To Skip or Not to Skip? Varying definitions of breakfast skipping and associations with disordered eating, obesity, and depression

Objective: Much of the previous research on breakfast skipping and its associations with disordered eating, obesity, and depression has been limited by the use of different definitions “breakfast skipping.” The present study examines breakfast skipping and its associations with these negative health correlates in the Add Health Wave III sample of adolescents and young adults using all the definitions of breakfast skipping employed by the literature within a seven-day timeframe. Method: The Wave III sample of Add Health is comprised of 15,197 participants; all those who responded to the breakfast consumption question were included in some portion of the data analysis. The three definitions of breakfast skipping employed in this study were missing breakfast at least once, at least four times, or at least six times during the past seven days. Results: Statistically significant gender differences were found in breakfast skipping frequency in two of three definitions; however, small effect sizes call into question the clinical significance of these differences. The two stricter definitions of breakfast skipping were also associated with purging in women and depression in men and women. Obesity was associated with breakfast skipping in all cases. Conclusion: These findings suggest that stricter definitions of breakfast skipping are more useful in identifying populations susceptible to these negative health behaviors. They also indicate the need to regularize meal patterns as a means of combating obesity. Breakfast Skipping and its Negative Health Correlates 5 Introduction Objectives This thesis examines the prevalence of breakfast skipping among adolescents and young adults as a function of differing operational definitions of breakfast skipping, as well as the relationship between varying definitions of breakfast skipping and disordered eating, obesity, and depression. First, I explore how applying different operational definitions of breakfast skipping change the incidence of breakfast skipping within the sample. Second, the study investigates the differences between breakfast skippers and consumers on a number of measures of disordered eating including binge eating and purging. Third, it also investigates breakfast skipping among obese versus non-obese individuals. Lastly, this thesis explores the relationship between breakfast consumption and depressed mood. All analyses are conducted separately by gender and key study variables are tested for gender differences. Literature Review The extant research on breakfast consumption shows a myriad of benefits associated with regular breakfast eating. A recent review examining the breakfast consumption literature found evidence suggesting breakfast eaters had lower body mass index (BMI), improved academic performance, and superior nutritional profiles compared to their breakfast skipping peers (Rampersaud, Pereira, Girard, Adams, & Metzl, 2005). Although not all breakfast research yields consistent results, especially concerning BMI (Rampersaud et al., 2005), general consensus exists that eating Breakfast Skipping and its Negative Health Correlates 6 breakfast is an integral part of a healthy diet and lifestyle, particularly in children and adolescents. Breakfast skipping has significantly increased among young people over the past thirty years, and children and adolescents are more likely to skip breakfast than any other meal (e.g., Siega-Riz, Popkin, & Carson, 1998). Breakfast skipping is more prevalent in girls than boys (e.g., Keski-Rahkonen, Kaprio, Rissanen, Virkkunen, & Rose, 2003; Shaw, 1998; Videon & Manning, 2003) and its occurrence increases from childhood through adolescence, with older children and adolescents being more likely to skip breakfast (e.g, Pearson, Biddle, & Gorely, 2009; Shaw, 1998). Data from the National Longitudinal Study of Adolescent Health (Add Health) show a decrease in breakfast consumption between Wave II and Wave III of data collection (Niemeier, Raynor, Lloyd-Richardson, Rogers, & Wing, 2006), indicating that a decrease in breakfast consumption over time occurred in the participants of the present study, mirroring the trend found in other samples. Breakfast skipping has been associated with higher BMI and overweight status in some but not all studies. The first longitudinal study to examine breakfast skipping and weight change in adolescents found cross-sectionally that children who skipped breakfast were more likely to be overweight (Berkey, Rockett, Gillman, Field, & Colditz, 2003). However, over the course of a year, overweight children who never ate breakfast experienced a decrease in BMI compared to overweight children who ate breakfast nearly every day. Interestingly, the opposite result occurred in normal weight children: children of normal weight who never ate breakfast gained weight compared to their peers who ate breakfast every day (Berkey et al., 2003). Breakfast Skipping and its Negative Health Correlates 7 Keski-Rahkonen and colleagues (2003) found cross-sectional associations between breakfast skipping and high BMI in adolescents, and Nicklas, Baranowski, Cullen, and Berenson (2001) found that adolescents with a consistent meal pattern of three meals a day were leaner. Adult samples have also revealed a relationship between regular breakfast consumption and decreased BMI, even among patients suffering from binge eating disorder (BED) (Masheb & Grilo, 2006; Wyatt et al., 2002). Obesity is widespread in the United States today, and much like breakfast skipping, its occurrence has increased over the past few decades among all age groups. Nicklas et al.‟s (2001) review paper examining energy intake in children from 1973 through 1994 suggests that changes in specific eating patterns, such as meal skipping, may explain the increase in adiposity among children. Using Add Health data, Gordon-Larsen, Adair, Nelson, and Popkin (2004) found an increased proportion of overweight and obese respondents from Wave II to Wave III. The significant increase in obese Add Health participants exemplifies the nationwide problem of obesity, and also provides a basis for examining obesity in association with breakfast skipping, which, as previously mentioned, has also increased over time. Why do adolescents choose to eat or skip breakfast? Several reasons for breakfast skipping in adolescents have been suggested, and many environmental factors associated with breakfast consumption have been identified. Common reasons to skip breakfast given by adolescents are lack of time, lack of hunger, and dieting to lose weight (Shaw, 1998). An important factor in breakfast consumption in adolescents is parental presence and influence at mealtime: one study found that parental breakfast eating was the factor most significantly associated with adolescent Breakfast Skipping and its Negative Health Correlates 8 breakfast eating, and that children of breakfast skippers had higher BMIs, suggesting transmission of breakfast skipping and correlated behaviors from parent to child (Keski-Rahkonen et al., 2003). In a study using Add Health Wave I data, parental presence at the evening meal was correlated with a decreased risk of skipping breakfast, and adolescents whose parents made decisions for them as to what they ate were significantly less likely to skip breakfast. Autonomy was a significant risk factor for breakfast skipping: adolescents who made their own decisions about what to eat were 25% more likely to skip breakfast (Videon & Manning, 2003). However, a later cross-sectional study examining genetic and environmental factors in breakfast eating patterns among 16-year-old Finnish twins found no significant effect of parental breakfast eating on child behavior. Instead, researchers found significant family environmental effects on child breakfast eating in both sexes. These results suggest that other types of parental effects may be present in determining child breakfast eating. Girls were found to be more influenced by the family environment than boys, with environmental influences possibly overriding genetically driven factors. In particular, disruption of family meal patterns may induce breakfast skipping in both sexes (Keski-Rahkonen, Viken, Kaprio, Rissanen, & Rose, 2004). Additionally, Franko, Thompson, Bauserman, Affenito, and StriegelMoore (2008) found that “family cohesion” was associated with higher rates of breakfast consumption, further suggesting a complex interplay between family environment and breakfast consumption rather than a straightforward relationship between, for example, parental and thus child breakfast eating or skipping. Pearson and colleagues (2009) provided a thorough and systematic review of the family Breakfast Skipping and its Negative Health Correlates 9 correlates of breakfast consumption among children and adolescents. Broadly, the review found that parental eating habits were positively correlated with both healthy and unhealthy child eating habits. In multiple studies, breakfast skipping has been associated with dieting, concerns about body weight, and body shape dissatisfaction (e.g., Barker, Robinson, Wilman, & Barker (2000); Shaw (1998); see Rampersaud et al. (2005) for review), suggesting that adolescents may skip breakfast to reduce daily caloric intake. Thus, adolescents who perceive their body weight as too high or are concerned with their weight may be more likely to skip breakfast. Fernandez-Aranda and colleagues (2007), using retrospective recall of childhood eating attitudes and behaviors, found that participants who reported eating breakfast during childhood and early adolescence were significantly less likely to have developed an eating disorder, specifically bulimia nervosa or eating disorder not otherwise specified (EDNOS). It should be noted that these findings were obtained using a newly developed instrument, were based on recall of early eating patterns, and have yet to be replicated using longitudinal d