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TRANSCRIPT
Martina Lundqvist, Nicklas Ennab Vogel, Lars-Åke Levin
CMT Report 2018:2
Center for Medical Technology Assessment
Effects of eating breakfast and school breakfast programmes on children and adolescents:a systematic review
Center for Medical Technology Assessment (CMT)
Center for Medical Technology Assessment is an inter-disciplinary research unit based at the Department of Medical and Health Sciences, Linköping University. The primary objective of CMT is to develop and sustain a high-quality research program in the area of health technology assessment and evaluation studies in health care.
Visit us at www.cmt.liu.se
Effects of eating breakfast and school breakfast
programmes on children and adolescents:
a systematic review
Martina Lundqvist Nicklas Ennab Vogel
Lars‐Åke Levin
CMT Report 2018:2
Printed by LiU Print Services Office, Linköping University LIU CMT RA/1802 ISSN 0283-1228 eISSN 1653-7556
Address: CMT Department of Medical and Health Sciences Linköping University 581 83 LINKÖPING Visiting Address: CMT Building 511-001, Entrance 76, level 13 Campus US Linköping Tel.: 013-28 10 00 Website: http://www.cmt.liu.se/
CONTENTS
ABBREVIATIONS .................................................................... 1
ABSTRACT .............................................................................. 3
CONCLUSION (IN SWEDISH) ................................................. 5
1. BACKGROUND .............................................................. 7
2. METHOD ....................................................................... 9
2.1 Selection of studies ........................................................ 9
2.2 Quality assessment ...................................................... 10
2.3 Result compilation ....................................................... 11
3. RESULTS ...................................................................... 12
3.1 Studies of Eating Breakfast .......................................... 28
3.1.1 Morbidity risk factors .............................................................. 28
3.1.2 Cognitive performance ............................................................. 29
3.1.3 Quality of life and Well-being .................................................. 29
3.1.4 Academic achievement ............................................................ 30
3.2 Studies of School Breakfast Programmes ..................... 31 3.2.1 Cognitive performance .............................................................. 31 3.2.2 Academic achievement ............................................................ 32
3.2.3 Weight/Obesity ........................................................................ 32
4. DISCUSSION ............................................................... 34
5. CONCLUSIONS ............................................................ 37
CONFLICT OF INTEREST ..................................................... 38
REFERENCES ....................................................................... 39
APPENDIX 1 ......................................................................... 47
1
ABBREVIATIONS
AD ACL – Activation-Deactivation Adjective Check List
ASC – After School Club
BC – Breakfast Consumption
BIC – Breakfast in Classroom
BMI – Body Mass Index
BP – Breakfast Programme
BW – Body Weight
CAT – Cognitive Ability Test
CDR – Cognitive Drug Research
CF – Cognitive Function
CL – Cognitive Load
CPT – Continuous Performance Test
CSHQ – Children’s Sleep Habits Questionnaire
CRF – Cardiorespiratory Fitness
CT – Controlled Trial
CVD – Cardiovascular Disease
d2 — Aufmerksamkeits-Belastungs-Test
DABS – The Diet and Behaviour Scale
DiaBP – Diastolic Blood Pressure
EB – Eating Breakfast
ECLS-K – Early Childhood Longitudinal Study-Kindergarten Class
ELA – English Language Arts
FRP – Free and Reduced Price
HDL – High-Density Lipoprotein
HDL-C – High-Density Lipoprotein-Cholesterol
HEI – Healthy Eating Index
HOMA-IR – Homeostasis Model Assessment-Insulin Resistance Index
HSCL-10 – Hopkins Symptoms Checklist (10-Item Version)
2
LDL – Low-Density Lipoprotein
LDL-C – Low-Density Lipoprotein-Cholesterol
LGT-3 — Lern- und Gedachtnistest
MetS – Metabolic Syndrome
N/A – Not Available
NAEP – National Assessment of Educational Process
NAPLAN – National Assessment Program-Literacy and Numeracy
PA – Physical Activity
PBF – Percent Body Fat
PSID-CDS – Panel Study of Income Dynamics-Child Development
Supplement
QALY – Quality Adjusted Life Years
RCT – Randomized Controlled Trial
RVIP – Rapid Visual Information Processing task
SAT – Scholastic Assessment Test
SBP – School Breakfast Programme
SysBP – Systolic Blood Pressure
SES – Socioeconomic Status
TAG – Triacylglycerol
TC – Total Cholesterol
TG – TriGlyceride
USBP - Universal School Breakfast Programme
VAS – Visual Analogue Scale
VGZ – Verfahren zur Erfassung des Gefühlszustandes
WIAT(III) – Wechsler Individual Achievement Test (3-Components)
WPQ – Well-being Process Questionnaire
(A+PAAC) – Physical Activity and Academic Achievement Across the
Curriculum
3
ABSTRACT
Background: Breakfast is often described as the most important meal of the day. The regularity of wholesome, daily meal patterns comprised of healthy foods is important for the physical and mental development of children and adolescents. One way to make sure that children and adolescents eat breakfast on a regular basis is to serve it at school. Several published reviews have examined the effects of eating breakfast and studied effects of school breakfast programmes on children and adolescents. Informed decisions of whether to promote eating breakfast or to introduce a school breakfast programme require a broader perspective. The aim was to conduct a systematic review of scientific publications that study the effects potentially relevant for economic evaluations of eating breakfast or implementing school breakfast programmes for children and adolescents. Method: In the systematic literature review, studies were identified by searching the electronic databases PubMed, CINAHL, Web of Science and PsycINFO from January 2000 through October 2017. The following inclusion criteria guided the selection of the identified studies: published articles from peer-reviewed journals with full text in English, studies collecting primary data, quantitative studies, studies performed in countries comparable to Sweden in terms of access and quality of nutrients, economic and social conditions and publications studying at least one of the topics; academic achievement, quality of life and wellbeing, risk factors/morbidity or cognitive performance. Results: Twenty-six studies on eating breakfast and eleven studies on school breakfast programmes fulfilled the inclusion criteria and were judged to be of at least moderate quality were included in the analysis. The results of the review of studies on eating breakfast showed positive and conclusive effects on cognitive performance, academic achievement, quality of life, well-being and risk factors/morbidity. This indicates that eating breakfast is important. The results of the studies on school breakfast varied. Minor positive effects were seen on cognitive performance and academic achievement. Most studies showed no effects and all studies suffered from different methodological weaknesses. Conclusions: The overall assessment of the studies on eating breakfast indicated positive effects. The studies on school breakfast programmes showed minor positive effects, but the majority of the studies showed no
4
effects and all studies suffered from different methodological weaknesses. In order to assess the cost-effectiveness of eating breakfast and of school breakfast programmes we need to know more about how the identified affects influence the societal cost and the individuals gain in quality-adjusted life years both in the short and the long term.
5
CONCLUSION (IN SWEDISH)
Bakgrund: Frukost beskrivs ofta som dagens viktigaste måltid och flera studier har visat att kostintag har en positiv effekt på barn och ungdomars såväl fysiska som mentala utveckling. Ett sätt att öka barn och ungdomars frukostintag är att servera frukost på skoltid. Idag finns flera publicerade översiktsatiklar som har granskat effekterna av att äta frukost såväl som effekterna av skolfrukostprogram. För att kunna fatta ett beslut om huruvida man ska lägga resurser på att främja frukost-ätande eller servera frukost på skoltid krävs dock ytterligare information. Syftet med rapporten är att systematiskt granska de vetenskapliga publikationer som studerar effekter av att äta frukost eller effekter av implementering av skolfrukostprogram potentiellt relevanta att inkludera i en ekonomisk utvärdering. Metod: En systematisk litteratursökning genomfördes. Studierna identifierades genom att söka de elektroniska databaserna PubMed, CINAHL, Web of Science och PsycINFO från januari 2000 till oktober 2017. De inklusionskriterier som tillämpades var: artiklar på engelska publicerade i granskade tidskrifter, artiklar som presenterar primärdata, kvantitativa studier, studier jämförbara med Sverige gällande näringsintag, ekonomiska och sociala förhållanden samt publikationer som studerar minst ett av ämnena; akademisk prestation, livskvalitet och välbefinnande, riskfaktorer/morbiditet eller kognitiv prestanda. Resultat: Tjugosex artiklar som studerade effekter av att äta frukost samt elva studier som studerade effekter av skolfrukostprogram uppfyllde de uppsatta inklusionskriterierna och bedömdes vara av minst måttlig kvalitet inkluderades i analysen. Studierna som studerade effekter av att äta frukost var samstämmiga. De visade att frukostätande hade positiva effekter på kognitiv prestanda, akademisk prestation, livskvalitet och välbefinnande samt på morbida riskfaktorer. Artiklar som studerade effekter av skolfrukostprogram visade på varierande resultat. Ett fåtal studier fann att skolfrukostprogram hade positiva effekter på kognitiv prestanda och akademisk prestation men majoriteten av studierna kunde inte påvisa några effekter. Flertalet av studierna var dock behäftade med metodologiska svagheter. Slutsats: Äta frukost har överlag positiva effekter på de studerade utfallsmåtten. Skolfrukostprogram har små till måttliga effekter på de studerade utfallsmåtten. Majoriteten av studierna som undersökte skolfrukostprogram visade dock inga effekter och alla studier var
6
behäftade med metodologiska svagheter. För att kunna bedöma kostnadseffektiviteten av att äta frukost och skolfrukostprogram, behöver vi mer kunskap om hur de identifierade effekterna påverkar samhällets kostnader och en individs livskvalitet och levnadsår, på såväl kort som lång sikt.
7
1. BACKGROUND
Breakfast is often described as the most important meal of the day. Overall, eating breakfast on a regular basis is linked to a range of beneficial health outcomes in adults, including improved cognition, physical activity, and lower risk of hypertension [2-4]. Moreover, several studies have focused on examining if breakfast habits have any bearing on school attendance, academic achievement and general health in children and adolescents. Research findings indicate that the regularity of wholesome, daily meal patterns comprised of healthy foods is important for the physical and mental development of children and adolescents [5]. The quality and regularity of breakfast consumption have also shown to be associated with mental performance, academic achievement, physical activity and quality of life [6-12]. Despite this, young people often skip breakfast [13], and the prevalence of children and adolescents skipping breakfast is increasing [14]. In addition, it has been shown that breakfast skipping is particularly common amongst children of lower socioeconomic status [15]. One way to make sure that children and adolescents eat breakfast on a regular basis is to serve it at school. A School Breakfast Programme (SBP) aims to provide a healthy breakfast in school, to improve e.g. nutrition and academic performance [16]. SBP is commonly supervised by staff, offering school children a nutritious breakfast at school before going to class [17]. A variant of SBP is Breakfast in Classroom (BIC). With BIC, students get breakfast in their classroom at the beginning of the school day, rather than in the cafeteria before school start. In addition to research studying the effects of eating breakfast (EB), there is a growing body of literature that aims to measure the effects of School Breakfast Programmes (SBP). Several published reviews have examined the effects of EB and SBP on children and adolescents [18-21]. Informed decisions of whether to promote eating breakfast or to introduce a school breakfast programme require a broader perspective. Since societal resources are scarce, and the needs are endless, choices between health interventions must be made. Economic evaluation of different interventions seeks to identify and quantify the costs and consequences of each alternative for well-founded and informed decision-making.
8
Economic evaluations are comparative analyses of alternative courses of action in terms of both costs and consequences. The costs are weighed against the health effects measured in such a way that it corresponds to a value, usually quality adjusted life-years (QALYs). This measure should ideally encapsulate the impact of an intervention on a person’s length of life, and the impact on their health-related quality of life which is recognized as an important indicator of treatment outcomes. To our knowledge there are no published economic evaluations of EB and SBP. In the absence of cost-effectiveness studies, and as a starting point for future economic assessments, this review will focus on studies that measure outcomes that directly or indirectly can be transformed into QALYs that are traditionally used in cost-effectiveness analysis. The aim was to conduct a systematic review of scientific publications that study the effects potentially relevant for economic evaluations of eating breakfast or implementing school breakfast programmes for children and adolescents.
9
2. METHOD
Studies were identified by searching the electronic databases PubMed, CINAHL, Web of Science and PsycINFO between January 2000 and October 2017.
To capture all relevant articles published in the field, two different search strategies were constructed. See table 1.
Table 1. Search strategies. Search strategy 1 Breakfast AND Children OR Adolescents OR Teen OR Youth OR students OR kids OR pupils AND Behavior OR Mental OR Learning OR Effect OR Cognitive OR Academic OR Achievement OR Performance OR Well-being OR Quality of life OR Health Search strategy 2 School AND Breakfast AND Children OR Adolescents OR Teen OR Youth OR students OR kids OR pupils AND Behavior OR Mental OR Learning OR Effect OR Cognitive OR Academic OR Achievement OR Performance OR Well-being OR Quality of life OR Health
2.1 Selection of studies
The overall inclusion criteria applied were:
Published articles from peer-reviewed journals with full text in English.
Studies collecting primary data. Quantitative studies. Studies performed in countries comparable to Sweden in terms of
access and quality of nutrients, economic and social conditions. Studies using well defined and valid measures of breakfast
consumption. Publications studying at least one of the following topics:
Academic achievement Quality of life and Well-being
10
Morbidity risk factors Cognitive performance
The association between eating breakfast and weight-related outcomes is a thoroughly studied topic with broad coverage in previous literature [22-24]. The established links for utilizing weight-related outcome measurements in cost-effectiveness analysis highlight the redundancy of further examinations of this association. Weight-related outcomes are therefore omitted from the EB section of this review [25, 26]. The review of SBP studies included studies using weight/obesity as outcome.
One of the authors (ML) conducted the search in October 2017. Initially, two of the authors (ML, NEV) read all titles and abstracts of the identified studies to determine the relevance of each article. If title and abstract met with the inclusion criteria, the study proceeded to the next stage of the review process. Studies with insufficient information in title and abstract also proceeded to the next stage of the review process. After this selection, all authors (ML, L-ÅL, NEV) read the remaining studies in full text, in order to confirm inclusion eligibility and to conduct the quality assessment.
2.2 Quality assessment
In pairs, the authors read the articles in full to assess both eligibility and scientific quality. If the two authors who made the initial assessment did not agree, the third author also read the article. The scientific quality assessment was based on the following criteria: adequate control group(s), randomization, sufficient statistical power, control of confounders, sufficient descriptions of experimental design, relevance of outcome measures and consistency between reported results and conclusions [27, 28]. In order not to let the results of the study affect the quality assessment, this was done separately without, as far as possible, reading the study results. The criteria for quality assessment varied with different study types. The quality of the studies was rated as high, moderate or low. A study rated ‘high quality’ had to fulfill all the quality criteria. Studies of moderate quality fulfilled several of the criteria. Finally, low-quality studies either failed to meet several of the criteria or had major shortcomings in certain criteria. Studies rated as being of high or moderate quality were included in the further analysis. The low-
11
quality studies were excluded. They are presented with a comment in Appendix 1. Tables 2 and 3 contain the following information from the included studies: reference, participant characteristics (number, age, gender), study design, study purpose, outcomes, authors conclusions and the scientific quality assessment.
2.3 Result compilation
A compilation of the study results based on statistical inference is presented in tables 4 and 5. A study was deemed positive if it had at least one statistically significant positive outcome measure; a study was deemed negative if it had at least one statistically significant negative outcome and a study was deemed ‘no effect’ if it showed no statistically significant results. A two-tailed p-value of 0.05 was considered statistically significant.
12
3. RESULTS
The flow chart in figure 1 illustrates the work process. Database searches identified 5,200 articles. No articles were identified through other types of article sources. After removal of duplicates, 2,958 unique articles remained. Exclusion based on information given in title and abstract resulted in the removal of 2,830 articles. Full-text articles were categorized as “Effect of Eating Breakfast” (EB) or “Effect of School Breakfast Programmes” (SBP). The full-text reading of the EB articles resulted in the additional exclusion of sixteen articles that did not meet the inclusion criteria, and eight were excluded due to low quality. Full-text reading of the SBP articles excluded 63 articles that did not meet the inclusion criteria, and three were excluded due to low quality. Finally, 26 EB articles and 11 SBP articles met the inclusion criteria and remained for further analysis. The 26 EB studies included in the analysis are summarized in table 2, and the 11 SBP studies included in the analysis are presented in table 3.
Records identified through database search
(n = 5200)
Scre
enin
g In
clu
ded
E
ligi
bili
ty
Iden
tifi
cati
on
Additional records identified through other sources
(n = 0)
Records after duplicates removed (n = 2958)
Records screened (n = 2958)
Records excluded (n = 2830)
Full-text EB articles assessed for eligibility
(n = 50)
Full-text articles excluded, with reasons
EB n = 16+8 SBP n = 63+3
EB studies included in synthesis (n = 26)
Full-text SBP articles assessed for eligibility
(n = 77)
SBP studies included in synthesis
(n = 11)
Figure 1. Flow chart of the work process. PRISMA 2009 Flow Diagram [1].
13
Ta
ble
2.
Sum
ma
ry o
f in
clu
ded
Ea
tin
g B
rea
kfa
st s
tud
ies.
F
irst
au
thor
(y
ear)
, Cou
ntr
y P
arti
cip
ants
St
ud
y d
esig
n
Stu
dy
pu
rpos
e O
utc
omes
A
uth
or c
oncl
usi
on
Scie
nti
fic
qual
ity
asse
ssm
ent
N
A
ge
Gen
der
(f
emal
e)
Mo
rbid
ity
risk
fa
cto
rs
Hal
lstr
om e
t al
. (2
013
), S
WE
, E
SP, B
EL
, DE
U,
FR
A G
RC
, IT
A,
AU
T [
29]
2929
14
.7
year
s 53
%
Cro
ss-s
ecti
onal
, ob
serv
atio
nal
T
o ex
amin
e th
e as
soci
atio
n
betw
een
bre
akfa
st
con
sum
pti
on a
nd
CV
D r
isk
fact
ors
in E
uro
pea
n
adol
esce
nts
.
Car
dior
esp
irat
ory
fitn
ess
Ph
ysic
al a
ctiv
ity
Seru
m T
AG
TC
HD
L-C
LD
L-C
Glu
cose
Fin
din
gs r
egar
din
g E
uro
pea
n a
dol
esce
nts
co
nfi
rm p
revi
ous
dat
a in
dic
atio
ns:
ad
oles
cen
ts w
ho
con
sum
e br
eakf
ast
regu
larl
y h
ave
low
er
bod
y fa
t co
nte
nt
than
ot
her
pee
rs. R
esu
lts
also
sh
ow t
hat
reg
ula
r B
C is
ass
ocia
ted
wit
h
hig
her
car
dio
-re
spir
ator
y fi
tnes
s an
d (
espe
cial
ly in
m
ale
adol
esce
nts
) w
ith
a h
ealt
hie
r ca
rdio
vasc
ula
r p
rofi
le
and
neg
atio
n o
f th
e ef
fect
of e
xces
s ad
ipos
ity
on T
C a
nd
L
DL
-C.
Mod
erat
e
Mar
latt
et
al.
(20
16),
USA
[3
0]
367
14.7
ye
ars
49%
O
bser
vati
onal
T
o ev
alu
ate
the
rela
tion
ship
bet
wee
n b
oth
br
eakf
ast
and
fast
food
co
nsu
mp
tion
on
sel
ecte
d
biom
arke
rs a
nd
imp
orta
nt
card
iova
scu
lar
and
m
etab
olic
ris
k fa
ctor
s am
ong
hea
lth
y ad
oles
cen
ts, a
nd
furt
her
ex
amin
e th
e re
lati
onsh
ip
BM
I
PB
F
S-, D
BP
L-,
HD
L
TG
Th
e fi
nd
ing
sugg
ests
th
at fa
st fo
od a
nd
BC
ar
e as
soci
ated
wit
h
som
e m
etab
olic
ally
im
por
tan
t ch
ron
ic
dis
ease
ris
k fa
ctor
s in
h
ealt
hy
adol
esce
nts
.
Mod
erat
e
14
betw
een
th
ese
die
tary
be
hav
iors
an
d t
he
know
n
risk
fact
or c
lust
erin
g th
at
occu
rs w
ith
th
e m
etab
olic
sy
nd
rom
e.
Glu
cose
Insu
lin
e
HO
MA
-IR
Met
S cl
ust
er s
core
Mos
chia
no
et a
l. (2
012
), I
TA
[31
] 8
00
10
≤
year
s 40
.6%
O
bser
vati
onal
T
o as
sess
th
e p
ossi
ble
asso
ciat
ion
bet
wee
n
hea
dac
he
and
sp
ecif
ic
hab
its
and
life
styl
e fa
ctor
s.
Hea
dac
he
Evi
den
ce o
f cle
ar
asso
ciat
ion
bet
wee
n
hea
dac
he
and
ir
regu
lar
inta
ke o
f m
eals
(es
pec
iall
y ir
regu
lar
brea
kfas
t)
and
sle
ep d
istu
rban
ce
wit
h s
ign
ific
ant
dif
fere
nce
s w
hen
co
mp
arin
g su
bjec
ts
wit
h a
nd
wit
hou
t h
ead
ach
e.
Mod
erat
e
Pap
outs
ou e
t al
. (2
014
), C
YP
, G
RC
, DE
U, I
TA
, SW
E, E
ST, B
EL
, E
SP [
32]
88
63
2 <
10
ye
ars
48
.8%
C
ross
-sec
tion
al
Obs
erva
tion
al
To
inve
stig
ate
the
rela
tion
ship
bet
wee
n
brea
kfas
t ro
utin
e an
d C
VD
ri
sk fa
ctor
s in
a
mu
ltin
atio
nal
sam
ple
.
Blo
od g
luco
se
TC
LD
L-C
HD
L-C
TG
PA
Dai
ly B
C c
ontr
ibu
tes
to c
ontr
olli
ng
sch
ool-
aged
ch
ild
ren
's w
eigh
t an
d li
pid
pro
file
. It
pro
mot
es h
igh
er P
A.
Mod
erat
e
Sese
et
al.
(20
12),
ESP
, G
BR
, FR
A, B
EL
, D
EU
, AU
T,
HU
N, G
RC
[33
]
826
14
.8
year
s 52
%
Obs
erva
tion
al
To
exam
ine
the
asso
ciat
ion
s of
foo
d be
hav
iors
an
d p
refe
ren
ces
wit
h m
arke
rs o
f in
suli
n
resi
stan
ce a
nd
clu
ster
ed
met
abol
ic r
isk
fact
ors
scor
e af
ter
con
trol
lin
g fo
r p
oten
tial
con
foun
der
s,
incl
ud
ing
bod
y fa
t in
E
uro
pea
n a
dole
scen
ts.
TG
TC
HD
L-C
Blo
od g
luco
se
SBP
HO
MA
-IR
Th
e re
sult
s of
th
is
stu
dy
ind
icat
e th
at
insu
lin
res
ista
nce
an
d
a cl
ust
ered
met
abol
ic
risk
fact
ors
scor
e ar
e p
osit
ivel
y as
soci
ated
w
ith
food
beh
avio
rs
and
pre
fere
nce
s.
Skip
pin
g br
eakf
ast
exp
lain
s p
art
of t
he
insu
lin
res
ista
nce
Mod
erat
e
15
vari
ance
.
Smit
h e
t al
. (2
010
), A
US
[34]
218
4 N
/A
53.3
%
Lon
gitu
din
al,
Obs
erva
tion
al
To
exam
ine
lon
gitu
din
al
asso
ciat
ion
s of
bre
akfa
st
skip
pin
g in
ch
ild
hoo
d a
nd
ad
ult
hoo
d w
ith
ca
rdio
met
abol
ic r
isk
fact
ors
in a
du
lth
ood
.
Mea
n W
eigh
t
Cir
cum
fere
nce
Car
diom
etab
olic
Ris
k fa
ctor
s
Par
tici
pan
ts s
kip
pin
g br
eakf
ast
in b
oth
ch
ildh
ood
an
d
adu
lth
ood
had
larg
er
wai
st c
ircu
mfe
ren
ces,
h
igh
er B
MIs
, an
d
poo
rer
card
iom
etab
olic
p
rofi
les
than
did
th
ose
wh
o re
por
ted
ea
tin
g br
eakf
ast
at
both
tim
e p
oin
ts.
Mod
erat
e
Wal
ter
(20
14),
U
SA [
35]
13 5
70
11-1
7 ye
ars
51%
C
ross
-sec
tion
al
To
stu
dy
how
life
styl
e be
hav
iors
(sk
ipp
ing
mea
ls,
wat
er in
take
, tob
acco
use
, al
coh
ol u
se, a
nd
ph
ysic
al
acti
vity
) an
d il
lnes
s-re
late
d fa
ctor
s (d
epre
ssio
n, s
omat
ic
com
pla
ints
, in
som
nia
, an
d
obes
ity)
wor
k to
geth
er t
o pr
edic
t h
ead
ach
e in
an
ad
oles
cen
t p
opu
lati
on.
Rec
urr
ent
hea
dac
he
Lif
esty
le b
ehav
iou
rs
and
illn
ess-
rela
ted
fa
ctor
s ar
e as
soci
ated
w
ith
ad
oles
cen
t h
ead
ach
e.
Skip
pin
g br
eakf
ast
thre
e or
mor
e ti
mes
w
as o
ne
of t
hem
.
Mod
erat
e
Wen
nbe
rg e
t al
. (2
015
), S
WE
[3
6]
88
9
16 y
ears
fo
llow
-up
age
: 18
, 21,
30
43
52.2
%
Lon
gitu
din
al,
Obs
erva
tion
al
To
anal
yse
wh
eth
er p
oor
brea
kfas
t h
abit
s in
ad
oles
cen
ce p
redi
ct t
he
met
abol
ic s
ynd
rom
e an
d
its
com
pon
ents
in
adu
lth
ood.
Met
abol
ic s
ynd
rom
e
Cen
tral
Obe
sity
Hig
h F
asti
ng
Glu
cose
Poo
r br
eakf
ast
hab
its
in a
dol
esce
nce
p
red
icte
d t
he
met
abol
ic s
ynd
rom
e in
ad
ult
hoo
d. O
f th
e m
etab
olic
syn
dro
me
com
pon
ents
, poo
r br
eakf
ast
hab
its
in
adol
esce
nce
pre
dic
ted
ce
ntr
al o
besi
ty a
nd
h
igh
fast
ing
glu
cose
in
ad
ult
hoo
d.
Mod
erat
e
Wen
nbe
rg e
t al
. (2
016
), S
WE
[3
7]
88
9
16 y
ears
fo
llow
-up
age
: 18
, 21,
52.2
%
Lon
gitu
din
al,
Obs
erva
tion
al
To
inve
stig
ate
wh
eth
er
irre
gula
r ea
tin
g of
mea
ls in
ad
oles
cen
ce p
redi
cts
the
met
abol
ic s
ynd
rom
e an
d
Met
abol
ic s
ynd
rom
e Ir
regu
lar
eati
ng
of
mea
ls in
ad
oles
cen
ce
pre
dic
ted
th
e m
etab
olic
syn
dro
me
Mod
erat
e
16
30 4
3 it
s co
mp
onen
ts in
ad
ult
hoo
d, a
nd
if a
ny
spec
ific
mea
l is
of
par
ticu
lar
imp
orta
nce
.
in a
du
lth
ood
, bu
t n
ot
ind
epen
den
tly
of B
MI
and
life
styl
e in
ad
oles
cen
ce. P
oor
brea
kfas
t in
ad
oles
cen
ce w
as t
he
only
sp
ecif
ic m
eal
asso
ciat
ed w
ith
futu
re
met
abol
ic s
ynd
rom
e,
even
aft
er
adju
stm
ents
. C
og
nit
ive
pe
rfo
rma
nce
Coo
per
et
al.
(20
11),
GB
R [
38]
96
13.3
ye
ars
62.5
%
Ran
dom
ized
cr
osso
ver
des
ign
T
o ex
amin
e th
e ef
fect
s of
br
eakf
ast
con
sum
pti
on o
n
cogn
itiv
e fu
nct
ion
, moo
d
and
blo
od g
luco
se
con
cen
trat
ion
in
adol
esce
nt
sch
oolc
hil
dre
n.
Mod
ifie
d A
D A
CL
(m
ood
que
stio
nn
aire
)
VA
S –
hu
nge
r,
full
nes
s
Blo
od g
luco
se
con
cen
trat
ion
CF
tes
ts:
Vis
ual
sea
rch
(f
ocu
sed
att
enti
on)
Stro
op (
neg
ativ
e p
rim
ing)
St
ern
berg
par
adig
m
(wor
kin
g m
emor
y)
BC
imp
rove
d t
he
accu
racy
of r
esp
onse
s on
th
e vi
sual
sea
rch
an
d S
troo
p t
ests
. BC
al
so im
pro
ved
re
spon
se t
imes
on
th
e m
ore
com
ple
x le
vels
of
th
e St
ern
berg
p
arad
igm
, bu
t d
id n
ot
hav
e co
nsi
sten
t ef
fect
s on
res
pon
se
tim
es o
n t
he
oth
er
test
s co
nd
uct
ed. B
C
was
par
ticu
larl
y be
nef
icia
l for
th
e m
ore
cogn
itiv
ely
dem
and
ing
task
s,
wh
erea
s th
e si
mp
ler
task
s co
uld
be
per
form
ed t
o a
sim
ilar
le
vel f
ollo
win
g br
eakf
ast
omis
sion
.
Mod
erat
e
Def
eyte
r an
d
Ru
sso
(20
13),
G
BR
[39
]
40
14.2
ye
ars
52.5
%
Cro
ssov
er d
esig
n
To
inve
stig
ate
the
effe
ct o
f br
eakf
ast
con
sum
pti
on o
n
cogn
itiv
e p
erfo
rman
ce a
nd
m
ood
in a
dol
esce
nts
, an
d
any
inte
ract
ion
th
at
brea
kfas
t co
nsu
mp
tion
Bon
d-L
ader
(m
ood
sc
ale)
VA
S -
thir
st, h
un
ger,
sa
tiet
y
Ove
rall
, it
app
eare
d
that
aft
er b
reak
fast
, p
arti
cip
ants
felt
mor
e al
ert,
sat
iate
d, a
nd
co
nte
nt. O
nly
in t
he
reca
ll t
ask
did
Mod
erat
e
17
mig
ht
hav
e w
ith
cog
nit
ive
load
. C
L t
ests
:
Del
ayed
wor
d r
ecal
l (m
emor
y
Ch
oice
rea
ctio
n t
ime
(att
enti
on)
RV
IP (
sust
ain
ed
atte
nti
on)
Stro
op (
neg
ativ
e p
rim
ing)
Seri
al 3
s, 7
s (a
tten
tion
, mem
ory)
per
form
ance
ap
pea
r to
be
sign
ific
antl
y m
odu
late
d b
y th
e in
tera
ctiv
e co
mbi
-n
atio
n o
f th
e ef
fect
of
BC
an
d t
ask
dif
ficu
lty,
w
ith
imp
rove
d
per
form
ance
at
tim
e tw
o w
hen
th
e ta
sk w
as
har
der
.
Hjo
rth
et
al.
(20
16),
DN
K
[40
]
710
-828
9.
9 ye
ars
49%
C
lust
er-
ran
dom
ized
cr
osso
ver
des
ign
To
exam
ine
the
ind
epen
den
t as
soci
atio
ns
betw
een
wei
ght
stat
us
and
li
fest
yle
ind
icat
ors
wit
h
cogn
itiv
e p
erfo
rman
ce in
8
- to
11-
year
-old
Dan
ish
ch
ild
ren
.
CSH
Q
CR
F
d2-
test
(c
once
ntr
atio
n)
Sen
ten
ce r
ead
ing
spee
d a
nd
cor
rect
nes
s
Mat
hem
atic
s p
rofi
cien
cy
Nor
mal
wei
ght
chil
dre
n h
ad h
igh
er
cogn
itiv
e p
erfo
rman
ce
com
pare
d t
o ov
erw
eigh
t/ob
ese
and
u
nd
erw
eigh
t ch
ild
ren
. D
aily
BC
was
as
soci
ated
wit
h h
igh
er
cogn
itiv
e p
erfo
rman
ce in
th
e d
2-te
st, m
ath
emat
ics
and
/or
sen
ten
ce-
read
ing
test
.
Mod
erat
e
Wes
nes
et
al.
(20
03)
, GB
R
[41]
29
12 y
ears
51
.7%
R
and
omiz
ed,
fou
r-w
ay
cros
sove
r d
esig
n
To
det
erm
ine
the
exte
nt
to
wh
ich
bre
akfa
st c
erea
ls
wou
ld h
elp
to
pre
ven
t d
ecli
nes
in c
ogn
itiv
e fu
nct
ion
in s
choo
l ch
ild
ren
.
CD
R t
est:
w
ord
pre
sen
tati
on,
imm
edia
te w
ord
re
call
, pic
ture
p
rese
nta
tion
, sim
ple
re
acti
on t
ime,
dig
it
vigi
lan
ce, c
hoi
ce
reac
tion
tim
e, s
pat
ial
and
nu
mer
ic w
orki
ng
mem
ory,
del
ayed
w
ord
rec
all,
wor
d a
nd
Skip
pin
g br
eakf
ast
imp
airs
att
enti
on a
nd
ep
isod
ic m
emor
y,
incr
easi
ng
in
mag
nit
ud
e ov
er t
he
mor
nin
g. I
nge
stin
g ca
rboh
ydra
tes
in t
he
form
of b
reak
fast
ce
real
s re
du
ces
atte
nti
on d
efic
it b
y m
ore
than
hal
f an
d,
for
som
e as
pec
ts o
f
Mod
erat
e
18
pic
ture
rec
ogn
itio
n
(att
enti
on, w
orki
ng
mem
ory,
ep
isod
ic
seco
nd
ary
mem
ory)
Bon
d a
nd
Lad
er
(moo
d, a
lert
nes
s)
mem
ory
(im
med
iate
w
ord
rec
all)
, pre
ven
ts
the
defi
cit
alto
geth
er.
No
ben
efit
s to
at
ten
tion
or
epis
odic
m
emor
y w
ith
th
e gl
uco
se d
rin
k; in
fact
, gr
eate
r in
itia
l im
pai
rmen
t w
ith
th
e d
rin
k th
an w
ith
no
dri
nk
or b
reak
fast
. Im
pro
vem
ents
in
aler
tnes
s an
d
con
ten
tmen
t d
id
occu
r fo
r 90
min
fo
llow
ing
the
glu
cose
d
rin
k, b
ut
effe
cts
fad
ed t
her
eaft
er,
wh
erea
s th
e be
nef
its
con
tin
ued
from
th
e tw
o ce
real
s.
Wes
nes
et
al.
(20
12),
GB
R
[42]
138
6 10
.59
year
s 52
%
Con
trol
led
tri
al
To
det
erm
ine
the
exte
nt
to
wh
ich
bre
akfa
st c
erea
ls
wou
ld h
elp
to
pre
ven
t d
ecli
nes
in c
ogn
itiv
e fu
nct
ion
in s
choo
l ch
ild
ren
.
Pow
er o
f att
enti
on
Res
pon
se s
pee
d
vari
abil
ity
Dig
it v
igil
ance
tas
k
Ch
oice
rea
ctio
n t
ime
task
Pic
ture
rec
ogn
itio
n
Pow
er o
f Att
enti
on, a
sc
ore
refl
ecti
ng
the
abil
ity
to fo
cus
atte
nti
on a
nd
avo
id
dis
trac
tion
, was
sl
owed
by
7% in
th
ose
chil
dre
n w
ho
did
not
h
ave
brea
kfas
t. T
he
abil
ity
to s
ust
ain
at
ten
tion
was
als
o co
mpr
omis
ed, 7
% le
ss
targ
ets
bein
g d
etec
ted
in
th
e di
git
vigi
lan
ce
task
wh
ile
23%
mor
e fa
lse
alar
ms
wer
e m
ade.
Th
e ab
ilit
y to
co
rrec
tly
iden
tify
p
ictu
res
was
imp
aire
d
by 9
% a
nd
spe
ed w
as
slow
ed b
y 9%
. Fin
ally
, th
e re
spon
se s
peed
va
riab
ilit
y w
as 1
0%
gr
eate
r in
ch
ild
ren
Mod
erat
e
19
wh
o di
d n
ot h
ave
brea
kfas
t. T
hes
e sc
ores
ref
lect
eve
ry
asp
ect
of c
ogn
itiv
e p
erfo
rman
ce
asse
ssed
, sh
owin
g a
com
preh
ensi
ve
dif
fere
nce
bet
wee
n
the
two
grou
ps.
W
iden
hor
n-
Mü
ller
(20
08
),
DE
U [
43]
104
17.2
ye
ars
46%
R
and
omiz
ed
cros
sove
r d
esig
n
To
det
erm
ine
wh
eth
er
brea
kfas
t h
ad e
ffec
ts o
n
the
cogn
itiv
e p
erfo
rman
ce
and
moo
d o
f hig
h s
choo
l st
ude
nts
.
d2-
Tes
t (c
once
ntr
atio
n s
pee
d
and
att
enti
on)
LG
T-3
(le
arn
ing
cap
acit
y, im
med
iate
m
emor
y)
VG
Z (
moo
d
asse
ssm
ent
scal
e)
Th
is c
ross
over
tri
al
dem
onst
rate
d p
osit
ive
shor
t-te
rm e
ffec
ts o
f br
eakf
ast
on c
ogn
itiv
e fu
nct
ion
ing
and
sel
f-re
por
ted
ale
rtn
ess
in
hig
h s
choo
l stu
den
ts.
Mod
erat
e
Pag
e et
al.
(20
09)
, USA
, SV
K, H
UN
, R
OU
, CZ
E [
44]
3121
16
.6
year
s 54
.7%
C
ross
-sec
tion
al
To
inve
stig
ate
self
-rat
ed
hea
lth
(SR
H)
in C
entr
al
and
Eas
tern
Eu
rop
ean
(C
EE
) ad
oles
cen
ts a
nd
de
term
ine
its
asso
ciat
ion
w
ith
psy
chos
ocia
l fu
nct
ion
ing
and
oth
er
dim
ensi
ons
of a
dol
esce
nt
hea
lth
.
Self
-Rat
ed H
ealt
h
R-U
CL
A L
onel
ines
s Sc
ale
Bec
k H
opel
essn
ess
Scal
e
Ch
eek
and
Bu
ss
Shyn
ess
Scal
e
Mac
Art
hu
r Sc
ale
of
Subj
ecti
ve S
ocia
l St
atu
s –
You
th
Ver
sion
Self
-Rat
ed H
app
ines
s
Self
-rel
ated
Hea
lth
ap
pea
rs t
o be
as
soci
ated
wit
h
psy
chos
ocia
l fu
nct
ion
ing
and
oth
er
dim
ensi
ons
of
adol
esce
nt
hea
lth
in
CE
E y
outh
. E
atin
g br
eakf
ast
was
on
e of
tw
elve
si
gnif
ican
t p
red
icto
rs
of S
RH
.
Mod
erat
e
Ric
har
ds
and
Sm
ith
(20
16),
G
BR
[45
]
230
7 13
.6
year
s 51
.5%
L
ongi
tud
inal
st
ud
y w
ith
tw
o cr
oss-
sect
ion
s
To
inve
stig
ate
the
effe
cts
of c
onsu
min
g en
ergy
d
rin
ks a
nd
mis
sin
g br
eakf
ast
on s
tres
s,
anxi
ety,
an
d d
epre
ssio
n in
a
coh
ort
of s
econ
dar
y
DA
BS
Exe
rcis
e fr
equ
ency
qu
esti
onn
aire
Self
-Ass
esse
d M
enta
l
Th
e cu
rren
t st
ud
y h
as
pro
vid
ed e
vid
ence
to
sugg
est
that
hig
h
stre
ss, a
nxi
ety,
an
d
dep
ress
ion
leve
ls in
ad
oles
cen
ts a
re
Mod
erat
e
20
sch
ool c
hil
dre
n.
Hea
lth
(W
PQ
-ite
ms)
as
soci
ated
wit
h
brea
kfas
t om
issi
on.
Th
e re
lati
onsh
ip is
u
nli
kely
to
be c
ausa
l in
nat
ure
an
d t
her
e m
ay b
e bi
-dir
ecti
onal
m
ech
anis
ms
invo
lved
, w
ith
men
tal h
ealt
h
also
infl
uen
cin
g w
het
her
or
not
br
eakf
ast
is
con
sum
ed.
Smit
h (
2010
),
GB
R [
46]
213
8.1
1 ye
ars
50.7
%
Sep
arat
e gr
oup
s d
esig
n
To
exam
ine
the
effe
cts
of
con
sum
ing
dif
fere
nt
brea
kfas
t ce
real
s on
pa
ren
ts' p
erce
pti
ons
of t
he
aler
tnes
s, c
ogn
itiv
e fu
nct
ion
an
d o
ther
asp
ects
of
th
e w
ell-
bein
g of
th
eir
chil
dre
n.
Qu
esti
onn
aire
m
easu
res
of w
ell-
bein
g (a
lert
nes
s,
cogn
itiv
e d
iffi
cult
ies,
an
xiet
y, d
epre
ssio
n,
emot
ion
al d
istr
ess,
fa
tigu
e, s
omat
ic
sym
pto
ms,
p
osit
ive/
neg
ativ
e m
ood
, sym
pto
ms,
bo
wel
pro
blem
s).
Bre
akfa
st c
erea
l co
nsu
mp
tion
by
chil
dre
n is
ass
ocia
ted
wit
h g
reat
er w
ell-
bein
g.
Mod
erat
e
Aca
de
mic
ach
ieve
me
nt
Bos
chlo
o et
al.
(20
12),
NL
D
[47]
605
14.8
1 ye
ars
56%
C
ross
-sec
tion
al
To
inve
stig
ate
wh
eth
er
adol
esce
nts
wh
o h
abit
ual
ly
skip
bre
akfa
st h
ave
low
er
end
-of-
term
gra
des
th
an
adol
esce
nts
wh
o ea
t br
eakf
ast
dai
ly.
Bre
akfa
st
Con
sum
pti
on
Att
enti
on P
robl
em
Scal
e
Sch
ool p
erfo
rman
ce –
ar
ith
met
ic m
ean
of
subj
ects
Du
tch
, m
ath
emat
ics
and
E
ngl
ish
.
Stu
dy
show
s th
at
brea
kfas
t sk
ipp
ing
and
sch
ool
per
form
ance
are
re
late
d, p
arti
ally
m
edia
ted
by
atte
nti
on.
No
cau
sal c
oncl
usi
ons
dra
wn
.
Mod
erat
e
Bu
rrow
s et
al.
(20
17),
AU
S [4
8]
4245
11
.33
year
s 50
.55%
O
bser
vati
onal
T
o co
nd
uct
sec
ond
ary
anal
ysis
to
exam
ine
asso
ciat
ion
s be
twee
n a
ra
nge
of d
ieta
ry b
ehav
iou
s
Die
tary
beh
avio
rs
NA
PL
AN
(re
adin
g,
wri
tin
g, s
pel
lin
g,
Th
e fi
nd
ings
d
emon
stra
te t
he
asso
ciat
ion
bet
wee
n
die
tary
beh
avio
rs a
nd
Mod
erat
e
21
and
ch
ild
ren
's a
cad
emic
ac
hie
vem
ent.
gr
amm
ar/
pu
nct
uat
ion
, n
um
erac
y)
hig
her
aca
dem
ic
ach
ieve
men
t.
Bre
akfa
st w
as o
nly
si
gnif
ican
tly
asso
ciat
ed w
ith
th
e ac
adem
ic d
omai
n o
f w
riti
ng.
Fau
ght
et a
l. (2
017
), C
AN
[49
] 28
60
8
14.1
ye
ars
50.9
%
Obs
erva
tion
al
To
char
acte
rize
th
e as
soci
atio
ns
betw
een
h
ealt
h b
ehav
iors
an
d s
elf-
rep
orte
d a
cad
emic
ac
hie
vem
ent.
Qu
esti
onn
aire
(a
cad
emic
ac
hie
vem
ent,
PA
, h
ealt
hy
eati
ng
hab
its,
sl
eep
, scr
een
tim
e,
BW
-sta
tus,
SE
S)
Th
e p
rese
nt
fin
din
gs
dem
onst
rate
th
at
life
styl
e be
hav
iors
are
as
soci
ated
wit
h
acad
emic
ac
hie
vem
ent.
Mod
erat
e
Lie
n (
200
7),
NO
R [
50]
730
5 15
-16
ye
ars
50.6
%
Cro
ss-s
ecti
onal
su
rvey
T
o ex
amin
e th
e re
lati
onsh
ip b
etw
een
m
enta
l dis
tres
s, a
cad
emic
pe
rfor
man
ce a
nd
regu
lar
brea
kfas
t co
nsu
mp
tion
ac
ross
gen
der
an
d
imm
igra
tion
sta
tus.
Ave
rage
gra
de
for
mat
hem
atic
s, w
ritt
en
Nor
weg
ian
, En
glis
h
and
soc
ial s
cien
ce.
HSC
L-1
0 (
men
tal
dis
tres
s)
Th
e im
pli
cati
ons
of
skip
pin
g br
eakf
ast
on
men
tal d
istr
ess
and
acad
emic
p
erfo
rman
ce a
re
stro
nge
r fo
r bo
ys t
han
gi
rls
and
str
onge
r fo
r N
orw
egia
ns
than
im
mig
ran
ts.
Mod
erat
e
Lit
tlec
ott
et a
l. (2
016
), G
BR
[12
] 30
93
(bas
elin
e),
3055
(fo
llow
-u
p)
9-11
ye
ars
50.8
%
(bas
elin
e)
49
.5%
(f
ollo
w-u
p)
Obs
erva
tion
al
To
exam
ine
the
lin
k be
twee
n b
reak
fast
co
nsu
mp
tion
in 9
- to
11-
year
-old
ch
ild
ren
an
d
edu
cati
onal
ou
tcom
es
obta
ined
6-1
8 m
onth
s la
ter.
Ed
ucat
ion
al
outc
omes
: SA
T-
scor
es
Sign
ific
ant
pos
itiv
e as
soci
atio
n b
etw
een
se
lf-r
epor
ted
BC
an
d
edu
cati
onal
ou
tcom
es.
Mod
erat
e
Pto
mey
et
al.
(20
16),
USA
[51
] 69
8
7.5
year
s 50
.5%
C
lust
er-
ran
dom
ized
co
ntr
olle
d t
rial
To
det
erm
ine
wh
eth
er
brea
kfas
t co
nsu
mp
tion
or
con
ten
t af
fect
s ac
adem
ic
ach
ieve
men
t m
easu
red
by
stan
dar
diz
ed t
ests
.
WIA
T-I
II
Bot
h B
C a
nd
br
eakf
ast
con
ten
t m
ay
be a
ssoc
iate
d w
ith
im
pro
ved
stan
dar
diz
ed t
est
per
form
ance
in
elem
enta
ry s
choo
l st
ud
ents
.
Mod
erat
e
22
Sam
pas
a-K
anyi
nga
&
Ham
ilto
n
(20
17),
CA
N [
52]
9912
15
.2
year
s 4
8.6
%
Obs
erva
tion
al
To
inve
stig
ate
the
asso
ciat
ion
bet
wee
n
brea
kfas
t co
nsu
mp
tion
an
d s
choo
l con
nec
ted
nes
s an
d t
o ex
ten
d p
revi
ous
rese
arch
on
th
e as
soci
atio
n
betw
een
bre
akfa
st
con
sum
pti
on a
nd
ac
adem
ic a
chie
vem
ent.
Sch
ool c
onn
ecte
dn
ess
(qu
esti
onn
aire
)
Aca
dem
ic
per
form
ance
(go
od
mar
ks: 7
0%
-10
0%
, p
oor
mar
ks: <
70%
)
Pro
vid
es s
up
por
tin
g ev
iden
ce fo
r th
e as
soci
atio
n b
etw
een
re
gula
r B
C a
nd
hig
her
sc
hoo
l con
nec
ted
nes
s an
d a
cad
emic
p
erfo
rman
ce.
Mod
erat
e
Stea
an
d
Tor
stve
it (
2014
),
NO
R [
53]
2432
15
-17
year
s 51
%
Cro
ss-s
ecti
onal
st
ud
y T
o ex
amin
e th
e as
soci
atio
ns
betw
een
se
vera
l lif
esty
le h
abit
s an
d
acad
emic
ach
ieve
men
t in
ad
oles
cen
t gi
rls
and
boy
s.
Self
-rep
orti
ng
ques
tion
nai
re
(die
tary
-,P
A-,
sm
okin
g- a
nd
sn
uff
ing
hab
its,
ac
adem
ic
ach
ieve
men
t)
Reg
ula
r m
eal p
atte
rn,
inta
ke o
f hea
lth
y fo
od
item
s an
d b
ein
g p
hys
ical
ly a
ctiv
e w
ere
all a
ssoc
iate
d w
ith
in
crea
sed
od
ds
of
hig
h a
cad
emic
ac
hie
vem
ent,
wh
erea
s th
e in
take
of
un
hea
lth
y fo
od a
nd
be
vera
ges,
sm
okin
g ci
gare
ttes
an
d
snu
ffin
g w
ere
asso
ciat
ed w
ith
d
ecre
ased
od
ds
of
hig
h a
cad
emic
ac
hie
vem
ent.
Mod
erat
e
N/A
– N
o in
form
atio
n A
vail
able
Ta
ble
3.
Sum
ma
ry o
f in
clu
ded
Sch
ool B
rea
kfa
st P
rog
ram
me
stu
die
s.
Fir
st a
uth
or
(yea
r), C
oun
try
Par
tici
pan
ts
Stu
dy d
esig
n
Stu
dy
pu
rpos
e O
utc
omes
A
uth
or c
oncl
usi
on
Scie
nti
fic
qual
ity
asse
ssm
ent
N
A
ge/G
rad
es
Gen
der
(f
emal
e)
Co
gn
itiv
e p
erf
orm
an
ce
Moo
re e
t al
. (2
014
), G
BR
11
1 sc
hoo
ls (
n ≈
45
00
) A
ge r
ange
9-
11 y
ears
N
/A
RC
T/
Pre
-, p
ost
stu
dy/
C
ross
-sec
tion
al d
esig
n
To
exam
ine
imp
acts
of
the
Pri
mar
y Sc
hoo
l
Nu
mbe
r of
h
ealt
hy
and
u
nh
ealt
hy
item
s
Un
iver
sal b
reak
fast
p
rovi
sion
may
red
uce
so
cio-
econ
omic
Mod
erat
e
23
[54]
F
ree
Bre
akfa
st
Init
iati
ve in
Wal
es
on in
equ
alit
ies
in
chil
dre
n's
die
tary
be
hav
iors
an
d
cogn
itiv
e fu
nct
ion
ing.
at b
reak
fast
Fru
its
+
vege
tabl
es a
nd
u
nh
ealt
hy
item
s d
uri
ng
rest
of
the
day
Bre
akfa
st
skip
pin
g an
d
atti
tud
es
Ep
isod
ic
mem
ory
(gro
up
)
Hyp
erac
tivi
ty
ineq
ual
itie
s in
co
nsu
mp
tion
of h
ealt
hy
brea
kfas
t it
ems
and
br
eakf
ast
skip
pin
g.
Shem
ilt
et a
l. (2
00
4), G
BR
[5
5]
6042
9.
83
50.2
%
RC
T/
obse
rvat
ion
al
anal
ysis
T
o d
escr
ibe
the
econ
omic
s of
UK
sc
hoo
l bre
akfa
st
clu
bs, t
o es
tim
ate
cost
s re
sult
ing
from
clu
bs a
nd
to
inve
stig
ate
rela
tion
ship
s be
twee
n c
osts
an
d
outc
omes
.
Lif
e, H
ealt
h a
nd
Sc
hoo
l Q
ues
tion
nai
re
scor
es
Th
e St
ren
gth
s an
d D
iffi
cult
ies
Qu
esti
onn
aire
sc
ores
Th
e T
rail
M
akin
g T
est
scor
es
Fam
ily
Qu
esti
onn
aire
sc
ores
Sch
ool
atte
nd
ance
Pu
nct
ual
ity
Att
ain
men
t
Inte
nti
on t
o tr
eat
anal
ysis
sh
owed
th
at
pu
pil
s in
inte
rven
tion
gr
oup
had
: -
imp
rove
d
con
cen
trat
ion
at
3 m
onth
s in
to s
tud
y -
few
er r
epor
ts o
f sk
ipp
ed c
lass
es a
nd
sk
ipp
ed d
ays
at s
choo
l w
ith
in la
st m
onth
at
1 ye
ar.
Hig
her
pro
por
tion
of
pri
mar
y-ag
ed b
reak
fast
cl
ub
atte
nd
ees
rep
orte
d ea
tin
g fr
uit
for
brea
kfas
t an
d h
ad b
ord
erli
ne
or
abn
orm
al c
ond
uct
an
d
tota
l dif
ficu
ltie
s sc
ores
(p
rim
ary-
aged
) an
d
pro
soci
al s
core
(s
econ
dar
y-ag
ed)
com
par
ed t
o n
on-
Mod
erat
e
24
atte
nd
ees.
Aca
de
mic
ach
ieve
me
nt
An
zman
-Fra
ca
et a
l. (2
015
),
USA
[56
]
446
sch
ools
N
/A
N/A
O
bser
vati
onal
T
o es
tim
ate
the
imp
act
of a
B
reak
fast
in t
he
Cla
ssro
om (
BIC
) p
rogr
amm
e on
Sc
hoo
l Bre
akfa
st
Pro
gram
me
par
tici
pat
ion
, sc
hoo
l at
ten
dan
ce, a
nd
ac
adem
ic
ach
ieve
men
t.
Sch
ool l
evel
: B
reak
fast
p
arti
cip
atio
n
Att
end
ance
ra
tes
Gra
de
leve
l:
Aca
dem
ic
ach
ieve
men
t
BIC
-pro
gram
see
ms
to:
- In
crea
se s
choo
l br
eakf
ast
par
tici
pati
on
Imp
rove
ove
rall
sch
ool
atte
nd
ance
rat
es.
Mod
erat
e
Cor
cora
n e
t al
. (2
016
), U
SA
[57]
N =
10
00
-11
00
sc
hoo
ls n
=
7130
00
-73
00
00
pu
pil
s
Gra
des
4 -
8
N/A
O
bser
vati
onal
, lo
ngi
tud
inal
stu
dy
To
esti
mat
e B
ICs
imp
act
on m
eals
p
rogr
amm
e p
arti
cip
atio
n,
bod
y m
ass
ind
ex
(BM
I),
ach
ieve
men
t, a
nd
atte
nd
ance
.
Sch
ool m
eals
p
rogr
amm
e p
arti
cip
atio
n
BM
I an
d
obes
ity
Stu
den
t A
chie
vem
ent
Att
end
ance
Off
erin
g br
eakf
ast
in
clas
sroo
m (
BIC
) in
crea
ses
sch
ool
brea
kfas
t p
arti
cip
atio
n.
Stu
dy
pro
vid
es n
o ev
iden
ce o
f hop
ed-f
or
gain
s in
aca
dem
ic
per
form
ance
, or
of
fear
ed in
crea
ses
in B
MI
and
obe
sity
.
Mod
erat
e
Kle
inm
an e
t al
. (2
00
2) U
SA
[58
]
97
Gra
de
ran
ge
3-5:
82%
Gra
de
ran
ge
6: 1
8%
59%
P
re-,
pos
t- s
tud
y T
o d
eter
min
e w
het
her
nu
trie
nt
inta
ke a
nd
ac
adem
ic a
nd
p
sych
osoc
ial
fun
ctio
nin
g im
pro
ve a
fter
th
e st
art
of a
u
niv
ersa
l-fr
ee
sch
ool b
reak
fast
p
rogr
am (
USB
P).
Hun
ger
Sch
ool
brea
kfas
t p
arti
cip
atio
n
Psy
chos
ocia
l fu
nct
ion
ing
Aca
dem
ic
per
form
ance
sc
ores
Par
tici
pat
ion
in a
sch
ool
brea
kfas
t p
rogr
amm
e en
han
ced
dai
ly n
utr
ien
t in
take
. Im
pro
vem
ents
in
nu
trie
nt
inta
ke w
ere
asso
ciat
ed w
ith
si
gnif
ican
t im
pro
vem
ents
in
stu
den
t ac
adem
ic
perf
orm
ance
an
d
psy
chos
ocia
l fu
nct
ion
ing
wh
ile
also
red
uci
ng
Mod
erat
e
25
hu
nge
r.
Leo
s-U
rbel
et
al. (
2013
), U
SA
[59]
7238
43
Gra
des
3-8
49
.6%
O
bser
vati
onal
, d
iffe
ren
ce-i
n-
dif
fere
nce
s d
esig
n
To
exam
ine
the
imp
act
of t
he
imp
lem
enta
tion
of
a u
niv
ersa
l fre
e sc
hoo
l bre
akfa
st
pol
icy
on m
eals
p
rogr
amm
e p
arti
cip
atio
n,
atte
nd
ance
, an
d
acad
emic
ac
hie
vem
ent.
Mea
l p
rogr
amm
e p
arti
cip
atio
n
Stu
den
t at
ten
dan
ce
Stan
dar
diz
ed
mat
h a
nd
re
adin
g te
st
scor
es
Un
iver
sal p
rovi
sion
se
rvic
es in
crea
se
prog
ram
par
tici
pat
ion
by
soci
al r
ath
er t
han
ec
onom
ic p
rici
ng
mec
han
ism
s; b
y re
duc
ing
stig
ma.
No
evid
ence
of p
rogr
amm
e pa
rtic
ipat
ion
infl
uen
ce
on e
du
cati
onal
ou
tcom
es.
Mod
erat
e
Mh
urc
hu
et
al.
(20
13),
NZ
L
[60
]
424
9.4
year
s 53
%
RC
T
1-y
ear
step
ped
wed
ge-
clu
ster
To
inve
stig
ate
the
effe
cts
of a
free
sc
hoo
l bre
akfa
st
pro
gram
me
(SB
P)
in N
ew Z
eala
nd
on
ch
ild
ren
’s
sch
ool
atte
nd
ance
. Se
con
dar
y ai
ms
wer
e to
exa
min
e th
e im
pac
t of
th
e br
eakf
ast
pro
gram
me
on
chil
dre
n’s
ac
adem
ic
ach
ieve
men
t, s
elf-
rep
orte
d g
rad
es,
sen
se o
f be
lon
gin
g at
sc
hoo
l, be
hav
ior,
sh
ort-
term
h
un
ger,
bre
akfa
st
hab
its
and
food
se
curi
ty.
Sch
ool,
SBP
at
ten
dan
ce
Aca
dem
ic
ach
ieve
men
t
Self
-rep
orte
d
read
ing
grad
e
Sen
se o
f be
lon
gin
g
Beh
avio
r
Hun
ger
Bre
akfa
st h
abit
s
Foo
d s
ecu
rity
A fr
ee S
BP
did
not
hav
e a
sign
ific
ant
effe
ct o
n
chil
dre
n's
sch
ool
atte
nd
ance
or
acad
emic
ac
hie
vem
ent
but
had
si
gnif
ican
t p
osit
ive
effe
cts
on c
hil
dre
n's
sh
ort-
term
sat
iety
ra
tin
gs, i
.e. r
edu
ced
h
un
ger.
Hig
her
SB
P
atte
nd
ance
rat
es m
ay b
e re
quir
ed t
o in
flue
nce
sc
hoo
l att
end
ance
an
d/o
r ac
adem
ic
outc
omes
.
Mod
erat
e
Rib
ar e
t al
. (2
013
), U
SA
[61]
N =
10
sch
ools
n =
80
78
Gra
de
1-2:
n =
Gra
de
ran
ge
1-5
Ran
ge
47.3
–
50.0
%
Pre
-, p
ost-
chan
ge
des
ign
T
o in
vest
igat
e st
uden
t ou
tcom
es
asso
ciat
ed w
ith
ch
ange
s in
th
e av
aila
bili
ty o
f
Sch
ool m
eal
par
tici
pat
ion
Sch
ool
atte
nd
ance
Swit
ch fr
om u
niv
ersa
l fr
ee t
o el
igib
ilit
y-ba
sed
SB
P r
edu
ced
bre
akfa
st
part
icip
atio
n; l
arge
st
red
ucti
on o
ccu
rrin
g
Mod
erat
e
26
328
1
3-5:
n =
479
7
un
iver
sal f
ree
brea
kfas
ts a
t el
emen
tary
sc
hoo
ls.
Tes
t sc
ore
per
form
ance
am
ong
stu
den
ts
inel
igib
le t
o fr
ee o
r re
duc
ed-p
rice
mea
ls.
Swit
ch t
o el
igib
ilit
y-ba
sed
pro
visi
on d
id n
ot
har
m t
est
scor
es o
r at
ten
dan
ce r
ates
.
We
igh
t/O
be
sity
Gle
ason
an
d
Dod
d (2
00
9),
USA
[62
]
2228
G
rad
es 1
-12
50.6
%
Obs
erva
tion
al, c
ross
-se
ctio
nal
T
o es
tim
ate
the
rela
tion
ship
be
twee
n
par
tici
pat
ion
in
sch
ool m
eal
pro
gram
mes
an
d
chil
dre
n's
bod
y m
ass
ind
ex (
BM
I)
and
th
eir
like
lih
ood
of
bein
g ov
erw
eigh
t or
obe
se, t
esti
ng
the
hyp
oth
esis
th
at s
choo
l mea
l p
arti
cip
atio
n
infl
uen
ces
stud
ents
' wei
ght
stat
us,
as
mea
sure
d b
y th
eir
BM
I an
d
ind
icat
ors
of
over
wei
ght
and
ob
esit
y.
BM
I
BM
I z
scor
e
Obe
sity
Ove
rwei
ght
No
evid
ence
th
at S
BP
p
arti
cip
atio
n
con
trib
ute
s to
ris
ing
rate
s of
ch
ildh
ood
ob
esit
y.
Mod
erat
e
Hof
fert
h a
nd
C
urt
in (
200
5),
USA
[63
]
1268
(19
97
PSI
D-C
DS)
A
ge r
ange
6-
12 y
ears
N
/A
Obs
erva
tion
al
To
exam
ine
wh
eth
er in
com
e is
li
nke
d t
o ov
erw
eigh
t in
sc
hoo
l-ag
e ch
ild
ren
. Sec
ond
, it
exp
lore
s w
het
her
food
BM
I
Ove
rwei
ght
No
evid
ence
th
at
chil
dre
n fr
om p
oor
fam
ilie
s ar
e m
ore
like
ly
to b
e ov
erw
eigh
t or
th
at
food
pro
gram
mes
co
ntr
ibu
te t
o ov
erw
eigh
t in
th
ese
chil
dre
n.
Mod
erat
e
27
pro
gram
s su
ch a
s th
e F
ood
Sta
mp
P
rogr
am, t
he
Nat
ion
al S
choo
l L
un
ch P
rogr
am,
and
th
e Sc
hoo
l B
reak
fast
P
rogr
am a
re
asso
ciat
ed w
ith
ov
erw
eigh
t am
ong
chil
dre
n in
d
iffe
ren
t in
com
e gr
oups
.
Sud
har
san
an
et a
l. (2
016
),
USA
[64
]
6495
G
rad
es 5
& 8
49
.7 %
O
bser
vati
onal
, d
iffe
ren
ce-i
n-
dif
fere
nce
s
To
det
erm
ine
wh
eth
er r
ecei
vin
g br
eakf
ast
at
sch
ool i
s re
late
d
to c
han
ges
in
chil
dre
n's
wei
ght
betw
een
th
e fi
fth
an
d e
igh
th
grad
es, a
nd
w
het
her
th
e re
lati
onsh
ip
betw
een
sch
ool
brea
kfas
ts a
nd
ob
esit
y va
ries
for
ch
ild
ren
of
dif
fere
nt
soci
oeco
nom
ic
back
grou
nd
s.
Obe
sity
F
or m
ost
chil
dre
n,
rece
ivin
g sc
hoo
l br
eakf
ast
is u
nre
late
d t
o ob
esit
y. F
or c
hil
dre
n
from
fam
ilie
s be
low
th
e fe
der
al p
over
ty li
ne,
u
nh
ealt
hy
obes
ity
betw
een
fift
h a
nd
eig
hth
gr
ade
cou
ld b
e re
late
d t
o th
e re
ceip
t of
sch
ool
brea
kfas
t in
fift
h g
rad
e.
Mod
erat
e
N/A
– N
o in
form
atio
n A
vail
able
28
3.1 Studies of Eating Breakfast
In total, 26 studies were included in the analysis. All studies were published between 2003 and 2017. The countries represented were the UK (seven studies), the US (three studies), Canada, Norway, Australia, Sweden (two studies each), and Denmark, Germany, Italy and the Netherlands (one study each). Four studies were multinational. Most of the studies included were observational. Five were randomized controlled trials, one was a non-randomized trial and one used a separate-group design. The number of participants included in the studies varied from 29 to 28,608. Based on the predetermined inclusion criteria, they all study children and adolescents. The majority studied adolescents [12, 29-31, 33, 35-39, 41-50, 52, 53]. Only four studied children with a mean age below ten years [32, 34, 40, 51]. The studies included a variety of outcome measures and instruments. Based on the applied criteria, studies were divided into four categories. Studies of morbidity risk factors associated with eating or not eating breakfast were most common [29-37]. In addition, studies of links between breakfast and academic achievement were frequent [12, 47-53]. In six studies, the association between breakfast eating and cognitive disorders was analyzed [38-43]. Finally, in three studies the link between breakfast eating and QoL and/or well-being was studied [44-46]. No study concerning the cost-effectiveness of eating breakfast was found. Table 4 shows a compilation of the EB study results.
3.1.1 Morbidity risk factors
All the studies that had morbidity risk factors as outcomes were observational studies. Most of the studies examined the association between breakfast consumption and the metabolic syndrome. Marlatt et al. found that higher levels of breakfast consumption were significantly associated with lower risk for insulin resistance as well as other risk factors for metabolic syndrome [30]. This is in line with what both Sese et al. and Wennberg et al. concluded in their studies [33, 36, 37]. The two studies conducted by Wennberg et al. were longitudinal with 27 years of follow-up. In both studies, they found an association between poor breakfast habits and future risk of developing metabolic syndrome. Hallstrom et al. studied the association between breakfast consumption
29
and cardiovascular disease risk factors. Their results indicated that adolescents who regularly consumed breakfast had higher cardiorespiratory fitness and lower total adiposity [29]. However, they did not find any significant effect of breakfast consumption on blood lipid levels, blood pressure or insulin resistance, in females. Two studies examined the association between breakfast skipping and headache [31, 35]. Both found that irregular breakfast eating is associated with headache.
3.1.2 Cognitive performance
A various number of instruments and test were used to measure cognitive performance among the studies included. All of them found that eating breakfast has positive effects on cognitive performance. Wesnes et al. concluded in both their studies that breakfast improved children’s attention [41, 42]. Cooper et al. found that eating breakfast had particularly beneficial effects when study participants faced more cognitively demanding tasks [38]. They also measured self-reported tension and calmness between the breakfast and no breakfast groups, but found no difference. In addition, they found that breakfast consumption improved response time measured with Sternberg paradigm, a memory-scanning task for short term memory testing. This effect was not possible to confirm with other similar tests measuring response time. Wesnes et al. also showed that breakfast affects response speed variability. Participants who had breakfast showed lower response speed variability. Hjorth et al. and Widenhron-Müller used the d2-test to measure selective and sustained attention and visual scanning speed. Hjorth et al. found a positive interaction between breakfast consumption and d2-test results [40]. Widenhorn-Müller showed beneficial effects of breakfast on short-term memory and mood but not on sustained attention [43].
3.1.3 Quality of life and Well‐being
All of the included studies used different measurements to study the association between breakfast consumption and QoL and/or well-being. However, the results are consistent. Page et al. found that eating breakfast was one of twelve significant predictors of self-rated health measures [44]. Richards and Smith provided evidence showing that stress, anxiety and depression were associated with skipping breakfast [45]. Nevertheless, they highlighted the possibility that mental health might influence whether a person consumes breakfast or not. Smith et al. also found that breakfast consumption is linked to increased well-being [46].
30
3.1.4 Academic achievement
All the studies that investigated breakfast consumption and academic achievement found positive associations between breakfast consumption and academic achievement. In a study conducted by Lien in Norway, the implications of skipping breakfast on mental distress and academic achievement were stronger for boys than girls and were stronger for native Norwegians than immigrants [50]. Burrows et al. concluded that dietary behavior overall was associated with higher academic achievement, but that breakfast was only significantly associated with the domain writing [48].
Table 4. Compilation of results from EB studies. First author Cognitive
Performance Academic Achievement
Morbidity Risk Factors
QoL/ Well-being
Hallstrom et al. [29] +
Marlatt et al. [30] +
Moschiano et al. [31] +
Papoutsou et al. [32] +
Sese et al. [33] +
Smith et al. [34] +
Walter [35] +
Wennberg et al. [36] +
Wennberg et al. [37] +
Cooper et al. [38] +
Defeyter and Russo [39] +
Hjorth et al. [40] +
Wesnes et al. [41] +
Wesnes et al. [42] +
Widenhorn-Müller [43] +/-
Page et al. [44] +
Richards and Smith [45] +
Smith [46] +
Boschloo et al. [47] + +
Burrows et al. [48] +
Faught et al. [49] +
Lien [50] + +
Littlecott et al. [12] +
Ptomey et al. [51] +
Sampasa-Kanyinga & Hamilton [52]
+
Stea and Torstveit [53] +
Number of studies indicating positive effects
7 (100%) 8 (100%) 9 (100%) 4 (100%)
31
3.2 Studies of School Breakfast Programmes
In total, 11 studies were included in the analysis. The studies were published between 2002 and 2016. The countries that were represented were the US (eight studies), the UK (two studies), and New Zealand (one study). The number of participants included in the studies varied from 97 to 723,843. The age of the participants in the studies varied. Most of them examined children and adolescents in a range of ages using data from different grades. Ribar et al. and Hofferth and Curtin studied children that were a bit younger (between 6-12 years). Seven studies were observational studies [55-57, 59, 62-64]. Two were randomized controlled trials and the remaining two used pre-post design. Most of the studies compared regular SBP participation with non-participation. However, a few had slightly different approaches. Ribar et al. examined changes from universal free school breakfast programmes to eligibility-based programmes, which is quite different from previous studies which only investigated intervention changes in the opposite direction. The majority of the studies examined the effects of SBP. Corcoran et al. examined BIC. Anzman-Frasca et al. compared BIC with non-BIC schools (where non-BIC schools offered traditional SBP). The identified outcome measures used in the studies included were cognitive performance, academic achievement and weight/obesity. Studies of academic achievement were most common. No studies of the association between QoL and/or well-being and SBP were identified. Nor did any studies examine the association between SBP and different morbidity risk factors. Furthermore, no study of the cost-effectiveness of SBP was identified. Table 5 shows a compilation of the SBP study results.
3.2.1 Cognitive performance
Moore et al. used several different outcomes to study the effect of free SBP compared to non-free SBP [54]. They found that free SBP had no effect on episodic memory but concluded that SPB might reduce socio-economic inequalities in terms of breakfast skipping. Shemilt et al. also studied several outcome measures [55]. They showed that SBP improved
Number of studies indicating negative effects
1 (14%) 0 (0%) 0 (0%) 0 (0%)
Number of studies indicating no effects
0 (0%) 0 (0%) 0 (0%) 0 (0%)
+ = Positive effect, - = Negative effect, 0 = No effect
32
concentration and reduced the number of days the adolescents skipped classes and school.
3.2.2 Academic achievement
Studies of the association between SBP and academic achievement showed varied results. Anzman-Frasca et al., Corcoran et al., Leos-Urbel et al. and Mhurchu et al. all concluded that serving breakfast had no effect on educational outcomes. Mhurchu et al. found that SBP had no effects on children’s school attendance rates but had significant positive effects on children’s short-term satiety ratings [60]. More specifically, Leos-Urbel et al. examined meal programme participation, student attendance and standardized mathematics and reading test scores [59]. They found no impact on educational outcomes from meal programme participation. However, results indicated that universal free SBP increased participation among children previously eligible to free school breakfast. Anzman-Frasca et al. also showed that participation rates were greater in BIC schools compared to non-BIC schools, and found an association between BIC participation and improved overall school attendance rates [56]. However, as stated above, they found no difference regarding performance in mathematics and reading in the group that received BIC versus the group that did not. Kleinman et al. differed from the other studies [58]. They found that students participating in SBP enhanced their daily nutritional intake and found an association with significant improvements in academic performance. Ribar et al. had a slightly different approach [61]. They studied if switching from a free to an eligibility-based SBP reduced participation. They found that it led to substantially reduced participation rates. However, they found no evidence that the reduced participation harmed test scores or attendance.
3.2.3 Weight/Obesity
Three of the studies used weight/obesity as outcome measure. In principle, all three studies agreed. Gleason & Dodd found no evidence that SBP participation contributes to childhood obesity [62]. Hofferth & Curtin also found no evidence that food programmes contribute to overweight in children from poor families [63]. Sudharsanan et al. reported that for most children, receiving school breakfast was unrelated to obesity [64]. However, SBP participation in 5th grade was possibly
33
associated with weight gain between 5th and 8th grade, for children from families in poverty compared to children of similar socioeconomic status that did not receive breakfast. The study conducted by Corcoran et al. also used weight/obesity as outcome measure [57]. In line with the other studies, they found no association of excessive weight gains or obesity rates from BIC.
Table 5. Compilation of results from SBP studies. First Author Cognitive
Performance Academic Achievement
Weight/ Obesity
Anzman-Frasca et al. [56] 0 Corcoran et al. [57] 0 0 Gleason and Dodd [62] 0 Hofferth and Curtin [63] 0 Kleinman et al. [58] + + Leos-Urbel et al. [59] 0 Mhurchu et al. [60] 0 Moore et al. [54] 0 + Ribar et al. [61] 0 Shemilt et al. [55] + + Sudharsanan et al. [64] -
Number of studies indicating positive effects
1 (50%) 2 (29%) 2 (33%)
Number of studies indicating negative effects
0 (0%) 0 (0%) 1 (14%)
Number of studies indicating no effects 1 (50%) 5 (71%) 3 (50%) + = Positive effect, - = Negative effect, 0 = No effect
34
4. DISCUSSION
This review searched for studies examining the effects of eating breakfast (EB) and of school breakfast programmes (SBP) respectively. Throughout the review, the results of the two searches were handled separately. The EB studies included focused mainly on studying the effects of eating breakfast versus not eating breakfast; divided into four categories of study outcomes. Similarly, the range of study outcomes in the SBP studies were divided into three outcome categories. All studies included in the analysis met the inclusion criteria of this review and were judged to be of at least moderate quality. Consequently, the excluded studies either failed to meet the inclusion criteria or had a low study quality rating. There was a notable variation in study design across the studies. In general, studies were either of observational or experimental design. The strongest study design for drawing causal relationship is the randomized controlled trial. Observational studies are important and common but also vitiated by several limitations. This is important to keep in mind when interpreting and assessing the value of the results presented in observational studies. For instance, it is problematic to assign the effects of eating breakfast to its sole nutritional value. Whether children eat breakfast or not and whether it has any substantial effect on study outcomes might very well be derived from a large number of unobserved influential factors, such as the children’s social environment and parental support. Variation in the studied type of breakfast intervention also differed. In the SBP category, each intervention had a unique design. The interventions could include Breakfast In Classroom (BIC), universal-free school breakfast programme, extended availability and serving capacity of school breakfast, and the launch of information campaigns to promote breakfast eating to schoolchildren, their parents and staff. It was not possible to draw any definite conclusions regarding the importance of how the breakfast is served. However, possible mechanisms related to the serving of breakfast are discussed below. The results of the SBP studies varied. A few studies showed that SBP had minor positive effects regarding cognitive performance and academic achievement. Studies examining the association between SBP and weight/obesity showed both positive and negative effects. However, the majority of the studies found no effects at all. In addition, no studies examined the effects of SBP on quality of life, well-being and morbidity
35
risk factors. Two of eleven SBP studies examined the effects of BIC. Both studies found that BIC improved the overall participation rate compared to SBP [56, 57]. Breakfast access can be facilitated when served in the classroom, reaching students who otherwise are unlikely to participate. However, based on the two studies included in this review it is difficult to draw any firm conclusions regarding this. Moreover, none of these studies showed any effects in any of our outcome topics. Leos-Urbel et al. found that universal-free SBP increased participation rates primarily among those who previously skipped eligibility-based school breakfast. The increased participation rates were driven by social mechanisms, as the stigma of receiving eligibility-based SBP vanished. These studies highlight reasons for introducing universal-free SBP interventions. Eligibility-based SBPs that target individual schoolchildren in need of interventional support may therefore prove unsuccessful. This supports the conclusion of Moore et al., that universal-free SBP might reduce socio-economic inequalities among schoolchildren. Many of the SBP studies included suffered from methodological weaknesses. This could potentially explain the thin set of observable effects. Whether the detected associations were of a causal nature remains unanswered, since few studies were randomized controlled trials. The most common shortcoming among the SBP studies was the lack of confounder control. For example, the recurring lack of control for whether the children had breakfast at home or elsewhere. The review of EB studies showed positive and conclusive effects on cognitive performance, academic achievement, quality of life, well-being, and morbidity risk factors. This is clear evidence that eating breakfast is important. The consistently positive results may indicate different forms of bias. There is always a risk of publication bias that could contaminate this type of review, which could have overestimated the strength of the evidence [65]. In addition, it is also possible that authors facing non-significant results can tweak the hypothesis to better suit data. This is known as HARKing – hypothesizing after the results are known [66]. Also, the lack of control for confounders in the EB studies may have affected the results. As it is not possible to adjust for all confounders, it is difficult to establish a clear causal link between intervention and outcome [67]. EB studies that examine the association between breakfast and weight/obesity has been thoroughly studied and reviewed before. Therefore, such studies were excluded from this review. However, despite the exclusion of the weight/obesity effects of eating breakfast in this review, it should be noted that it is relevant to include weight/obesity in economic evaluations of breakfast.
36
To conduct this review, several considerations and restrictions had to be applied. Including only studies from regions comparable to Sweden restricted the study catchment area to Europe and North America, plus Australia and New Zealand. The potential exclusion of relevant studies from other nations is one limitation. In the assessment of study quality, the risk of incorrect classification is contingent. Although, by proactively disregarding the study results in the articles included when performing quality assessment, the authors took measures to limit the risk of study quality misclassification. Studies of breakfast attract researchers from different discipline. In part, this explain the high diversity in designs of SBP interventions, the multiple definitions and the measurement methods used in studying EB. Often, systematic reviews include a meta-analysis component. Meta-analysis uses statistical methods to synthesis data from the systematic review into a single quantitative outcome. Pooling results from different instruments and outcomes may lead to between-study heterogeneity and biased meta-analysis [68]. Therefore, meta-analysis of this research area is currently unwarranted. Our interest in finding and valuing the effects that can be attributed to breakfast eating and SBP emanates from the question of the cost-effectiveness of breakfast interventions. Our study cannot answer that question, but shows that breakfast eating and SBP do have effects that could be used in economic evaluations, especially when using decision analytic modeling, calculating the long-term cost and effects of intervention. For instance, improved cognitive performance and academic achievements may influence long-term effects on an individual’s productivity through improved school results, grades, higher education. Further, this gives higher human capital, which can be reflected in higher income, both for the individual and for society. Improvements in quality of life and well-being will have an immediate effect on the child’s/adolescent’s QALY weight but also, if the effects are sustained, on the long-term QALY gain. Finally, the health effects mediated by a reduction of long-term morbidity risk factors such as obesity, will contribute to lower morbidity/mortality and a reduction in health care costs. In order to answer the questions regarding cost-effectiveness of breakfast and interventions promoting breakfast, we need to know more about how the identified effects influence the societal cost and the individual’s QALY gain. There is also a need to develop models that can simulate breakfast interventions long-term costs and effects. In this study, we have started that work by identifying important model parameters.
37
5. CONCLUSIONS
The overall assessment of the eating breakfast studies indicated positive effects in cognitive performance, academic achievement, quality of life and well-being, and reduced long-term morbidity risk factors.
The school breakfast programmes studied showed minor positive effects regarding cognitive performance, academic achievement, with mixed impact on weight/obesity. However, most studies showed no effects, and all studies suffered from different methodological weaknesses.
Universal-free SBP, such as BIC, may lead to increasing participation rates. Uncertainty remains whether it has any impact on school attendance rates and socio-economic inequalities.
In order to answer the questions regarding cost-effectiveness of breakfast and breakfast interventions, we need to know more about the long-term effects of the interventions.
38
CONFLICT OF INTEREST
Financial support for conducting this review has been provided from Arla Foods. The authors have collected data and performed all analyses independently, and without unwarranted involvement from the funder.
39
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47
APPENDIX 1
Presented in table 6 are studies that were excluded due to low quality and reasons for exclusion.
Table 6. Excluded studies due to low quality, with reasons for exclusion. Exclusion no.
First author (year)
Title Reason for low quality rating
Eating Breakfast studies 1 Adolphus et
al. (2015) [69] The Relationship between Habitual Breakfast Consumption Frequency and Academic Performance in British Adolescents
1, 6
2 Benton and Jarvis (2007) [70]
The role of breakfast and a mid-morning snack on the ability of children to concentrate at school
1, 3, 5
3 Karatzi et al. (2014) [71]
Dietary patterns and breakfast consumption in relation to insulin resistance in children. The Healthy Growth Study
1, 7
4 Kral et al. (2012) [72]
Effects on cognitive performance of eating compared with omitting breakfast in elementary schoolchildren
1, 3, 5
5 López-Sobaler et al. (2003) [73]
Relationship between habitual breakfast and intellectual performance (logical reasoning) in well-nourished schoolchildren of Madrid (Spain)
2
6 Maffeis et al. (2012) [74]
Breakfast skipping in prepubertal obese children: hormonal, metabolic and cognitive consequences
5
7 McIsaac et al. (2015) [75]
The Association between Health Behaviours and Academic Performance in Canadian Elementary School Students: A Cross-Sectional Study
1
8 Overby et al. (2013) [76]
Self-reported learning difficulties and dietary intake in Norwegian adolescents
1, 3
School Breakfast Programs studies 9 Ask et al.
(2006) [77] Changes in dietary pattern in 15 year old adolescents following a 4 month dietary intervention with school breakfast--a pilot study
1, 3, 5, 6,7
10 Frisvold (2015) [78]
Nutrition and Cognitive Achievement: An Evaluation of the School Breakfast Program
6
11 Paxton et al. (2012) [79]
Nonsignificant relationship between participation in school-provided meals and body mass index during the fourth-grade school year
1
Matters causing low quality rating: 1) No RCT, 2) Lack of adequate control group(s), 3) Lack of control for confounders, 4) Insufficiently described experimental design, 5) Insufficient statistical power, 6) Non-relevant outcome measures, 7) Non-consistency between reported results and conclusions.
CMT RAPPORTSERIE/CMT DISCUSSION PAPERS (Reports with titles in English in brackets are only available in Swedish) 1986:1 P Carlsson, B Jönsson: Makroekonomisk utvärdering av medicinsk teknologi - En
studie av introduktionen av cimetidin för behandling av magsår (Medical technology assessment in a macroeconomic perspective - A study of the introduction of cimetidine for treatment of ulcers)
1986:2 L-Å Levin: Betablockerare som profylaktisk behandling efter akut hjärtinfarkt - en samhällsekonomisk analys (Beta-blockers as prophylaxis after acute myocardial infarction - a cost-effectiveness study)
1986:3 B Jönsson: Prevention som medicinsk teknologi - hälsoekonomiska aspekter
(Prevention as a medical technology - economic aspects) 1986:4 B Jönsson: Economic aspects of health care provision - is there a current crisis? 1986:5 B Jönsson: The economics of drug regulation 1986:6 P Carlsson, H-G Tiselius: Utvärdering av alternativa teknologier för behandling av
urinvägskonkrement - uppläggning av studien (Evaluation of alternative technologies for treatment of upper urinary tract calculi - study design)
1986:7 S Björk, A Bonair: Att mäta livskvalitet (Quality of life measurements) 1986:8 G Karlsson: Samhällsekonomisk utvärdering av käkbensförankrade broar - en förstudie
(Economic evaluation of jaw-bone anchored bridges - a pilot study) 1986:9 Verksamhetsberättelse 1985/86 och plan för 1986/87 1986:10 P Carlsson, H-G Tiselius: Utvärdering av stötvågsbehandling av njursten - Redovisning
av ett års verksamhet (Evaluation of extracorporeal shockwave lithotripsy treatment for upper urinary tract calculi - The first year experiences)
1986:11 B Jönsson: Health Economics in the Nordic Countries: Prospects for the Future 1986:12 B Jönsson: Cost Benefit Analysis of Hepatitis-B Vaccination 1987:1 P Carlsson, B Jönsson: Assessment of Extracorporeal Lithotripsy in Sweden 1987:2 P Carlsson, H Hjertberg, B Jönsson, E Varenhorst: The cost of prostatic cancer in a
defined population 1987:3 B Jönsson, S Björk, S Hofvendahl, J-E Levin: Quality of Life in Angina Pectoris. A
Swedish Randomized Cross-Over Comparison between Transiderm-Nitro and Long-acting Oral Nitrates
1987:4 Verksamhetsredovisning 1986/87 och plan för 1987/88 1987:5 B Jönsson: Ekonomiska konsekvenser av de nya behandlingsriktlinjerna för hypertoni
(Economic consequences of new guidelines of hypertension 1987:6 B Jönsson, G Karlsson: Cost-Benefit of Anesthesia and Intensive Care 1987:7 J Persson, L Borgquist & C Debourg: Medicinsk teknik i primärvården. En enkätstudie
riktad till vårdcentraler och medicintekniska avdelningar ( Medical devices in primary health care)
1988:1 J Persson (ed.): Innovation assessment in rehabilitation. Workshop proceedings 1988:2 C Debourg, L Borgquist & J Persson: Fördelning av hjälpmedel och kostnad på
sjukdomsgrupp (Aids for disabled and costs related to groups of diagnoses) 1988:3 BJönsson, G Karlsson & R Maller: Ekonomisk utvärdering av antibiotika (Economic
evaluation of antibiotics) 1988:4 Carlsson, P: Stötvågsbehandling av gallsten (ESVL-G) En konsekvensanalys av att
införa ESVL-G i den sydöstra sjukvårdsregionen (Extracorporeal shock Wave lithotripsy treatment of biliary stones - A consequence analysis of an introduction of the technology in the south-east health care region)
1988:5 Carlsson, P: Extrakorporal stötvågslitotripsi vid behandling av njursten och gallsten
(Extracorporeal shock wave lithotripsy in treatment of renal and biliary stones) 1988:6 Andersson, F & Gerdtham, U: En studie av sjukvårds- utgifternas bestämningsfaktorer
i ett internationellt och nationellt perspektiv (A Study of the Determinants of Health Expenditures in a National and International Perspective)
1988:7 Bonair, A: Spridning av medicinsk teknologi - en internationell jämförelse (Diffusion of
medical technology - an international comparison) 1988:8 Andersson, F, Brodin, H & Stalfelt A-M: Kostnader för behandling av akut myeloisk
leukemi - En analys av kostnadsvariationer över tiden (The Cost of Treating Acute Myeloid Leukemia - An Intertemporal Cost Analysis)
1988:9 Gerdtham, U, Andersson, F, Sögaard, J & Jönsson, B: Econometric analysis of health
care expenditures A cross-section study of the OECD-countries 1989:1 Persson J: Ethical codes in biomedical and clinical engineering - an international
comparison 1989:2 Gerdtham U: Läkemedelsförsörjningen i Sverige (The Provision of Pharmaceuticals in
Sweden) 1989:3 Andersson, F: Effektiv patenttid för nya läkemedelssubstanser registrerade i Sverige
1965-1987 (Effective Patent Life of New Chemical Entities Approved in Sweden between 1965 and 1987
1989:4 Rehnberg, C, Westerberg, I & Carlsson, P: Hälso- och sjukvård i Kanada. En analys av
organisation, styrning och finansiering (Health care in Canada - Organisation, Management and Financing)
1989:5 Carlsson, P, Pedersen, K, Varenhorst, E: Ekonomisk utvärdering av
prostatacancerscreening med dubbelpalpation - En pilotstudie på vårdcentraler i Norrköping (Economic evaluation of screening for prostate cancer with digital palpation)
1989:6 Falk, J, Haglund, J, Hultberg, T & Persson, J: Blodtrycksmätning i primärvården
(Indirect measurement of blood pressure in primary health care) 1989:7 Jönsson, B & Karlsson, G: Neonatal intensivvård av barn med mycket låg födelsevikt
(Economic aspects of neonatal intensive care of very-low-birth-weight infants) 1989:8 Jönsson, B, Horisberger B, Bruguera, M & Matter:L: Cost-benefit analysis of hepatit-B
vaccination. A Computerised decision model for Spain
1989:9 Jönsson, B: Medicinsk teknologi - utveckling, utnyttjande och utvärdering (Medical
technology - development, utilization and assessment) 1990:1 Johannesson, M, Borgquist, L, Elenstål, A, Jönsson, B, Tilling, B: Läkemedels- och
konsultationskostnad för hypertoni vid en vårdcentral (Hypertension treatment in an out-patient setting: the costs of drugs and physician visits)
1990:2 Johannesson, M, Jönsson, B, & Gerdtham, U-G: Kostnads-effektanalys av behandling
mot högt blodtryck - en metodstudie (Cost-effectiveness analysis of hypertension treatment - methodological issues)
1990:3 Gerdtham, U-G: Den förändrade åldersstrukturens effekt på sjukvårdskostnaderna
(Implications of the changing age structure on the health care costs) 1990:4 Jönsson, B: The cost of diabetes and the cost-effectiveness of interventions 1990:5 Johannesson, M & Jönsson, B: Cost-effectiveness analysis of hypertension treatment -
methodological issues 1990:6 Persson, J, Fagnani, F, Hutton, J, Jorgensen, T & Saranummi, N: Survey of Health
Care Systems and Potential of Information Technology 1990:7 Johannesson, M, Borgquist, L, Jönsson, B & Råstam, L: Kostnaderna för behandling av
hypertoni i Sverige - en analys av olika interventionsgränser och behandlingsmix (The costs of hypertension treatment in Sweden - an analysis of various intervention strategies and mix of treatment)
1990:8 Jönsson, B, Brorsson, B, Carlsson, P & Karlsson, G: Assisterad befruktning vid ofrivillig
barnlöshet. Hälsoekonomiska aspekter. (Artificial fertilization in case of unwanted childlessness - economic aspects)
1991:1 Ekberg, K, Lindén, M & Persson, J: Medicinsk teknik och arbetsmiljö. Del I: Effekter på
hälsa, vårdkvalitet och säkerhet. Del II: Klinikvis redovisning. (Medical technique and working environment Part I: Effect on health, quality of care and security. Part II: A record of performance on clinic level)
1991:2 Garpenby, P: Ny organisation för psykiatrin i Östergötland - en studie av
implementering inom ett landsting. (A new organization of psyciatric care in Östergötland - a study of implementation in a County Council)
1991:3 Johannesson, M, Hedbrant, J & Jönsson, B: A computer simulation model for cost-
effectiveness analysis of cardiovascular disease prevention 1991:4 Nordenfelt, L: Quality of Life and Health Promotion. Two Essays in the Theory of
Health Care 1991:5 Carlsson, P, Garpenby, P, Bonair, A: Kan sjukvården styras? En rapport om spridning
och kontroll av medicinsk teknologi. (Is control of health care possible? A report on the diffusion and control of medical technology.)
1991:6 Brodin, H: Köer till vård - Myt och verklighet. (Queues in health care - myth and reality) 1991:7 Carlsson, P, Tiselius, H-G, Borch, K: Some aspects of extracorporeal shock wave
lithotripsy for renal and biliary stone treatment
1991:8 Rehnberg, C: Primärvård i privat entreprenad - En sammanfattning av ett års verksamhet i Norrköping. (Primary Care on contract - a summary of the first year in Norrköping)
1992:1 Carlsson, P, Jönsson, B, Ahlstrand, C: Prevalence and costs of benign prostatic
hyperplasia in Sweden 1992:2 Persson, J (ed.): Advancing the role of biomedical engineering in health care
technology assessment. Proceedings of a joint session organized by IFMBE (International Federation for Medical and Biological Engineering) and ISTAHC (International Society of Technology Assessment in Health Care), at the ISTAHC Eighth Annual Meeting, Vancouver, June 14-20, 1992
1992:3 Jonsson, D, Zethraeus, N, Mansfield, M, Wålinder, J: Hälsoekonomisk analys av
klozapinbehandling vid farmakoterapifraktär scizofreni - en pilotstudie 1992:4 Bonair, A, Persson J: Innovation and technology transfer in health care. COMETT-
ASSESS General Overview 1992:5 Carlsson, P, Varenhorst, E, Pedersen, K: Assessment of screening for carcinoma of the
prostate - An introduction 1992:6 Carlsson, P, Ahlstrand, C, Jönsson, B. Surgical treatment of benign prostatic
hyperplasia - Manifestations, complications and costs 1992:7 Chowdhury, S, Persson, J. Videophones for Surgeon - Pathologist Consultations: A Pre-
implementation Study 1993:1 Johannesson M, Jönsson B. Ekonomisk utvärdering av osteoporos prevention 1993:2 Carlsson P, Hedbrant J, Pedersen K, Varenhorst E, Gray D. An evaluation of prostate
cancer screening using a decision analytic model 1993:3 Hass U, Persson J, Brodin H, Andersson A. Utvärdering av datorbaserade
hjälpmedelsteknologier - effekter och kostnader. En utvärdering initierad av REDAH-projektet
1993:4 Karlsson G. Att mäta behandlingsresultat inom sjukvården. En teoretisk jämförelse
mellan QALYs och HYEs. Arbetsrapport 1994:1 Garpenby P. Introduktion av metoder inom psykiatrin i Blekinge, Västmanland och
Östergötland - en jämförande studie 1994:2 Garpenby P, Carlsson P. Utvärdering och förslag till organisation av nationella register
för kvalitetskontroll inom hälso- och sjukvården 1994:3 Skargren E, Carlsson P, Gade M, Rosenbaum A, Tropp H, Öberg B, Ödman UM. En
jämförelse av två behandlingsstrategier - kiropraktik och sjukgymnastik - vid rygg/nackbesvär
1994:4 Lindvall P, Karlsson G. Primärvård under kommunalt huvudmannaskap. En första bild
av försöksverksamheten i Katrineholms kommun 1994:5 Rahmqvist M, Carlsson P. Ålder och andra faktorers betydelse för ohälsa och
vårdutnyttjande 1994:6 Karlsson G, Lindvall P. Kommunal primärvård i Katrineholm. Vårdutnyttjande 1990-
1992
1995:1 Lundh U. De äldre östgötarnas levnadsförhållanden, hälsa och erfarenheter av hälso-
och sjukvård 1995:2 Hass U, Karlsson G. Sambandet mellan kostnader för hjälpmedel och andra insatser
för personer med funktionsnedsättningar 1995:3 Lindvall P, Karlsson G, Rosén I. Primärvårdsförsöket i Katrineholm. En lägesbild av
verksamheten utifrån ett personalperspektiv 1995:4 Andersson A, Brodin H. Rehabilitering/habilitering av döva och dövblinda med
ytterligare funktionsnedsättningar - en ekonomisk pilotstudie 1995:5 Karlsson G, Andersson A. Hjälpmedel till personer med funktionsnedsättning - en
hälsoekonomisk analys 1995:6 Hass U, Persson J, Brodin H, Andersson A. Brukarinflytande och hjälpmedelsval -
betydelse för hjälpmedelsförskrivning, livskvalitet och kostnader 1995:7 Karlsson G, Lindvall P, Rosen I. Kommunal primärvård i Katrineholm.
Vårdutnyttjande, vårdkvalitet och hälsa utifrån ett befolkningsperspektiv 1995:8 Jonsson D, Husberg M. Hälsoekonomisk utvärdering av rehabilitering för personer
sjukskrivna mer än 30 dagar. En jämförande studie i Östergötland 1995:9 Jonsson D, Husberg M. Samhällsekonomiska aspekter på reumatisk sjukdom 1995:10 Holmberg H, Carlsson P. Primärvård i privat och offentlig regi - En uppföljning av
primärvårdsverksamheten i Norrköping 1995:11 Bäckman K, Jonsson D. Utvärdering av den särskilda ersättningen för rehabiliterings-
och behandlingsinsatser inom hälso- och sjukvården (Dagmar 485) i Östergötland åren 1991-1994
1995:12 Skargren E, Carlsson P, Gade M, Rosenbaum A, Tropp H, Öberg B, Ödman UM.
Kostnads- och effektanalys av behandling med kiropraktik eller sjukgymnastik vid rygg-/nackbesvär - Uppföljning efter 6 månader
1996:1 Varenhorst E, Carlsson P, Hagström I, Holmberg H, Lindahl T, Löfman O, Noorlind
Brage H, Pedersen K, Wågermark J. Sex års erfarenhet med screening för prostatacancer - en pilotstudie på vårdcentraler i Norrköping
1996:2 Ardeby O, Persson J, Borgquist L. Medicinsk teknik i primärvården - utveckling 1986-
1995 1996:3 Rahmqvist M, Bäckman K. Landstingsenkät -95. Östgötarnas erfarenheter av
primärvård, sjukhusvård och tandvård 1996:4 Garpenby P. Att omsätta psykiatrireformen i handling - en första redovisning från
Östergötland 1996:5 Konsensusuttalande. God strokevård i Östergötland. Landstinget i Östergötland i
samarbete med Centrum för utvärdering av medicinsk teknologi 1996:6 Hass U, Jonsson D. Uppföljning av kostnaderna för lagen om stöd och service till vissa
funktionshindrade under 1994 (LSS 1992/93)
1996:7 Garpenby P, Carlsson P. Nationella kvalitetsregister inom hälso- och sjukvården - en uppföljande studie
1996:8 Lindvall P. Introduktion av nya teknologier vid behandling av schizofreni under
perioden 1935 - 1990 1996:9 Bäckman K, Brodin H. Äldres färdtjänstutnyttjande - bakgrundsfaktorer med exempel
från Norrköping 1996:10 Rahmqvist M, Bäckman K. Östgötarnas hälsa, levnadsvanor och
läkemedelsförbrukning 1996:11 Ardeby O, Ausmeel H, Persson J. Internet som verktyg för hälso- och sjukvården -
handledning och exempel 1996:12 Persson J, Brodin H. Prototype tool for assistive technology cost and utility evaluation 1996:13 Holmberg H, Carlsson P, Varenhorst E, Kalman D. Ekonomiska konsekvenser av nya
medicinska metoder i vården av prostatacancer. - En beräkning av sjukvårdskostnader under hela vårdperioden
1997:1 Jonsson D, Husberg M. Utvärdering av olika vårdalternativ inom mödrahälsovården i
Östergötland - Kostnader, vårdkonsumtion och vårdkvalitet 1997:2 Jonsson D, Husberg M. Uppföljning av kostnaderna för lagen om stöd och service till
vissa funktionshindrade under 1995 (LSS 1992/93) 1997:3 Rahmqvist M, Garpenby P. Kommunal primärvård i Katrineholm. Vårdutnyttjande,
vårdkvalitet och hälsa - en jämförelse mellan 1993 och 1996 1997:4 Larsson SA, Garpenby P, Lindvall P. Kommunal primärvård i Katrineholm. Perspektiv
på utveckling och samverkan 1997:5 Garpenby P, Lindvall P. Primärvård under kommunalt huvudmannaskap. CMTs analys
av försöket i Katrineholm 1997:6 Jonsson D, Rahmqvist M, Husberg M. Psykiska besvär bland långtidssjukskrivna i
Östergötland 1997:7 Lindvall P. Interna budgetöverenskommelser vid Lasarettet i Motala - Rationell
styrning eller mode? 1997:8 Jonsson D, Husberg M. Samhällsekonomiska aspekter på användning av neuroleptika 1997:9 Rahmqvist M, Jonsson D. Psykisk ohälsa och vårdutnyttjande i Östergötland 1991 -
1995 1998:1 Lundh U, Sandberg J. De äldre östgötarnas levnadsförhållanden, hälsa och
erfarenheter av hälso- och sjukvård 1998:2 Hass U, Persson J, Brodin H, Andersson A. Utvärdering av datorbaserade
hjälpmedelsteknologier. En utvärdering initierad av REDAH-projektet. Slutrapport mars 1998
1998:3 Byrsjö J, Persson J. Information för hälso- och sjukvården vid Internet och CD-ROM -
en annoterad förteckning 1998:4 Andersson A, Levin L-Å. Sjukvård i hemmet - en litteraturgenomgång
1998:5 Sennfält K. Kostnadsnyttoanalys av behandlingar vid kronisk njursvikt. En pilotstudie 1998:6 Vimarlund V, Timpka T, Ferraz Nunez J, Jonsson, D. Utvärdering av
yrkesrehabilitering 1998:7 Jonsson D, Husberg M, Foldemo A. Hälsoekonomisk utvärdering av psykiatrireformen
i Östergötland 1998:8 Garpenby P, Larsson SA. Att genomföra psykiatrireformen i vardagen - en uppföljande
studie från Östergötland 1998:9 Garpenby P, Byrsjö J. Den medicinska faktadatabasen MARS inom Socialstyrelsen - en
utvärdering 1998:10 Ceder M, Garpenby P. Patientinformation avseende bröstcancer och diabetes - en
utvärdering 1998:11 Öberg B, Funkesson K. En beskrivning av rehabiliteringskedjan mellan kommun och
landsting i Östergötland. Patienters, anhörigas och personalens perspektiv 1998:12 Löfström L. Riskfaktorer och Resultat inom Hjärtkirurgin - från data till information
och åtgärder. En introduktion till litteratur och metoder 1999:1 Rahmqvist M, Johansson G. Patienttillfredsställelse i öppen och sluten sjukhusvård i
Östergötland 1997 1999:2 Hass U, Persson J. Utvärdering av ortoser och ortopedteknisk verksamhet 1999:3 Garpenby P, Larsson SA. Inställningen till vårdprogram bland personal inom barn- och
ungdomspsykiatrin – en lägesrapport från Östergötland 1999:4 Jonsson D, Husberg M. Hälsoekonomisk utvärdering av Rehabhuset von Platen – EU-
projekt: Socialfond mål 3 1999:5 Jonsson D, Husberg M. Samhällsekonomiska kostnader för reumatiska sjukdomar 1999:6 Garpenby P, Larsson SA. Hälsoinformation via Internet, bibliotek och
patientinformationscentraler – en systematisk litteraturgranskning 1999:7 Sennfält K, Carlsson P, Magnusson M. Kostnadsnyttoanalys vid behandling av kronisk
njursvikt, med fokus på hämodialys och peritonealdialys 1999:8 Rahmqvist M, Lindgren I, Larsson S. Hörselstudien 1998: Nytta av hörapparat och
erfarenheter av hörselvården i Östergötland 2000:1 Larsson SA, Schmidt A, Persson J. Dövblindas upplevelser och erfarenheter av
projektet ”Nya möjligheter i arbetslivet”. Delprojekt för dövblinda inom EU-projektet Horizon
2000:2 Bäckman K, Schmidt A, Carlsson P, Karlsson E. Hjärtsjukdomars samhällskostnader 2000:3 Garpenby P, Husberg M. Hälsoinformation idag och i morgon. Östgötarnas
användning av och förtroende för olika informationskällor 2000:4 Jonsson D, Husberg M. Samhällsekonomiska kostnader för reumatoid artrit och
fibromyalgi
2000:5 Larsson SA, Jonsson D. Utvärdering av Dagmarmedel i Östergötland 1995-1999 2001:1 Lundh U. Äldres hälsa. En studie av befolkningen i Östergötland och Kalmar län 2001:2 Hellbom G, Samuelsson K, Jonsson D, Persson J. Instrument för resultatmätning vid
hjälpmedelsbaserad rehabilitering 2001:3 Bäckman K, Carlsson P, Karlsson E, Schmidt A. Cost of heart disease in Sweden 2002:1 Henriksson M, Carlsson P. Att mäta hälsorelaterad livskvalitet – en beskrivning av
instrumentet EQ-5D 2002:2 Götherström U-C, Persson J, Jonsson Dick. Samhällsekonomisk utvärdering av post-
och teletjänster för funktionshindrade – modellutveckling och tillämpning 2002:3 Rahmqvist M. Nytta av hörapparat och erfarenheter av hörselvården i Östergötland 2002:4 Husberg M, Larsson SA, Jonsson D, Persson J. Hälsoekonomisk utvärdering av
rehabilitering vid Smärt- och Rehabiliteringscentrum, Universitetssjukhuset i Linköping
2003:1 Roback K, Persson J, Hass U. Spridning och implementering av medicintekniska
produkter. Bakgrundsrapport 2003:2 Liss P-E. Metoder för bedömning och rangordning av vårdbehov – En översikt 2003:3 Götherström U-C, Persson J. Instrumentet IPPA för resultatmätning vid
arbetslivsinriktad rehabilitering 2003:4 Bernfort L, Nordfeldt S. AD/HD och relaterade tillstånd hos barn och ungdomar.
Epidemiologi, behandling och hälsoeffekter i Sverige, Norge och Danmark samt situationen i Östergötland
2003:5 Schmidt A, Husberg M, Bernfort L. Samhällsekonomiska kostnader för reumatiska
sjukdomar 2003:6 Henriksson M, Carlsson P. Att läsa och kvalitetsgranska hälsoekonomiska
modellstudier 2003:7 Garpenby P, Götherström U-C, Larsson, SA. Inställningen till vårdprogram bland
personal inom barn- och ungdomspsykiatrin i Östergötland 2004:1 Andersson A, Carlsson P, Lundborg M, Gunnarson A. Ohälsans kostnader.
Kartläggning av vårdutnyttjande för olika sjukdomsgrupper i Östergötland 2004:2 Bernfort L, Persson J. Bredbandstjänster för funktionshindrade - utvärdering av
brukarnyttan 2004:3 Rahmqvist M. Kvalitet i vården ur patientens perspektiv: Variationer i betyg mellan
olika patientgrupper och vårdenheter 2004:4 Henriksson M, Lundgren F. Screening för pulsåderbråck i buken - en hälsoekonomisk
utvärdering 2005:1 Bernfort L, Persson J. Mobil videokommunikation för döva. Utvärdering av
brukarnyttan
2005:2 Garpenby P, Husberg M. Hälsoinformation i vår tid. Östgötarnas användning av nya och gamla informationskällor
2005:3 Bernfort L, Nordfeldt S. AD / HD i ett samhällsekonomiskt perspektiv 2005:4 Bernfort L, Fernell E. Hur påverkas vardagslivet av ADHD och närliggande
funktionsnedsättningar? Analys och sammanfattning av en enkätstudie riktad till riksförbundet Attentions medlemmar
2006:1 Bartha E, Kalman S, Carlsson P. Postoperativ smärtlindring - till vilket pris? En
hälsoekonomisk modellanalys av två smärtlindringsmetoder 2006:2 Nordfeldt S, Arvidsson E, Bernfort L. Sjukvårdens och skolans insatser för barn med
AD/HD - föräldrars erfarenheter. En intervjustudie 2006:3 Mårtensson J, Carlsson P, Arvidsson E, Frank L, Lindström K, Borgquist L. Erfarenhet,
kunskap och inställning till prioriteringar - En intervjustudie med personal i primärvården
2006:4 Garpenby P. Procedurrättvisa och praktisk prioritering - tre fall från svensk hälso- och
sjukvård 2006:5 Davidson T, Levin L-Å. Kostnaden för förmaksflimmer i Östergötland 2007:1 Garpenby P. Inställningen till vårdprogram bland personal inom barn- och
ungdomspsykiatrin i Östergötland - en kompletterande intervjustudie 2007:2 Jacobsson F. Monetära ersättningsprinciper i hälso- och sjukvård 2007:3 Persson J, Husberg M, Hellbom G, Fries A. Kostnader och effekter vid förskrivning av
rollatorer 2007:4 Rahmqvist M. Befolkningens hälsa och samhällets kostnader för vård och
produktionsbortfall - Resultat från ULF-studien 1996 och 2005 2007:5 Tinghög G, Carlsson P, Synnerstad I, Rosdahl I. Samhällskostnader för hudcancer samt
en jämförelse med kostnaderna för vägtrafikolyckor 2007:6 Arvidsson E, André M, Borgquist L, Carlsson P, Lindström K. Så resonerar läkare och
sjuksköterskor vid prioriteringar av patienter i primärvård 2007:7 Hallert, E, Husberg M, Schmidt A, Jonsson D. Sjukdomsförlopp, kostnader och
livskvalitet vid nydebuterad reumatoid artrit 2007:8 Heintz E. The cost-effectiveness of foetal monitoring with ST analysis (Master’s Thesis,
IEI) 2008:1 Bistoletti P, Sennfält K. En hälsoekonomisk modellstudie av primärscreening mot
livmoderhalscancer med cellprov- och HPV DNA-test 2008:2 Schmidt A, Andersson A. Östgötars samhällskostnader för ohälsa fördelat på
sjukdomsgrupper - 2006 2008:3 Alwin J, Persson J, Krevers B. Teknik för personer med demens. En utvärderingsstudie
av teknikintervention för personer med demenssjukdom och deras närstående 2008:4 Davidson T, Levin L-Å. Närståendes konsekvenser – Hur kan de inkluderas i den
hälsoekonomiska analysen?
2008:5 Persson J, Arlinger S, Husberg M. Kostnader och effekter vid förskrivning av hörapparat
2008:6 Jacobsson F. Mål och mått. En dokumentation och utvärdering av en resultatbaserad
ersättning inom primärvården 2009:1 Roback K. Värmemätning för diagnos av begynnande fotproblem vid diabetes.
Metodöversikt samt försöksanvändning av fotindikatorn SpectraSole Pro 1000 2009:2 Bernfort L. Hälsoekonomiska utvärderingar – Vad menas och hur gör man? 2009:3 Rahmqvist M, Husberg M. Effekter av sjukvårdsrådgivning per telefon. En analys av
rådgivningsverksamheten 1177 i Östergötland och Jämtland 2009:4 Roback K, Carlsson P. Evidensgraderingssystemet GRADE. Ett sätt att granska
vetenskaplig kunskap om metoder och arbetssätt i hälso- och sjukvården 2010:1 Carlsson P, Alwin J, Brodtkorb T-H, Heintz E, Persson J, Roback K, Tinghög G.
Nationellt system för utvärdering, prioritering och införandebeslut av icke-farmakologiska sjukvårdsteknologier – en förstudie
2010:2 Levin L-Å, Andersson D, Anell A, Heintz E, Hoffman M, Schmidt A, Carlsson P.
Styrformer för effektiv läkemedelsanvändning 2010:3 Davidson T, Husberg M, Janzon M, Levin L-Å. Kostnader och kostnadseffektivitet av
ett införande av dabigatran hos patienter med förmaksflimmer (preliminär version – ej för spridning eller citering)
2011:1 Davidson T, Husberg M, Janzon M, Levin L-Å. Kostnader och kostnadseffektivitet av
ett införande av dabigatran hos patienter med förmaksflimmer 2011:2 Brodtkorb T-H, Alwin J, Heintz E, Roback K, Carlsson P. Förutsättningar för etablering
av en nationell prioriteringskommitté i hälso- och sjukvården. Erfarenheter från andra länder
2012:1 Bernfort L, Nyström Kronander U. Allergenspecifik immunoterapi vid behandling av
allergisk rinit. Behandlingseffekter, kostnader och kostnadseffektivitet 2012:2 Bernfort L (red) QALY som effektmått inom vården. Möjligheter och begränsningar 2013:1 Davidson T, Levin-L-Å, Bergström A. En pilotstudie av självtestning vid behandling
med oral antikoagulantia. Hälsoekonomiska aspekter 2013:2 Garpenby P, Nedlund A-C. Ordnat införande av metoder i klinisk verksamhet. En
studie av försök med dialogmöten inom Landstinget i Östergötland 2013:3 Rahmqvist M. Infektioner i slutenvård. Omfattning och kostnader i Östergötland – en
pilotstudie 2013:4 Lundqvist M, Davidson T. Hälsoekonomisk analys av hemtandvård jämfört med
tandvård på stationär klinik för äldre vid särskilda boenden 2015:1 Aronsson M, Carlsson P, Levin L-Å. Hälsoekonomisk förstudie av digital patologi. Var
finns de potentiella vinsterna? 2015:2 Bernfort L, Gerdle B, Rahmqvist M, Husberg M, Levin L-Å. Chronic pain in an elderly
population in Sweden. Impact on costs and quality of life
2015:3 Garpenby P. Evidensbaserade policybeslut i hälso- och sjukvård. Redovisning av nio strategier
2016:1 Rahmqvist M. Hur fungerar punktprevalensmetoden som mätinstrument i sluten
sjukhusvård? Kostnader och prevalenser för vårdrelaterade infektioner i somatisk slutenvård i Östergötland 2012
2016:2 Roback K, Bernfort L, Lundqvist M, Alwin J. Ordnad utmönstring av hälso- och
sjukvårdsmetoder 2017:1 Rahmqvist M. Läkarbesök och läkemedelskonsumtion bland barn med astma, diabetes
och andra kroniska sjukdomar. Ett metodexempel på hur journaldata kan omvandlas till epidemiologi och sjukvårdskostnader
2018:1 Eriksson T, Levin L-Å. Utvärdering av vårdval ryggkirurgi i Stockholms län 2018:2 Lundqvist M, Ennab Vogel N, Levin L-Å. Effects of eating breakfast and school
breakfast programmes on children and adolescents: a systematic review Rapporterna kan beställas från CMT till en kostnad av 150 kronor exklusive moms. Kontakta vår administratör på tel: 013-285779. Vid beställningar av mer än 10 ex ges rabatt.
