THE POWER OF SCHOOL BREAKFAST

Keith T. Ayoob, EdD, RDN, FADNAlbert Einstein College of Medicine

March 4, 2018

Disclosures

• General Mills Bell Institute of Health & Nutrition• Pure Circle Stevia Institute• Chobani• Monsanto• Calorie Control Council• The Glutamate Society

Past clients

• Want Disney Corporation• Dannon• United Soybean Board• Unilever• Cranberry Marketing Commission• Florida Citrus Commission• Haas Avocado Board

• Dairy Boards of:• New England• Alaska• Idaho• Midwest, and lots of others

• Council for Responsible Nutrition• Tchotchke recipient: pens, pads,

keyrings, tote bags, refrigerator magnets, wooden spoons, spatulas, recipe cards, cook books, cell phone & laptop chargers, an apple wedger…

EATING BREAKFAST DAILYSo…why do we care?

Skipping Breakfast: It starts young

9-year-old white students

Ate BKFST Skipped BKFST

23%

• Skipping breakfast: common in young children

• Disproportionately common among minority children77%

9-year-old Af-Am students

Basch VCE Skipped BKFST

57%

43%

Basch CE. J School Health, 2011

2011 REVIEW: Breakfast Consumption Among Urban Minority Youth

• Over ½ of high school students skipped breakfast the day of the survey

• 1 in 5 4th-graders skipped breakfast a/o lunch >3x/week

• Urban students: TWICE as likely to skip breakfast

Basch CE J of School Health 2011

Skipping Breakfast:A bad habit gets worse with age

19-yr-old White students

Ate BKFST Skipped BKFST

68%

32%

9-yr-old Afr-Am girls

Ate BKFST Skipped BKFST

22%

78%

• Breakfast consumption declines as students age

• Even worse for minority youth

• NOTE: Absolutedisparities decreased with age, but relativedisparities increased

Basch CE. J School Health, 2011

Building a Culture of WELLNESS

Starts with BREAKFAST

GOAL:Ensuring That Every

Child Is Ready to Learn

Children’s DIETS lack enough:

• Fruits & vegetables• Low-fat dairy• Whole grains

BREAKFAST: A UNIQUELY NUTRITIOUS MEAL

• Tends to be the most nutrient-rich meal.

• Ideal time for filling dietary gaps:• Fruit• Low-fat dairy• Whole grains

• Nutrients lost when breakfast is skipped: These nutrients are usually NOT made up the rest of the day.

How Breakfast Helps Learning

It’s Food for Thought!

SKIPPING BREAKFAST IMPAIRS LEARNING

Hungry kids can’t learn

• NOT just a factor of income• Among low-income families,

hungry kids are more likely to: • Repeat a grade• Receive special ed services• Show objectively measurable

emotional, behavioral, academic problems

Kleinman et al, Pediatrics 101(1) 1998

GOT HUNGER? GOT TROUBLE.

BREAKFAST SKIPPERS AND BEHAVIOR

Breakfast & grades

0

0.5

1

1.5

2

2.5

Odds of below average grades

Boys Girls

• Controlled for: • parental education level, • family structure, • dieting, • smoking, • soft drink intake

• DIRECT relationship between SKIPPING breakfast & poor grades

Lien L. Public Health Nutrition, 2006

Breakfast & mental distress

00.5

11.5

22.5

33.5

Odds ratios – 95% CI

Boys Girls

• Controlled for: • parental education level, • family structure, • dieting, • smoking, • soft drink intake

• DIRECT relationship between SKIPPING breakfast & higher mental distress

Lien L. Public Health Nutrition, 2006

Breakfast & behavior problems

0

0.2

0.4

0.6

0.8

1

1.2

BK skippers BK eaters

Behavioral problems • 9th & 10th graders• Self-reported diet & behavior • 70% decrease in likelihood of

“behavioral problems” in students who ate breakfast regularly

• Or: 250% GREATER likelihood in breakfast skippers…

• Not true for any other meal

Overby & Hoigaard Food & Nutr Research, 2012

Breakfast & cognitive function

• Regularly-eaten breakfast associated with improved cognitive function by 2.4 points

• Regularly-eaten breakfast predicted improved cognitive function

Almomani et al, Scand J Occ Ther 2013

2.4 points*

*on LOTCA

Breakfast eaters score higher

• “Day-of-the-test” breakfast eaters vs. skippers

• SIGNIFICANTLY higher scores in spelling, reading, math when breakfast was eaten (WIAT)

90

92

94

96

98

100

102

104

Spelling Reading Math

Standardized test scores

BK skippers BK eaters

Ptomey, et al. JACN, 2016

2013 review: The impact of habitual breakfast

Adolphus et al, Front Hum Neurosci (2013)

• Better on-task classroom behavior.

• Habitual breakfast & school breakfast programs:

• POSITIVE effect on academic performance

• Best results: • math/arithmetic scores• Poorly nourished children

2013 review: The impact of habitual breakfast

Adolphus et al, Front Hum Neurosci (2013)

• “…habitual breakfast (frequency and quality) and SBPs have a positive effect on children’s academic performance with clearest effects on mathematic and arithmetic grades in undernourished children.”

• “The evidence indicated a mainly positive effect of breakfast on on-task behavior in the classroom.”

2009 review: Breakfast & cognitive performance – children & adolescents

• 45 studies, 1950-2008• Overall conclusions:

• Habitual breakfast is best• May be linked to improved attendance and

reduced absenteeism• Nutritionally vulnerable students benefit the

most

Hoyland et al Nutr. Research Rev. 2009

SCHOOL breakfast works better

• Especially better MATH scores when schools offer the SBP• Kids eating breakfast at school, CLOSER TO CLASS AND TEST-

TAKING TIME – produced better standardized test scores than when kids skipped breakfast or ate breakfast at home

Frisvold, Public Economics 2015; Ptomey et al. J Am Coll Nutr 2016; Vaisman et al. Arch of Ped Adol Med 1996

The impact of habitual SCHOOL breakfast

• Reduces marginal food insecurity• Reduces nutritional impact of poor home diets• Reduced reports of hunger

Khan, et al J of School Health (2009); Nalty, et al. J of Nutr (2013); Kleinman et al, Nutr & Metab (2002)

Students felt breakfast helps them

0102030405060708090

Math/Rdng &Std test scores

Mem/Attn &Prob slvg

Healthy habits Rch/MntnHealthy Wt

Bkfst Eaters Bkfst skippers

• Get better math scores• Have better memory retention

& problem solving• Get & keep healthier habits• Reach/maintain healthier

weight

Hearst MO et al. J Sch Health 2016

Students say breakfast helps with…

65

51

0

10

20

30

40

50

60

70

Agree/strongly agree

“…getting along better with my peers”

BK eaters BK skippers

• Overall, nearly 3 in 5 students felt eating breakfast together helped with peer relationships

• True even for HALF of students who typically skipped breakfast

Hearst, et al. J School Health, 2017

Anyone Can be Too Hungry to LearnNo breakfast offered

at meetingNo food until

lunchtimeNurse at the front of

the roomAllowed participants

to feel what skipping breakfast feels like

The “VALUE ADDED” of SCHOOL BREAKFAST

Better nutrition, better health

SCHOOL breakfast = better health

• SBP participation is associated with:• LOWER BMI• LOWER risk of overweight• LOWER probability of obesity

Wang, et al. Pediatric Obesity (2016); Gleason & Dodd, JADA, (2009)

SCHOOL breakfast = better nutrition

• FACT: School breakfast is more balanced & more complete than most home breakfasts

• SBP eaters:• Get more “nutrients of concern”: calcium, fiber, vitamin D, potassium• Get more vitamins C & A• More likely to meet or exceed recommended nutrient standards

Clark & Fox. J Am Acad Diet. (2009); Bhattacharya et al. J Hum Resources (2006)

MAIN BARRIERS TO SBP PARTICIPATION

• Stigma associated with eating breakfast at school

• Getting to school in time to eat.

Basch CE J of School Health 2011

Students WANT breakfast in the classroom

0

10

20

30

40

50

60

Strongly disagree Disagree Agree Sterongly agree

“I’m uncomfortable eating in my classroom”

BK eaters BK skippers

• Eaters and skippers say:

• They don’t mind eating breakfast in class!

Hearst, et al. J School Health, 2017

Breakfast in the classroom

• Associated with IMPROVED math & reading scores• Improvement was best among

• LOW-performing students

• LOW BMI

• NOT associated with increases on obesity

Imberman & Kugler, J of Policy Anal & Mgmt (2014); Corcoran et al, J of Policy Anal & Mgmt (2016)

But what kind of breakfast?

Breakfast: “Whole” lot of good

• More servings of whole grains associated with higher scores in:

• Reading comprehension

• Fluency

• Mathematics

Ptomey, et al. JACN, 2016

Meal composition & Alertness

• 3 meal types:• High protein: 21% CHO, 52% Pro, 27% fat• Super high carb: 72% CHO, 27% fat• Regular: 18% pro: 55% CHO, 27% fat

Paz & Berry, Annals of Nutr & Metab; 1997

Meal composition & alertness

• Regular diet: best with performance• 55% CHO, 18% pro, 27% fat

• CHO:PRO ratio of 3:1 was suggested as optimal balance between mood & performance

• Typical breakfast:• WG Cereal, 1% milk, 4 oz. juice:

• CHO: 208 cal; PRO: 40 cal; Fat: 27 cal

• CHO:PRO ratio: 5:1

• Need protein?

Paz & Berry, Annals of Nutr & Metab; 1997

THE POWER OF PROTEIN

• Most children (and adults!) get enough• May not get enough, early enough• Most calories obtained after school through evening hours

WHAT DOESN’T WORK

BLOCK GRANTS• CBO says block grants could

“eliminate access to nutrition programs for some children and reduce it for others.”

• Can’t respond to changes in enrollment, need, number of eligible students

• Don’t address annual cost increases: food/commodity prices are historically among the most volatile & variable

BLOCK GRANTS• In poor economic times, school meal programs are even more

critically important. Block grant funding caps would reduce the ability of school meal programs to reach vulnerable children.

• REALITY: SCHOOL NUTRITION PROGRAMS HAVE NO GUARANTEE OF RECEIVING BLOCK GRANTS!

BLOCK GRANTSOne more thing…• SCHOOL NUTRITION PROGRAMS HAVE NO GUARANTEE OF

RECEIVING BLOCK GRANTS!• Diversion away from school meal programs is easy for states to do.• To effect positive change in school nutrition,

BLOCK GRANTS ARE UNACCEPTABLE. PERIOD.

A LITTLE MATH…• 6₵ extra per breakfast to

provide commodities• 11,667 breakfasts subsidized

for the price of 1 TOILET SEAT

Bureaucrat salaries

• Private sector: $70,000/year• Federal sector: $127,000/year• Excess: $57,000

• $57,000 could subsidize 950,000 breakfasts!

And some words about the elephant in

the room…

Child obesity & Low SES

HS Grad or less44%

Some College37%

College Grad19%

% Obese by education

Source: CDC.gov; MMWR Feb 16, 2018 67(6); 186-189.

≤130%64%

>130% to ≤350%

25%

>350%11%

% Obese based on income

Child obesity: An ethnic issue

White23%

Black30%

Hispanic34%

Asian13%

Obesity by ethnicity

White Black Hispanic Asian

• Multifactorial• VERY complicated• School breakfast: part of the

SOLUTION

CHILDHOOD OBESITY:WHAT LEGISLATORS NEED TO KNOW• School meals: part of the SOLUTION to child obesity.

• School meals:• Have strict calorie guidelines

• Guided by US Dietary Guidelines for Americans

• Strict portion control

• Must be varied

• Possibly the MOST BALANCED MEALS children receive during the day.

CHILDHOOD OBESITY:WHAT LEGISLATORS NEED TO KNOW• School breakfast MUST meet nutrient requirements• Possibly the MOST BALANCED MEALS children receive during the

day.• Skipped breakfast = nutrients lost

• These nutrients and FOOD GROUPS are NOT made up the rest of the day

• Likely the MOST BALANCED MEALS children receive consistently.

Food Sources of Added SugarsAges 2 Years and Older, 2015 Dietary Guidelines

Data Source: What We Eat in America (WWEIA) Food Category analyses for the 2015 Dietary Guidelines Advisory Committee

Dairy 4%

Empty-calorie DrinksWhere Do They Get Them-Where Do They Drink Them

Source: NCHS Data Brief No. 71, Figure 6. August 2011

School/day care

Drink at Home (53%) Drink Away from Home (47%)

And some parting words…• CONFIDENCE IN YOUR MESSAGE – IT’S JUSTIFIED• BE GENUINE:

• THEY NEED TO KNOW THAT YOU CARE BEFORE THEY’LL CARE ABOUT WHAT YOU KNOW

• KNOW YOUR GOALS:• INFORM & EDUCATE• SPEAK FROM EVIDENCE & FACTS• MOTIVATE LEGISLATORS TO TAKE ACTION

www.cuttothechasenutrition.com@DrKeithAyoob