Skipping breakfast associated with more atherosclerosis

The Importance of Breakfast in Atherosclerosis Disease - Insights From the PESA Study

Literature - Uzhova I, Fuster V, Fernández-Ortiz A, et al. - J Am Coll Cardiol 2017;70:1833–42


Not only the nutritional quality of a diet, but also eating patterns are important in the context of CVD prevention strategies. There are data showing that skipping breakfast is associated with obesity, diabetes, lipid disorders, and CHD risk [1-3].

This analysis of the PESA study evaluated the association between different breakfast patterns and subclinical atherosclerosis or CVD risk factors, in individuals without a history of CVD. The PESA study is an ongoing observational prospective cohort, assessing factors related to development and progression of atherosclerosis [4].

The breakfast patterns were evaluated with the computerized questionnaire of the ENRICA study [5]. Three groups were identified:

  • The ‘skipping breakfast’ (SBF) group: <5% of their total energy intake in the morning
  • The ‘low energy breakfast’ (LBF) group: 5 to 20% of their total energy intake in the morning
  • The ‘high energy breakfast’ (HBF) group: >20% of total energy intake in the morning

Of 4,052 participants aged between 40 and 54 years, 2.9% were in the SBF group, 69.4% were in the LBF group, and 27.7% were in the HBF group.

The ESC Systematic Coronary Risk Evaluation tool was used to assess CV risk. Non-coronary atherosclerosis was defined as the presence of a plaque in the right or the left carotid, or the aorta, or the right or left iliofemoral arteries. Coronary atherosclerosis was defined with a CAC score >0. Generalized atherosclerosis was defined by 4 to 6 affected arterial beds.

Main results

Compared with HBF and LBF, the SBF group consisted of mostly men, who were current smokers, were more likely to consume more energy and dietary cholesterol, and tended to consume more alcoholic and sugar-sweetened beverages, as well as red meat.

Cardiometabolic risk markers were more prevalent in the LBF group and even more so in the SBF group as compared with the HBF group, showing the greatest waist circumference and BMI, blood pressure, blood lipids, and fasting glucose levels, and the probabilities of presenting with obesity, abdominal obesity, metabolic syndrome, low HDL-c levels and hypertension were higher in the SBF than in the HBF group.

SBF participants had the highest ESC Systematic Coronary Risk Evaluation scores.

Subclinical atherosclerosis was observed more frequently in the SBF group (74.6%) than in the LBF (64.5%) and HBF (56.6%) group, with higher odds (vs. HBF) of having plaques in:

  • abdominal aorta OR: 1.79; 95% CI: 1.16 - 2.77
  • carotid OR: 1.76; 95% CI: 1.17 - 2.65
  • iliofemoral OR: 1.72; 95% CI: 1.11 - 2.64

Compared with HBF, SBF participants had significantly more non-coronary (OR: 1.55; 95% CI: 0.97 - 2.46) and generalized atherosclerosis (OR: 2.57; 95% CI: 1.54 - 4.31).

Participants in the LBF group had a higher risk of carotid (OR: 1.21; 95% CI: 1.03 - 1.43; (OR: 1.21; 95% CI: 1.03 - 1.43) or iliofemoral atherosclerotic plaques (OR: 1.17; 95% CI: 1.00 - 1.37).

Rectification: please note that initially, wrong percentages for subclinical atherosclerosis were written for the different breakfast groups


Skipping breakfast was associated with a higher risk of non-coronary and generalized atherosclerosis in a sample of asymptomatic individuals. These findings support the importance of healthy eating, including a rich breakfast.

Editorial comment

In their editorial article, Deedwania and Acharya [6] note that breakfast skippers eat more unhealthy and fatty food later during the day and at night, and adopt a general lifestyle that leads to metabolic disorders, and they conclude: ‘There is an urgent need for corrective public health measures to curb the global epidemic of obesity. Given the emerging evidence of association between altered dietary patterns and increased risk of obesity, metabolic syndrome, diabetes, subclinical atherosclerosis, and clinical CV events, it seems prudent to pay attention to diet and educate the public to implement simple lifestyle changes that include emphasis on a regular, hearty, and nutritious breakfast. These easy and economical public health measures can curb the oncoming tsunami of diabetes and CV disorders. Indeed, the wisdom of the ages that breakfast is the most important meal of the day has been proven right in the light of emerging evidence.’


1. van der Heijden AA, Hu FB, Rimm EB, et al. A prospective study of breakfast consumption and weight gain among U.S. men. Obesity 2007;15:2463–9.

2. Mekary RA, Giovannucci E, Willett WC, et al. Eating patterns and type 2 diabetes risk in men: breakfast omission, eating frequency, and snacking. Am J Clin Nutr 2012;95: 1182–9.

3. Shafiee G, Kelishadi R, Qorbani M, et al. Association of breakfast intake with cardiometabolic risk factors. J Pediatr (Rio J) 2013;89:575–82.

4. Fernández-Ortiz A, Jiménez-Borreguero LJ, Peñalvo JL, et al. The Progression and Early detection of Subclinical Atherosclerosis (PESA) study: rationale and design. Am Heart J 2013;166:990–8.

5. Guallar-Castillon P, Sagardui-Villamor J, Balboa-Castillo T, et al. Validity and reproducibility of a Spanish dietary history. PLoS One 2014;9:e86074.

6. Deedwania P and Acharya T. Hearty breakfast for healthier arteries. J Am Coll Cardiol 2017

Find this article online at JACC

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