al. The relationship of breakfast skipping and type of breakfast consumption with nutrient intake and weight status in children and adolescents: the National Health and Nutrition Examination Survey 1999–2006. J Am Diet Assoc. 2010;110(6):869–878. doi:10.1016/j.jada.2010.03.023 [CrossRef]
  8. Mayo Clinic. Nutrition and healthy eating. Available at: www.mayoclinic.com/health/high-fiber-foods/NU00582. Accessed on Aug. 16, 2013.

High-Fiber Breakfast Options

Food Serving Size Total Fiber (g)
Fruits
Raspberries 1 cup 8
  Pear, with skin 1 medium 5.1
  Apple, with skin 1 medium 4.4
  Figs, dried 2 medium 3.7
Grains
  Oat bran muffin 1 medium 5.2
  Bran flakes ¾cup 5.1
  Oatmeal 1 cup 4
  Whole-wheat bagel* 1 medium 4
  Whole-wheat English muffin* 1 medium 5
  Whole-wheat waffles* 2 waffles 5
Legumes, nuts, and seeds
  Black beans, cooked 1 cup 15
  Lima beans, cooked 1 cup 13.2
  Baked beans, vegetarian, canned 1 cup 10.4

Sample Breakfast Portion Sizes for a 6-Year-Old Child (Pick One from Each Food Group)

Milk products 1 cup skim milk, 1 cup low-fat or nonfat yogurt, ⅓ cup shredded cheese
Meat/protein ¼ cup cooked beans, 1 egg, 1 T peanut butter, 1 oz chicken
Bread/cereal 1–2 slices whole wheat bread, ½-1 cup cooked cereal, 1 cup dry cereal
Fruits ½ cup fruit*
Vegetables ½ cup vegetables

Sidebar.

Time Management Tips and Breakfast Consumption

Tips for a child who has time for an “on-the-go” breakfast:

  • Consume breakfast in the car or during walk to school. Suggest easy-to-carry food (eg, apple, banana, or milk in a water bottle). Offer whole fruit (eg, pears and apples), which contains higher levels of fiber than peeled fruit.
  • Pour cereal into a sealable sandwich bag. This way the child or adolescent can consume the dry cereal in the car or bus. Choose fortified cereal containing 3 g fiber and <10 g sugar per serving. The fiber will improve their level of satiety.
  • Offer low-fat string cheese, which can be peeled on the move.
  • Try a slice of whole wheat bread with peanut butter or hummus. This can be placed in a sandwich bag and consumed on the way to school.
  • Offer a hard-boiled egg. May add a dash of pepper.
  • For older children, consider adding a small handful of almonds, which contain omega-3 fatty acids and protein.

Tips for a child who has time for a 5-minute breakfast:

  • Offer fortified cereal with skim milk. Choose cereals with <10 g sugar and at least 3 g fiber per serving. May add chopped fresh fruit as a substitute for sugary cereal.
  • Provide fresh fruit, such as apples, bananas, oranges, mangos, blueberries, raspberries, blackberries, pears, or melons. Fresh fruit is naturally high in fiber and vitamins.
  • Make a fruit smoothie containing frozen/fresh fruit, skim milk, and ice in the blender. Blend until smooth.
  • Toast a piece of whole-wheat bread. Add a thin layer of peanut butter, tub margarine, or jelly.
  • Make scrambled eggs. If the child wants more than 1 egg, just add the egg whites from the additional eggs.
  • For beverages, offer skim or low-fat milk, even for children younger than 2 years.
  • If the child likes yogurt, suggest low-fat Greek yogurt. More brands are offering a wide variety of flavors, some including granola as a topping.

Tips for a child who has time for a balanced breakfast:

  • Make an omelet with 1 oz shredded chicken; ½ cup chopped vegetables including tomatoes, bell peppers, broccoli, and spinach; and ⅓ cup low-fat cheese. If the child would benefit from weight loss, opt for an egg white omelet with no cheese. Add 1 slice of whole wheat toast and ½ cup fruit for a balanced breakfast.
  • Make a fruit smoothie containing ½ to 1 cup frozen or fresh fruit, ¼ cup oatmeal, ½ cup fat-free milk, ½ cup plain Greek yogurt, and ice in the blender. Blend until smooth.
  • Make 1 cup slow-cooked oatmeal. May add ½ to 1 cup chopped fruit to oatmeal for a sweeter flavor. Add 1 scrambled egg on the side. Avoid instant oatmeal, which contains higher levels of sugar and overprocessed grains.
Authors

Lisa Wilhelm Jackson, MS, RD, LDN, CNSC, is Senior Pediatric Surgery and Trauma Dietitian, Ann and Robert H. Lurie Children’s Hospital of Chicago.

Address correspondence to: Lisa Wilhelm Jackson, MS, RD, LDN, CNSC, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Box 23, Chicago, IL 60611-2605; email: Jackson.w.lisa@gmail.com.

Disclosure: The author has no relevant financial relationships to disclose. 

10.3928/00904481-20130823-10

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