Dietary Choices for Breakfast in Children and Adolescents

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Dietary Choices for Breakfast in Children andAdolescentsCarlo Agostoni a & Furio Brighenti ba Department of Maternal and Pediatric Sciences, Fondazione IRCCS Cá Granda–OspedaleMaggiore Policlinico , University of Milan , Italyb Department of Public Health , University of Parma , ItalyPublished online: 28 Jan 2010.

To cite this article: Carlo Agostoni & Furio Brighenti (2010) Dietary Choices for Breakfast in Children and Adolescents, CriticalReviews in Food Science and Nutrition, 50:2, 120-128, DOI: 10.1080/10408390903467563

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Critical Reviews in Food Science and Nutrition, 50:120–128 (2010)Copyright C©© Taylor and Francis Group, LLCISSN: 1040-8398DOI: 10.1080/10408390903467563

Dietary Choices for Breakfastin Children and Adolescents

CARLO AGOSTONI1 and FURIO BRIGHENTI2

1Department of Maternal and Pediatric Sciences, Fondazione IRCCS Ca Granda–Ospedale Maggiore Policlinico, University ofMilan, Italy2Department of Public Health, University of Parma, Italy

Breakfast represents a healthy habit and associations with positive health outcomes have been widely described. Breakfastshould be consistent with local and family dietary traditions. The proportion of breakfast skippers in the pediatric andadolescent diet range 10–30% throughout the world. Policies and interventions supportive of breakfast consumption aretherefore encouraged. According to neurobehavioral data, the good example of parents and access to a variety of palatableand pleasant breakfast foods should drive children to become able to self-select breakfast models with balanced composition,while respecting recommended dietary allowances. A balanced macronutrient composition, the proposition of a variety ofmodels leading to a total energy density preferably within lower ranges (< 1–1.5), as well as glycemic indices in the lowerrange for the same food class, could emphasize the positive short- and long- term health outcomes now attributable tobreakfast.

Keywords Breakfast, dietary choices, parental dietary behavior, food balance, food variety

BREAKFAST HABITS THROUGHOUT THE WORLD

Breakfast habits have usually been linked to different lo-cal traditions, and in general up to few years ago the questionof having breakfast was more viewed at as a sort of positive,moralistic, “good start of the day,” than connected to a specificscientific issue. In the last several years regular breakfast con-sumption has been associated to a multitude of positive healthbenefits, yet young people are more likely to skip breakfast thanany other meal (Timlin and Pereira, 2007).

According to a revision of 47 observational studies on break-fast habits conducted in either United States and Europe, 10 to30% children and adolescents (within the considered countries)are actually skipping breakfast, increasingly according to age(Rampersaud et al., 2005).

The figure of 10–30% skipping breakfast is validated alsoby more recent surveys originating from different countries and

Presented as part of the invited workshop “Overall dietary balance for goodnutrition in children: the relevance of breakfast” given at the 2008 MilanoPedia-tria meeting, November 22, 2008, in Milan, Italy. The workshop was sponsoredby Soremartec Italia SrL. Its contents are solely the responsibility of the authors.The Symposium was chaired by Marcello Giovannini and Raanan Shamir.

Address correspondence to: Carlo Agostoni, MD, Department of Maternaland Pediatric Sciences, Fondazione IRCCS Ca Granda–Ospedale MaggiorePoliclinico, University of Milan, Via della Commenda, 9, I–20122 Milano,Italy. E-mail: [email protected]

continents, and seems to reflect a more general health and/orlifestyle habit, ranking with other unfavorable uses and social,familiar and psychophysical characteristics linked, within a vi-cious circle, to poorer metabolic outcomes.

FOOD CHOICES FOR BREAKFAST

The reasons for skipping breakfast in the light of recent sur-veys seem to be almost homogeneous on one hand side, andquite complex on the other. Common findings can be foundin the association of erratic breakfast habits with the extent ofsocial changes investing family and the whole social context,possibly leading to an early individual isolation. Complexityis related to the multivariate picture which emerges when thesingle causes are independently considered and analysed.

On one hand, the demographic and socio-economic back-ground of children and adolescents is an objective determinant,mostly unrelated to subjective perceptions and taste, that maydeeply affect the quality of diet (Hanson and Chen, 2007). Onthe other hand there are subjective situations, more difficult tobe quantified. For instance, according to an Australian surveyof 699 thirteen-year-olds, approximately 12% of the sampleskipped breakfast. Gender was the only statistically significantdemographic variable, with females skipping at over three timesthe rate of males. Skippers were more likely to be dissatisfied

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DIETARY CHOICES FOR BREAKFAST 121

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Macronutrients

Corn Flakes Breakfast

Recommended limit

Figure 1 Corn flakes breakfast: Energy percentage provided by breakfastmacronutrients in comparison with reference of macronutrient partitioning (12%of energy from protein, 60% from carbohydrate, 10% from sugars, 28% fromfat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). * Fiber: fiberpercentage of recommended amount (25 g).

with their body shape and to have been on a diet to lose weightthan were those who ate breakfast. However, in a follow-uptelephone survey, the reasons given for skipping breakfast werealmost exclusively lack of time and not being hungry in themorning. Therefore, in this case skipping breakfast was just amatter of individual choice (Shaw, 1998). We will briefly dis-cuss two major correlates of breakfast and breakfast skipping,that is, the social and family background, and the psychological,more subjective, components.

The Family/Social Context

Recent studies have investigated the individual perception ofbreakfast in terms of what is subjectively perceived and havetried to identify the individual’s attitudes towards breakfast,according to personal knowledge, beliefs, and family context.An example is represented by a study conducted in Sweden,where schoolchildren’s breakfast choices were investigated fo-cusing on their reported usual food intake and perceptions of

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Chocolate cereals Breakfast

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Figure 2 Chocolate cereals breakfast: Energy percentage provided by break-fast macronutrients in comparison with reference of macronutrient partitioning(12% of energy from protein, 60% from carbohydrate, 10% from sugars, 28%from fat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). * Fiber:fiber percentage of recommended amount (25 g).

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Brioche Breakfast

Recommended limit

Figure 3 Brioche breakfast: Energy percentage provided by breakfastmacronutrients in comparison with reference of macronutrient partitioning (12%of energy from protein, 60% from carbohydrate, 10% from sugars, 28% fromfat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). * Fiber: fiberpercentage of recommended amount (25 g).

fat-reduced or fiber-enriched alternatives (Berg et al., 2003).Children were investigated as far as personal views on what rep-resents a “good breakfast” (healthy vs tasty), usual personal andparental breakfast habits, and parents’ choices for their childrenbreakfast (“normative” breakfast). Even if food items were lim-ited, for the judgement on milk with varying fat content therewas little disagreement between the concepts of usual, tasty,healthy, and normative in comparison with the relatively widedisagreement between the same concepts considering bread withvarying fiber content (i.e. high-fiber bread and breakfast cerealsare perceived as healthy but consumption of these products islimited by palatability). As a matter of fact, the positive roleof parental choices in leading their children’s choices emerges,together with the need of their children to see combined theconcepts of healthy, tasty, and parental approval. Accordingly,the results indicate that parents have a pivotal role in influencingbreakfast choices via norms and by controlling the availability offoods, and that usual breakfast choices reported by children are

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Biscuits Breakfast

Recommended limit

Figure 4 Biscuits breakfast: Energy percentage provided by breakfastmacronutrients in comparison with reference of macronutrient partitioning (12%of energy from protein, 60% from carbohydrate, 10% from sugars, 28% fromfat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). * Fiber: fiberpercentage of recommended amount (25 g).

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122 C. AGOSTONI AND F. BRIGHENTI

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Plain Biscuits BreakfastRecommended limit

Figure 5 Plain biscuits breakfast: Energy percentage provided by breakfastmacronutrients in comparison with reference of macronutrient partitioning (12%of energy from protein, 60% from carbohydrate, 10% from sugars, 28% fromfat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). * Fiber: fiberpercentage of recommended amount (25 g).

indeed in many cases in accordance with their parents’ wishes.The family correlates of breakfast consumption among childrenand adolescents seem therefore to be fundamental to proposeand support positive breakfast habits.

The literature on family correlates of children and adoles-cent’s breakfast consumption has been recently reviewed (Pear-son et al., 2009). From 24 papers reviewed, 6 studied childrenand 19 studied adolescents. Few studies have examined thesame specific family correlates of breakfast consumption, limit-ing the possibilities of drawing strong or consistent conclusions.In support of the idea that social context plays a prominent rolein breakfast habits, parental breakfast eating and living in two-parent families were the correlates supported by the greatestamount of evidence in association with adolescent’s breakfastconsumption. Other recent data confirm that children’s percep-tion of parental emphasis on what is a good breakfast is animportant determinant (Cheng et al., 2008; Tapper et al., 2008).The question of the family socio-economic background has

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Melba toast BreakfastRecommended limit

Figure 6 Melba toast breakfast: Energy percentage provided by breakfastmacronutrients in comparison with reference of macronutrient partitioning (12%of energy from protein, 60% from carbohydrate, 10% from sugars, 28% fromfat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). * Fiber: fiberpercentage of recommended amount (25 g).

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Bread, butter and jam Breakfast

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Figure 7 Bread, butter and jam breakfast: Energy percentage provided bybreakfast macronutrients in comparison with reference of macronutrient parti-tioning (12% of energy from protein, 60% from carbohydrate, 10% from sugars,28% from fat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). *Fiber: fiber percentage of recommended amount (25 g).

been poorly investigated so far, but inverse associations betweensocio-economic deprivation and skipping breakfast or consump-tion of an unhealthy breakfast have been identified (Pearsonet al., 2009).

As a whole, these results suggest that parents act as posi-tive role models for their children by targeting their own di-etary behaviors and that family structure and socio-demographicbackground should be considered when designing programmesto promote healthy breakfast behaviors. Indeed, a more re-cent study examining the association between the frequencyof eating breakfast and overweight among Danish adoles-cents and whether the association differs between differentsocio-economic positions, has found that frequent consump-tion of breakfast is less protective against overweight amongschoolchildren from low socio-economic background com-pared to schoolchildren from higher positions (Fabritius andRasmussen, 2008).

As a general recommendation, parents and caregivers shouldprovide good examples, in agreement with the American Heart

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Malt and cereals brioche Breakfast

Recommended limit

Figure 8 Malt and cereals brioche breakfast: Energy percentage providedby breakfast macronutrients in comparison with reference of macronutrientpartitioning (12% of energy from protein, 60% from carbohydrate, 10% fromsugars, 28% from fat, 10% from saturated fat) (Italian Institute of Nutrition,1996). * Fiber: fiber percentage of recommended amount (25 g).

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Bread, hazelnut spread Breakfast

Recommended limit

Figure 9 Bread and hazelnut spread breakfast: Energy percentage providedby breakfast macronutrients in comparison with reference of macronutrientpartitioning (12% of energy from protein, 60% from carbohydrate, 10% fromsugars, 28% from fat, 10% from saturated fat) (Italian Institute of Nutrition,1996). * Fiber: fiber percentage of recommended amount (25 g).

Association that has underlined the necessity to provide a socialcontext for eating behavior (Gidding et al., 2005). This mighteven be more important for breakfast than any other eatingoccasions. A positive parental model might be a better methodfor improving a child’s diet than attempts at dietary control andrestriction (Scaglioni et al., 2008). Indeed, stronger parentalrestriction rules are related to a lower consumption of simplesugars in controlled meals (such as breakfast and lunch) but,in less controlled situations, are associated with preferences formore sweetened beverages (Liem et al., 2004).

Psychological Influences

Psychological influences on childhood diet and reasons forthe development of the individual taste and perceptions are rais-ing increasing attention and consideration given the possibilityto favorably influence later dietary habits and, possibly, the pre-disposition towards developing chronic-degenerative disorders.

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Salty Breakfast 1

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Figure 10 Salty breakfast 1: Energy percentage provided by breakfastmacronutrients in comparison with reference of macronutrient partitioning (12%of energy from protein, 60% from carbohydrate, 10% from sugars, 28% fromfat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). * Fiber: fiberpercentage of recommended amount (25 g).

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Salty Breakfast 2

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Figure 11 Salty breakfast 2: Energy percentage provided by breakfastmacronutrients in comparison with reference of macronutrient partitioning (12%of energy from protein, 60% from carbohydrate, 10% from sugars, 28% fromfat, 10% from saturated fat) (Italian Institute of Nutrition, 1996). * Fiber: fiberpercentage of recommended amount (25 g).

Few food and flavor preferences are innate, and most arelearned via eating experience. Such learning curve involvesassociative conditioning of food cues to aspects of thechild’s eating environment, especially the social contexts andphysiological consequences of eating (Birch, 1998a). Thepredisposition for associative conditioning affects the devel-opment of food acceptance patterns, resulting in preferencesfor foods offered in positive contexts, while foods presented innegative contexts will become more disliked via the learning ofassociations with the specific social and environmental stressor.Children also learn to prefer energy-dense foods when con-sumption of those foods is followed by positive post-ingestiveeffects, such as those produced by high-energy-density foodseaten in hungry conditions. If eating a food is perceived effectivein quenching the innately noxious feeling of hunger, a learnedpreference for that food can result (Birch, 1998b). Self-controlof dietary intakes has a key role in this context because, childrenusually adjust their energy intake at successive meals thuskeeping total daily energy intake relatively constant despite thehigh intra-meal variability of food consumption (Birch, 1991).Self-adjusting dietary intakes is critical in maintaining energy

Table 1 Breakfast models: Corn flakes breakfast

Nutritional facts Corn Flakes Breakfast % RDI1 RDI1

Energy (kcal) 277 14 2000Energy (kJ) 1166Protein (g) 9.6 16 60Carbohydrate (g) 51.5 17 300(Sugars) (g) 28.7 57 50Fat (g) 4.3 7 62(Saturated fat) (g) 1.9 9 22Fiber (g) 3.9 16 25

Breakfast composed by semi-skimmed milk/yogurt (200 ml), Corn Flakes (30g), Apple (150 g).Calculated GI: 57, Total ED: 0.79, ED from solids: 0.99.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a 2000kcal diet nutrient composition in the Italian population (Italian Institute of Nutri-tion, 1996).

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Table 2 Breakfast models: Chocolate cereals breakfast

Nutritional facts Chocolate cereals Breakfast % RDI RDI1

Energy (kcal) 280 14 2000Energy (kJ) 1177Protein (g) 9.5 16 60Carbohydrate (g) 50.6 17 300(Sugars) (g) 36.7 73 50Fat (g) 5 8 62(Saturated fat) (g) 2.3 11 22Fiber 4.2 17 25

Breakfast composed by semi-skimmed milk/yogurt (200 ml), chocolate cereals(30 g, Apple (150 g).Calculated GI: 55, Total ED: 0.80, ED from solids: 1.01.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a2000 kcal diet nutrient composition in the Italian population (Italian Instituteof Nutrition, 1996).

homeostasis and balance. Imposition of stringent parentalcontrols can potentiate preferences for high-fat, energy-densefoods, limit children’s acceptance of a variety of foods, anddisrupt children’s self-regulation of energy intake by alteringchildren’s responsiveness to internal cues of hunger and satiety.This can occur when anxious parents assume that childrenneed help in determining what, when, and how much to eatand impose feeding practices that provide children with fewopportunities for self-control (Birch and Fisher, 1998). There-fore, raising children’s capability of self-regulating breakfasthabits may have beneficial long-term effects, in maintainingboth breakfast habits and its positive functional correlates.

The enhancement of breakfast food choices through the of-fer of a variety of balanced breakfast models could be a help-ful way to maintain and improve breakfast habits. In contrastwith a somehow monotonous “normative” breakfast modelledon parental habits and beliefs (Berg, 2003), food variety andmultiple choices are traditionally offered for the other meals ofthe day, such as lunch or dinner. On the contrary, and consistentwith neurobehavioral observations, the attitude towards earlyfood variety might effectively reinforce positive experiencesand learned preferences towards healthy food habits (Skinner,2002). The early promotion of food variety at breakfast may

Table 3 Breakfast models: Brioche breakfast

Nutritional facts Brioche Breakfast % RDA RDA1


Breakfast composed by semi-skimmed milk/yogurt (200 ml), brioche (50 g,Apple (150 g).Calculated GI: 41, Total ED: 0.93, ED from solids: 1.37.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a2000 kcal diet nutrient composition in the Italian population (Italian Institute ofNutrition, 1996).

Table 4 Breakfast models: Biscuits breakfast

Nutritional facts Biscuits Breakfast % RDI RDI


Breakfast composed by semi-skimmed milk/yogurt (200 ml), biscuits (52,2 g,fresh orange juice (100 ml).Calculated GI: 57, Total ED: 0.99, ED from solids: 4.18.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a2000 kcal diet nutrient composition in the Italian population (Italian Instituteof Nutrition, 1996).

be helpful also in preventing food neophobia, that is associ-ated with reduced preferences for all food groups (Russell andWorsley, 2008).

Therefore, proposed strategies to maintain and promotebreakfast habits should rely on the capability of parents to serveas positive example of breakfast eating from the early ages,while leaving children free to select among a variety of models,in order to improve their ability of self-regulate food intakes.Taste preferences and liking are important for motivation to eatcertain foods, but social-cultural and physical environmentalfactors that determine availability and accessibility of foods, aswell as nutrition knowledge and abilities should also be consid-ered. Special policies should be planned for children with themost disadvantaged social backgrounds.

What is a Balanced Breakfast Model?

If we consider an ideal breakfast composition to be basedon the overall daily dietary balance, we should also considerbreakfast within the traditional dietary habits of a given coun-try. Indeed, any breakfast recommendation should primarily takeinto account the overall dietary intake and balance in addition

Table 5 Breakfast models: Plain biscuits breakfast

Nutritional facts Plain Biscuits Breakfast % RDI RDI


Breakfast composed by semi-skimmed milk/yogurt (200 ml), plain biscuits (52,2g, fresh orange juice (100 ml).Calculated GI: 46, Total ED: 1.10, ED from solids: 4.9.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a 2000kcal diet nutrient composition in the Italian population (Italian Institute of Nu-trition, 1996).

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Table 6 Breakfast models: Melba toast breakfast

Nutritional facts Melba toast Breakfast % RDI RDI


Breakfast composed by semi-skimmed milk/yogurt (150 ml), melba toast (50g), jam (30 g), fresh orange juice (100 ml).Calculated GI: 60, Total ED: 1.14, ED from solids: 3.40.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a2000 kcal diet nutrient composition in the Italian population (Italian Instituteof Nutrition, 1996).

to other more subtle health outcomes. Most of the availabledata currently used as a base for recommendations come fromNorth-American and Commonwealth countries, whose dietaryuses and lifestyle are typically different when compared toother regional or rural economies. When considering, for in-stance, the overall carbohydrate intakes, one could expect that acarbohydrate-based breakfast could contribute in a relevant wayto a better balance of macronutrient in an American setting com-pared to Mediterranean countries (where there is a widespreaduse of carbohydrate-rich foods such as bread and pasta in themain meals) and some Asian countries (where rice consumptionis prevalent).

Beside the equilibrating power of breakfast for what nutrientbalance is concerned, on a metabolic standpoint breakfast couldact as a regulator of energy intakes throughout the day, whilesupplying energy sources for the morning activities accordingto its effect on postprandial macronutrient metabolism and sati-ety. One example is the GI of breakfast’s food components, forwhich different effects have been reported (Nilsson et al., 2008).Energy intakes in preadolescent children at lunch may be down-regulated according to the values of breakfast glycemic indices,with a difference of around 100 Kcal/lunch in case of a high-GIbreakfast vs a low-GI breakfast (Warren et al., 2003). The trial

Table 7 Breakfast models: bread, butter and jam breakfast

Nutritional facts Bread, butter and jam Breakfast % RDI RDI

Energy (kcal) 359 18 2000Energy (kJ) 1502Protein (g) 10.2 17 60Carbohydrate (g) 56.5 19 300(Sugars) (g) 33.2 67 50Fat (g) 11.7 19 62(Saturated fat) (g) 6.1 28 22Fiber (g) 5, 56 22 25

Breakfast composed by semi-skimmed milk/yogurt (125 ml), bread (50 g), jam(30 g), butter (10 g), fresh orange juice (100 ml).Calculated GI: 48, Total ED: 1.13, ED from solids: 2.90.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a2000 kcal diet nutrient composition in the Italian population (Italian Instituteof Nutrition, 1996).

Table 8 Breakfast models: malt and cereals brioche breakfast

Nutritional facts Malt and cereals brioche Breakfast % RDI RDI


Breakfast composed by semi-skimmed milk/yogurt (220 ml), Malt and cerealsbrioche (30 g).Apple (200 g).Calculated GI: 37, Total ED: 0.71, ED from solids: 1.40.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a 2000kcal diet nutrient composition in the Italian population (Italian Institute of Nu-trition, 1996).

investigated the effects of 3 test breakfast models (low glycemicindex, GI, low GI with 10% added sucrose and high GI) onlunch intake, appetite, and satiety in a group of normal andoverweight children and showed that the type of breakfast eateninfluences the mean energy intake at lunchtime. Lunch intakeafter the high-GI breakfast was significantly higher that afterthe low-GI breakfast and low-GI breakfast with added sucrose(high-GI vs low-GI: 145 ± 54 kcal; high-GI vs low-GI plussucrose 119 ± 53 kcal; low-GI plus sucrose vs low-GI: 27 ± 54kcal). Accordingly, breakfast as the first meal of the day, mayaffect lunch intakes and (possibly) whole daily energy intake.Henry et al. (2007) found a tendency towards a reduced energyintake at lunch following a low-GI breakfast compared with ahigh-GI breakfast, given to preadolescent children on two nonconsecutive days per week, for a total of 11 weeks, although themean difference was low (18 kcal) and mainly confined to boys.On the contrary, Buyken et al. (2007) in a prospective study,reported a significantly higher daily energy intake in childrenin the lower tertile of breakfast GI but only for those whichconsumed a second early snack within 3 hours from breakfast.Since children in the different breakfast GI tertiles had the samebody composition, differences in energy absorption or energy

Table 9 Breakfast models: Bread and hazelnut spread breakfast

Nutritional facts Bread, hazelnut spread Breakfast % RDI RDI


Breakfast composed by semi-skimmed milk/yogurt (125 ml), bread (56 g), hazel-nut spread (37 g), apple (100 g).Calculated GI: 50, Total ED: 1.37, ED from solids: 1.94.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a 2000kcal diet nutrient composition in the Italian population (Italian Institute of Nu-trition, 1996).

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Table 10 Breakfast models: Salty breakfast 1

Nutritional facts Salty Breakfast 1 % RDI RDI

Energy (kcal) 456 23 2000Energy (kJ) 1908Protein (g) 26.3 44 60Carbohydrate (g) 42.1 14 300(Sugars) (g) 16.1 32 50Fat (g) 20.9 34 62(Saturated fat) (g) 7.0 32 22Fiber (g) 2.8 11, 4 25

Breakfast composed by bacon (30 g), eggs (50 g), whole bread (50 g), freshorange juice (100 ml), semi-skimmed milk/yogurt (125 ml).Calculated GI: 60 (excluding bacon and eggs), Total ED: 1.28, ED from solids:1.98.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a 2000kcal diet nutrient composition in the Italian population (Italian Institute of Nu-trition, 1996).

expenditure depending on breakfast carbohydrate compositionand quality might be hypothesized. Such hypothesis seems con-firmed by an enhanced fat oxidation during physical activityafter low GI compared to high GI test meals (Stevenson et al.,2005; 2006) and by a recent study which demonstrated a signif-icant 13 to 25% increase in DIT (diet-induced thermogenesis)after a low-GI breakfast compared to two high-GI breakfastwith the same energy content and respectively equal or higherglycemic load (Scazzina et al., in press). Moreover, lower GIof breakfast has been related to better cognitive performancein children in a number of studies (Ingwersen et al., 2006;Mahoney et al., 2005; Wesnes et al., 2003). Low GI carbo-hydrates might affect cognitive performances, including atten-tion, concentration, memory, and the ability to perform tasks,through different mechanisms, although only tentative hypothe-ses exist to fully support the effects seen in experimental settingsdue to limits in the design of the studies published (Glisenanet al., 2009). Taken together, these potential benefits of a low GIbreakfast seem to indicate that this could represent an overallpositive factor to be considered as a supplementary indicator ofbalance for the childrens’ breakfast. However, further research is

Table 11 Breakfast models: Salty breakfast 2

Nutritional facts Salty Breakfast 2 % RDI RDI


Breakfast composed by herrings (30 g), egg (50 g), cheddar (30 g), whole bread(50 g), fresh orange juice (100 ml), semi-skimmed milk/yogurt (125 ml).Calculated GI: 60 (excluding herrings, eggs and cheddar), Total ED: 1.22, EDfrom solids: 2.95.1RDI%: percentage of Recommended Daily Intakes (RDI) calculated for a 2000kcal diet nutrient composition in the Italian population (Italian Institute of Nu-trition, 1996).

needed before strong enough evidence can be drawn to supportrecommendations on the “ideal” breakfast GI.

Associations have been found between high breakfast ED(ED) and other unfavorable dietary habits on one side, and, tosome extent, with later BMI development in men. In a recentsurvey of National US data (Kant et al., 2008) energy density(ED) of 24-h dietary intake (considering either ED of foods plusnutritive beverages and ED of foods only) were lower amongbreakfast reporters. Moreover, the data showed that the meanBMI of women breakfast reporters was lower than that of noreporters (27.9 compared with 29.4), whereas BMI in men in-creased with increasing ED of breakfast foods and nutritivebeverages, suggesting the opportunity to provide informationon food choices to maintain the ED of breakfast within a rangefavorable as far as health outcomes.

Therefore a balanced breakfast model should follow threeindications: (1) to be consistent with the local dietary habits tomaintain the daily and periodical dietary allowances and balanceof macronutrient distribution, (2) to include a sufficient amountof carbohydrates, preferably deriving from fiber-rich low-GIsources, (3) to present a limited ED. A breakfast including threefood items, such as a source of milk and milk-derived products(preferably low-fat), cereals (preferably whole, unrefined), andfruit (preferably fresh fruit or natural juices with no added sugarto prevent an increase of ED) generally meet these indications.Other models, particularly salty breakfast models, might presentmarked imbalances of macronutrients, with high-protein, high-fat food items providing lower amounts of fiber and slowlyabsorbed carbohydrates, unless a marked shift in the averagecomposition of the other meals of the daily diet is implemented,.

BREAKFAST: PROPOSALS AND MODELS

According to previous considerations, we may assume that,within a “structured” familial social context, where parents serveas as example and not as authoritative advisors, while consider-ing the opportunity to meet both health and taste requirements,a reasonable turn-over of different breakfast patterns and mod-els could help maintaining not just good breakfast habits butalso dietary patterns favorable on the medium and long-termoutcomes.

Tables 1 to 9 represent proposals allowing for variety andtaste within an acceptable composition as far as macronutrientdistribution, ED, and reduced GI. The macronutrient composi-tion of breakfast models is based on the nutrient database offood composition of the Italian Institute of Nutrition (ItalianInstitute of Nutrition, 1998). ED and GI have been calculatedaccording to Kant et al. (2008) and Wolever et al. (2006), re-spectively. The latter is an estimate of GI for a mixed mealand, despite some criticisms (Flint et al., 2004), it likely rep-resents the correct ranking of the glycemic response elicitedwhen mixed breakfasts are consumed (Wolever et al., 2006). InTables 10 and 11 salty breakfast models are also reported, witha prevalence of high-protein, high-fat foods, leading to some

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inbalances in macronutrient distribution. Figures 1 to 11 repre-sent the energy percentage provided by macronutrients of thebreakfast models in comparison with the Italian RecommendedDietary Allowances for the repartition of energy, that is, 12% ofenergy from protein, 60% from carbohydrate, 10% from addedsugars, 28% from fat, 10% from saturated fat, within a dailyenergy intake of around 2000 kcal, adapted to preadolescentsand adolescents (Italian Institute of Nutrition, 1996).

CONCLUSIONS

Breakfast represents a healthy habit and associations withpositive health outcomes have been widely described. Breakfastshould be consistent with local and family dietary traditions.According to neurobehavioral data, the good example of par-ents should drive children to become able to self select breakfastmodels with varied and balanced composition, while respectingrecommended dietary allowances. A balanced energy supply, acomposition based on palatable and pleasant foods, the propo-sition of a variety of models inclusive of foods balanced inboth micronutrients and macronutrients, leading to a total EDpreferably within lower ranges (< 1–1.5) as well as GI in thelower range for the same food class (Brand-Miller et al., 2009)possibly resulting in a reduced overall glycemic response couldemphasize the positive short- and long- term health outcomesnow attributable to breakfast.

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Dietary Choices for Breakfast in Children and Adolescents

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