Breakfast Cereal and Nutrition Education on Body Mass Index and Diet Quality in Elementary School Children: A Pilot Study

Objective: Skipping breakfast has been associated with an increased risk of obesity. This randomized controlled pilot study tested whether emphasizing breakfast consumption, in conjunction with nutrition counseling, would improve weight status and dietary quality in children. Design and Methods: Twenty children were recruited and randomized to a breakfast (BF, n=11) or control (n=9) intervention. Both groups received weekly group nutrition counseling for 12 wk but breakfast consumption was emphasized, and ready-to-eat (RTE) cereal provided, to BF only. Anthropometric measurements were taken weekly. Three-day food records were taken at baseline and endpoint. Results: Weight status did not change significantly, however, children in BF displayed an overall decrease in BMI (-1.0±5.1%) whereas children in the control group had an overall increase (1.1±7.2%) from baseline (P=0.52). Three-day food records (BF, n=6; control, n=5) revealed group x time interactions on total sugars (P=0.007), folate (P=0.05), vitamin B12 (P=0.03), sodium (P=0.05), niacin (P=0.009), and vitamin B6 (P=0.023). Except for sodium, BF had improvements in these nutrients relative to the control group. Conclusions: Preliminary data from this study show that the provision of RTE cereal with weekly nutrition counseling may positively affect intake of essential nutrients. The effects of breakfast consumption on weight status are still uncertain. DOI : 10.14302/issn.2379-7835.ijn-14-534 Corresponding Author: Marie-Pierre St-Onge, Ph.D, , FAHA 1150 St. Nicholas Avenue, room 121H, New York, NY 10032; Phone 212-851-5578 Fax 212-851-5579; Email: ms2554@columbia.edu Running title: Breakfast consumption and weight in children


Introduction
Obesity is the primary nutritional disorder affecting children in the United States. 1 The prevalence of obesity among children remains alarmingly high, particularly among minority and underserved populations. 2 Recent population surveys show that 18% of children are obese, but these numbers can be as high as 1 in 3 in some ethnic groups. 2 Being obese during childhood is associated with more severe and costly lifetime health burden. 3 For this reason, identifying dietary interventions to prevent future weight gain is a public health and research priority.
Breakfast consumption is one possible intervention target. Participation in school breakfast programs is inversely related with childhood obesity, suggesting that infrequent breakfast consumption could be a risk factor for developing obesity. 4 School children who consumed breakfast everyday had a significantly lower BMI † than children who did not consume breakfast regularly. 5 Moreover, breakfast skipping was associated with increased intra-abdominal adiposity in Latino youths. 6 Breakfast skipping in childhood may also be associated with poor adult health outcomes. A longitudinal study of Australian youth revealed that children who reported more frequent breakfast skipping were more likely to develop metabolic complications during adulthood. 7 Thus, breakfast consumption may be an important area to target to improve both current and future health.
Unfortunately, breakfast skipping is not uncommon. A national survey found that 20% of American children and 31.5% of adolescents are breakfast skippers. 8 This study also found that there are particular benefits, including lower total fat and cholesterol intakes, higher dietary fiber and micronutrient intakes, for children and adolescents who consume RTE ‡ cereal for breakfast. A study of lowincome, minority children from Texas also found improved nutritional intake and lower BMI in children who regularly consumed RTE cereal over a 3-year period. 9 Breakfast skipping may be a frequent yet preventable behavioral target for obesity prevention.
Additionally, encouraging RTE cereal as a form of breakfast may help improve nutritional intake.
A randomized controlled trial testing the effects of RTE cereal consumption on weight status found that only children who received combined RTE cereal and nutrition education improved their weight status; children in groups receiving just RTE cereal for breakfast, RTE cereal for breakfast and dinner, and control did not have improvements in weight. 10 However, it is presently not known whether promoting breakfast consumption, specifically RTE cereal consumption, among non-or infrequent breakfast consumers will improve weight status and nutritional intake.
The purpose of the present study was to test the impact of breakfast consumption, as part of a

Dietary Intake Measures
Dietary intake was assessed from parent-

Statistical Analysis
The main outcome measures were changes in body weight, BMI, BMI z-score, and waist circumference, from baseline to wk 12. Only completers were included in the analysis. Completers were classified as those children who attended counseling sessions through wk 10. Week 10 and 11 measurements were carried forward for those who did not show up at the endpoint visit. One child, who attended the last measurement, was removed from the completers' analyses because she failed to attend 5 of the 12 sessions. Including this child in the analyses did not affect the results, and data are presented without her.
In addition, two children reported high breakfast consumption at screening (everyday). One child, randomized to the control group, reported low breakfast consumption for 11 of the 12 wk of the study (<5 times/ wk) and therefore was considered a habitual breakfast skipper and was retained in the analyses. The other child, randomized to the BF group, reported high breakfast consumption throughout the study (6-7times/ wk). Data were similar when analyzed with or without this child and therefore he was kept in the final analyses.
Mixed models analysis of variance with group assignment and time as main effects and group assignment x time interaction were run for all outcome measures. These analyses were adjusted for age. Sex was not a significant covariate for any of the outcome variables and was therefore not included in the models.
Differences in percent change in BMI and change in BMI z-score between groups were assessed using an unpaired t-test.
Change in intake of total fat, saturated fat, and calcium from baseline to week 12 were secondary endpoints that were analyzed by mixed models analysis of variance, controlling for body weight and energy intake. Time, group assignment, and time x group assignment interaction were included as independent variables in these models. Six children in the BF group and 5 in the control group provided food records at both  Figures 1 and 2).

Food Intake and Lifestyle Habits Data
There was no group, time, or group x time interaction on energy, carbohydrate, and protein intakes (       A sample size analysis conducted at 80% power Additionally, a review of childhood obesity interventions suggests that interventions aimed at weight loss in obese children are more effective when they combine dietary interventions with physical activity and behavior change components. 19 The present study suggests that increasing healthy breakfast consumption among overweight or obese non-breakfast consumers has the potential to improve weight status. Perhaps, if this approach was combined with other intervention strategies, it could be even more effective. This should be considered in future studies.

Conclusion
In conclusion, this study found that nutrition counseling focusing on breakfast consumption, coupled with provision of RTE cereal, results in improvements in diet quality without affecting weight status. However, our small sample size limited our ability to detect significant differences in change in BMI and waist circumference between groups. Nevertheless, our data suggest that our intervention may lead to beneficial, albeit small effects on body composition. Further research is necessary to determine whether sustained improvements in breakfast consumption leads to lasting effects on diet quality and ultimately affect weight status in obese children.